■'Ik, A PRACTICAL TREATISE ON THE DISEASES OF INFANCY AND CHILDHOOD. BY THE SAME AUTHOR. TANNER'S PRACTICE OF MEDICINE. From the Third London Edition. A MANUAL OF THE PRACTICE OF MEDICINE, by T. H. Tanner, M. D. Author of " A Manual of Clinical Medicine and Physical Diagnosis,'' and of "A Treatise on the Diseases of Women and Children," &c, . Blisters.................................................. 80 6. Purgatives.............................................. &- 7. Emetics.................................................. 86 8. Expectorants.............................;............ 89 9. Diaphoretics........................................... 91 10. Sedatives and Narcotics............................ 92 11. Alteratives and Resolvents....................... 98 12. Stimulants and Tonics.............................. 103 CHAPTER IV. The Management and Education of Children :— Section 1. Management of the Infant at Birth............. 108 2. F.n.d of Infants....................................... Ill 3. Weaning................................................ 117 4. Cleanliness and Clothing.......................... 119 5. Exercise and Sleep................................... 122 6. The Nursery........................................... 126 7. Moral and Intellectual Training.................. 127 CHAPTER V. Aicidents and Diseases occurring at, or soon after, Birth :— Sirliun 1. Still-born Children.................................. i;];-; 2. Injuries received during Birth.................... 141 3. Cephalhematoma...................................... 143 4. X.-fvi Materni.......................................... 144 5. Sclerema................................................ 146 C>. Inflammation, &c, of Umbilici-.................. 14X 7. Intestinal Hemorrhage............................. 149 8. Swelling of the Breasts............................. 152 CONTENTS. xiii CHAPTER VI. PAGE Congenital Malformations....................................... 152 CHAPTER VII. Non-Congenital Deformities..................................... 173 CHAPTER VIII. Dentition............................................................... 18G CHAPTER IX. Diseases of the Eye :— Section 1. Diseases of the Eyelids................,............ 195 2. Diseases of the Conjunctiva....................... 199 3. Diseases of the Sclerotic and Cornea........... 206 4. Diseases of the Iris................................. 208 5. Congenital Cataract................................. 211 6. Amaurosis............................................. 2i2 7. Encephaloid Fungus of the Eyeball............ 214 8. Strabismus............................................. 215 CHAPTER X. Diseases of the Ear :— Section 1. Otalgia.................................................. 218 2. Otitis.................................................... 219 3. Otorrhoea......................................r........ 221 4. Deaf-dumbness........................................ 223 CHAPTER XI. Diseases of the Skin :— Section!. Classification, &c..................................... 225 2. Order 1.—Exanthemata........................... 228 3. Order 2.—Hsemorrhagia........................... 233 4. Order 3.—Vesiculas................................. 235 5. Order 4.—Bullae..................................... 240 XIV CONTENTS. Section 6. Order 5.—Pustulse........... 7. Oudf.k G.—Parasitica........ S. Order 7.—Papulae........... 9. Order 8.—Squamae.......... 10. Order 9.—Tubercula........ 11. Order 10.—Macuhu........... CHAPTER XII. The Eruptive fevers :— Section 1. Introduction..................... 2. Small-pox.................._....... 3. Cow-pox..................!........ 4. Chicken-pox...................... 5. Measles............................ G. Scarlet Fever.................... CHAPTER XIII. Infantile Fever................................ CHAPTER XIV. Infantile I.ntkrmjttent Fever............. CHAPTER XV. (iENERAL DISEASES :— Section 1. Scrofula.......................... 2. Tuberculosis..................... 3. Syphilis.......................... 4. Bronchocele and Cretinism.. CHAPTER XVI. Diseases of the Nervous System :— Section 1. Introduction..................... 2. Convulsions..................... 3. Congestion of the Brain..... CONTENTS. XV PAGE. Section 4. Apoplexy............................................... 297 5. Acute Hydrocephalus.............................. 299 6. Simple Encephalitis................................ 305 7. Chronic Hydrocephalus............................. 308 8. Inflammation of the Membranes and Sub- stance of the Spinal Cord....................... 312 9. Infantile Trismus.................................... 314 10. Epilepsy................................................ 316 11. Eclampsia Nutans,.................................. 319 12. Chorea................................................... 320 13. Paralysis....................:......................... 322 14. N^ght Terrors, Disorders of the Mind, and Idiocy................................................ 324 CHAPTER XVII. Diseases of the Organs of Respiration and Circula- tion :— Section 1. Coryza.................................................. 328 2. Croup..................................................". 330 3. Spasm of the Glottis................................. 345 4. Hooping-cough....................................... 347 5. Pleurisy.....?.......................................... 353 6. Bronchitis.............................................. 358 7. Pneumonia............................................. 364 8. Phthisis................................................, 370 9. Pericarditis............................................ 374 10. Endocarditis and Carditis.......................... 379 CHAPTER XVIII. Diseases of the Organs of Digestion and Assimila- tion :— Section 1. Diseases of the Mouth and Fauces.............. 380 2. Diseases of the Stomach............................ 386 3. Diseases of the Intestines........................... 391 4. Peritonitis.................•............................ 405 5. Tabes Mesenterica.................................... 408 6. Diseases of the Liver................................. 409 NVl CONTENTS. CHAPTER XIX. I'AOB. Diseases of the Urinary and Genital Organs :— Section!. Acute Desquamative Nephritis................... 415 2. Cancer of the Kidney............................... 417 3. Infantile Diuresis..................................... 417 4. Incontinence of Urine............................... 419 5. Diseases of the Male Genital Organs............ 420 G. Diseases of the Female Genital Organs......... 422 CHAPTER XX. Accidents, Burns, &c:— Section!. Foreign Bodies in the Air-passages............. 424 2. Burns and Scalds..................................... 430 3. Frostbite and Chilblains............................ 436 4. Carbuncles and Boils................................ 437 5. Blows and Bruises.................................... A'.Vd APPENDIX OF FORMULAE.................................... 441 A PRACTICAL TREATISE ON THE DISEASES OF INFANCY AND CHILDHOOD. CHAPTER I. GENERAL OBSERVATIONS ON THE PERIOD OF INFANCY AND CHILDHOOD. SECTION I.--INTRODUCTION. The trite maxim, that—a large and healthy population is the life and strength of a nation, and the source of its success in science, art, agriculture, and commerce, can hardly be quoted too often; since, though none probably will deny its truth, yet there are very many who will not act upon the pre- cepts that such an observation ought to inculcate. It would indeed be well if our political economists could be led to be-. lieve, that in London and most of our large towns and cities, there are numerous gold mines, that only require working with energy and perseverance to yield a more satisfactory return than the auriferous veins of Australia. Were the filthy streets and courts at present inhabited by no small por- tion of the population swept away, and replaced by thorough- fares into which light and fresh air could freely penetrate, the Registrar-General's returns of deaths would be certainly less- ened: while, with model lodging-houses and other healthy dwellings, many of the indigent would become useful and respectable members of society, instead of—as now—incum- brances upon the industrious. The facilis descensus has been tested by many a poor man, who, driven from his miserable, ill-ventilated, and badly-drained home, has been led to seek a solace at the gin-palace; whence drink, idleness, and poverty 3 % 20 INTRODUCTION. have soon conducted him to the hospital, workhouse, or prison. The very usefulness of the poorer classes, as instruments for the creation of wealth and all the luxuries it procures, ought to be sufficient to make us mindful of their claims; and the most urgent of these claims is—that they be saved from all unnecessary and preventable disease. At present—to take only one example from a host—scrofula, in one or other of its numerous forms or complications, runs riot; and the chil- dren of the poor are either prematurely cut off, or the seeds of future disease are sown, to bear subsequently an abundant harvest.* A statistical inquiry into the amount of mortality which occurs in infancy would be out of place in the present treatise. It may suffice to mention, that there is distinct evidence to prove that in the present day more than one-fourth—in the unhealthy districts of some large manufacturing towns not let. than one-third, and even a greater proportion—of all the children ushered into the world, and born to endure for three- score years and ten, are cut off within the first five years after birth :f and if we may argue from past experience, there is but little doubt that much of this mortality is due to the unhealthiness of the majority of the homes of the working classes; the unjustifiable use of stimulants, drugs, and quack medicines containing opium, &c.; the prejudices, neglect, and * The deaths of 96,521 persons were registered in the last quarter of the yeor 1856; and the rate of mortality in the three months was 20 per 1000 per annum. In the districts comprising the chief towns in which nearly half the population is living, the people died at the rate of 24, while in the remaining districts, comprising small towns and country parishes, the death-rate was IT in 1000. This shows in a strong light how much room there is for improvement in our large towns; for it is well known than many fatal agents which may be arrested are at work in the small towns and country parishes.__Regis- trar-GeneraVs Quarterly Returns of Births and Deaths in England for Oct., Nov., and Dec, 1856. f Registrar-General's Annual Reports of Births, Deaths, $c, from 1838. INTRODUCTION. 27 ignorance of nurses and parents; and to other removable causes. So directly is infant life influenced by good or bad management, that less than a century ago the London work- houses presented the almost incredible result of twenty-three deaths in every twenty-four infants under one year of age ! this frightful devastation being allowed to go on for a long time almost unnoticed, as it was deemed beyond the reach of remedy. But when, in consequence of a parliamentary in- quiry, an improved system of management was adopted, and the parish officers of London and Westminster were obliged to send their infant poor to be nursed in the country, at proper distances from town, the proportion of deaths was speedily reduced from 2,600 to 450 a year.* Mr. McCulloch, in his Statistical Account of the British Empire,\ quotes a table from the Lancet of 1835-36, show- ing the births and deaths under five years of age, according to the London Bills of Mortality, for one hundred years, in five periods of twenty years each, and also the number dying under five years of age out of one hundred born; the results of which demonstrate that the mortality of children in London has been constantly on the decline. The table runs thus:— 1730-49 1750-69 1770-89 1790-1809 1810-29 Total births, . . . Total deaths un- I der five years, / 315,156 285,087 307,395 195,094 319,477 180,058 386,393 159,571 477,910 151,794 Dying per cent. 1 under five years, / 74-5 63-0 51-5 41-5 31-8 Here it appears that in the 20 years, 1730-49, out of 100 born, 74-5 died under the age of 5 years; while during the 20 years, 1810-29, only 31-8 died out of the same number. * Dr. Andrew Combe, On the Management of Infancy. 6th ed. p. 3. Edinburgh, 1847. f Page 543. 4th ed. London, 1854. 28 INTRODUCTION. If, then, half the children formerly cut off at an early aye in England be now reared, it will appear—argues mv. McCul- loch, rather illogically—that a vast number of weakly chil- dren arc annually introduced into the English population; and that unless we take proper means to fortify the constitu- tion in manhood, the relative vigor will not increase in the same ratio as the population. Again, even as late as 183S, we find Mr. Maclean, in his visit to St. Kilda,* stating that the population of this island is decreasing rather than increasing, owing to the excessive mortality at all times going on in infancy, for " eight out of every ten children die between the eighth and twelfth day of their existence." The great, if not the only cause of this ter- rible destruction of life, was the filth amidst which the in- habitants lived, and the noxious effluvia which pervaded their houses, owing to their being used during the winter months as stores for manure; since the air of the island was good, the water excellent, and the clergyman, who lived exactly as his neighbors did, except as regarded the condition of his house, had a family of four children, all strong and healthy. But the most striking proof, probably, that can be given to show that infant mortality may be diminished by very ordi- nary care, is to be found in the records of the Dublin Lying-in Hospital. It appears that, from the foundation of this hos- pital, in 1757 up to 1783, the number of infants born alive in its wards amounted to 17,650, of which number 2,944 had died of convulsions, or what is commonly termed nine-day fits; so that, for the first twenty-five years this institution was open, nearly every sixth child died. Such excessive mortality prompted Dr. Joseph Clarke, on being appointed the Master, to seek minutely for its cause; and he was quickly led to infer that something defective existed in the construction of the building, preventing its perfect ventilation. This soon proved to be the case; for on the adoption of measures which ren- dered the wards more airy and more easily kept clean, the * Chambers' Edinburgh Journal, Nov. 1838. INTRODUCTION. 29 mortality at once diminished, until of 8,033 children, born subsequently, only 419 died, that is about 1 in 19 J, or from 5 to 6 in 100.* Happily this rate of mortality has continued to diminish; for, during the Mastership of Dr. Collins, be- tween the years 1825 and 1832, the total number of children born was 16,654, of which number 284 died previous to the mother leaving the hospital, or about 1 in 58}. This moder- ate mortality will appear almost trifling when it is considered that it includes not only all the deaths that occurred in chil- dren born prematurely, and in twins, but also every instance where the heart ever acted, or where respiration ceased in a few seconds after birth.-j* What then do these observations teach us? Simply this: that disease and untimely death result not from necessity, or from chance, or accident, but really from the infringement of those laws and conditions, on the due observance of which the Creator has decreed that the health and welfare of the various organs of the body shall depend. As surely as we make sanitary improvements, so as certainly will our yearly death-roll be diminished; while at no period of life will the decrease of mortality be more marked than in that of infancy. The true essentials for securing infant health, in the great majority of cases, are few and simple. Pure air, cleanliness, suitable clothing, with plain and natural food, will do very much towards preventing disease; while prompt and skilful medical aid will equally assist the vis medicatrix naturca in conquering that which may be inevitable. The time has fortunately passed away, when physicians and surgeons felt an aversion to undertaking the treatment of any severe infan- tile disorder; for, systematic knowledge has taken the place of conjectural judgment, and with increased experience and practical skill, has come greater confidence in the legitimate use of the remedies with which nature has so bountifully sup- * A Sketch of the Life and Writings of Dr. Joseph Clarke. By Robert Collins, M. D. London, 1849. f Practical Treatise on Midwifery. By R. Collins, M. D. London, 1836 3-- 30 AVERAGE DURATION OF LIJ'K. plied us. Hence, although our first exertions are to be directed towards the promotion of health and the prevention of disease by the means just noticed, and especially by so improving our large towns, that they may no longer be desig- nated uthe graves of mankind;" yet we must also be careful so to study our art, that we may be enabled successfully to cope with those disorders and unfortunate accidents to which all organized beings are more or less subjected, and which— in the present state of science—seem unavoidable. SECTION II.—THE AVERAGE DURATION OP LIFE. Addison, in one of the numbers of the Spectator,* has an allegory in which he compares human life to a bridge standing in the midst of the tide, consisting of threescore and ten entire arches, with several broken arches, making a total of about one hundred " As I was counting the arches, the Genius told me that this bridge consisted at first of a thousand arches, but that a great flood swept away the rest, and left the bridge in the ruinous condition I now beheld it. But tell me further, said he, what thou discoverest on it. I see multitudes of people passing over it, said I, and a black cloud hanging on each end of it. As I looked more attentively, I saw several of the passengers dropping through the bridge into the great tide that flowed underneath it; and, upon further examination, perceived there were innumerable trap-doors that lay con- cealed in the bridge, which the passengers no sooner trod upon but they fell through them into the tide and immediate- ly disappeared. These hidden pitfalls were set very thick at the entrance of the bridge, so that throngs of people no sooner broke through the cloud, but many of them fell into them. They grew thinner towards the middle, but multiplied and lay closer together towards the end of the arches that were entire." The following remarks—which, together with the Life-Table are compiled from the Registrar-General's Fifth Annual Re- * No. 159. The First Vision of Mirza. AVERAGE DURATION OF LIFE. 31 port—show how many fall through these hidden pitfalls at the different periods of existence; and hence, to a certain ex- tent, they measure the danger which we all have to encounter in passing over this bridge of life :— Let us suppose that 100,000 children were born alive on the 1st January, 1841; and that they were the offspring of all ranks and classes of Englishmen. From the usual proportion of the two sexes registered, it will appear that 51,274 were boys, and 48,726 girls. Of the 100,000 children, 14,631 have perished during the first year, leaving 85,369 alive on 1st January, 1842 : they were exactly a, year old, and are placed against the age " 1" of the table. On 1st January, 1843, the survivors were two years old, and in number 80,102 ; so that 5,267 have died in the second year. On 1st January, 1846, the fifth birthday was attained, and there were 74,201 living. Consequently, in the first five years, 25,799 children, out of 100,000 have died. During the next five years, when the children leave home more, and when—as it appears from the parliamentary returns—great numbers pass part of the day at school, the mortality becomes considerably less, so that we find 70,612 alive at the age of ten; while from ten to fifteen the loss is small, 68,627 living to the latter age. The loss of life among girls now becomes rather greater than among boys, and it continues so for the ensuing five years, when both sexes are more detached from the care of their parents, and the majority pursue the professions or trades by which they afterwards gain a livelihood. The mortality appears to increase rather rapidly from twelve to fifteen; and then at a slow, regular rate from the age of fifteen to fifty-five : 66,059 attain the age of twenty. It was stated that 51,274 boys were born alive to 48,726 girls; but the mortality in infancy is greater among boys than girls ; so that 31,958 males attain the age of twenty-five, and 31,623 females attain the age of twenty-four. This is about the average age of marriage in England; and the number of the two sexes is then nearly equal. The chance of living from twenty-five to forty-five is 32 AVERAGE DURATION OF LIFE. rather in favor of English women ; the violent deaths of men counterbalancing the dangers of child-bearing. At the age of sixty, 37,996 will be still alive; while 24,531 attain the age of seventy, /. c, 11,823 men, and 12,708 women—the mortal- ity of the latter being less than that of the former after fifty- five. At the age of eighty, there is but little doubt that about 9,000 of the 100,000 will still be found alive; but after this period the observations grow uncertain, although we may cal- culate that 1,140 will attain the age of ninety, 16 will be centenarians, and 1 man and 1 woman, out of the 100,000, may remain to complete their one hundred and fourth year. For convenience of reference, these calculations are ar- ranged in the following table, which also contains a register showing the expectation of life :—i. e., the mean number of years which, at any given age, the members of a community, taken one with another, may expect to live. The mean dura- tion of life is found by adding the age to the expectation of life :—thus, the mean duration of a boy's life at five j-ears of age is 5 + 49-64=54-04. The probable duration of life is the age at which a given number of children born into the world will be reduced one half; so that there is an equal chance of their dying before or after that age. Thus out of 51,274 males and 48,726 females—a total of 100,000 new-born infants— about one-half of each sex will have died before completing the age of 45; so that the probable life-time of an infant at birth is 45 years. This table reads thus:—Of 100,000 births, 51,274 will be male children, and 48,726 females; of which number 85 369 will be alive at the end of one year, or 43,104 males and 42,265 females. So again, of the 100,000, one male and one female will live to the age of 104. To learn the expectation of life the table should be read as follows :—At birth a child's expectation of life is 41-10 years- if a boy, 40-19 years; if a girl, 42-18 years. Again, at the age of 40, a person's expectation of life is 27-14 years: hence the mean age to which persons who attain the age of 40 live i>, 10+27-14=67-14 years. AVERAGE DURATION OF LIFE. Life-Table for England. 33 Living. Males. Females. Expectation of Life. Age. Persons. Mates. 1 Females. 0 100,000 51,274 48,726 41-16 40-19 42-18 1 85,369 43,104 42,265 47-13 46-71 47-55 2 80,102 40,388 39,714 49-19 48-82 49.57 3 77,392 39,018 38,374 49-89 49-52 50-29 4 75,539 38.064 37.475 50-11 49-74 50-48 5 74,201 37,385 36,816 50 01 49-64 50.38 10 70,612 35,564 35,048 47-44 47-08 47-81 15 68,627 34,573 34,054 43-74 43-35 44-13 20 66,059 33,324 32,735 40-34 39-88 40-81 25 63,295 31,958 31,337 36-99 36-47 37-52 30 60,332 30,473 29,859 33-68 33-13 34.25 35 57,172 28,867 28,305 30-40 29-83 30-99 40 53,825 27,145 26,680 27-14 26-56 27.72 45 50,301 25,311 24,990 23-86 23-30 24-43 50 46,621 23,376 23.245 20-55 20-02 21-07 55 42,796 ' 21,355 21,441 17-16 16-68 17-63 60 37,996 18,808 19,188 14-00 13-59 14-40 65 31,852 15,589 16,263 11-20 10-86 11-52 70 ' 24,531 11,823 12,708 8-78 8-51 9-03 75 16,664 7,867 8,797 6-74 6-53 6-92 80 9,398 4,316 5,082 5-07 4-92 5-20 85 4,021 1,780 2,241 3-75 3-64 3-83 90 1,140 481 659 2-74 2-68 2-77 95 174 69 105 2-13 2-22 2-06 100 16 7 9 • • 104 2 1 1 With regard to the sex of children it may be interesting to the reader to learn, that although nothing positive is known, yet it seems very probable that the differentiation depends on the relative ages of the parents. The following table, by Mr. Sadler,* indicates the proportion in Great Britain of male births to 100 females, under the conditions mentioned in the first column :— Father younger than mother . Father and mother of equal age Father older by 1 to 6 years • « 6 to 11 " " 11 to 16 " " 16 and more • 86-5 94-8 103-7 126-7 147-7 163-2 * Law of Population. Vol. ii., p. 343. Quoted by Dr. Carpenter in The Principles of Human Physiology. 5th ed., p. 856. London, 1855. 34 CONDUCT OF WOMEN DURING PREGNANCY. Thus it seems that the more advanced age of the father has a very decided influence in occasioning a preponderance of male children; and this tallies with what we know to be the case, —for, as a rule, in this country the husband is older than the wife, and the proportion of births is about 106 males to 100 females. SECTION III.—THE CONDUCT OF WOMEN DURING PREGNANCY. 1. General Observations.—There are but few medical practitioners who are not occasionally consulted as to the care which women ought to take of themselves during pregnancy, with regard to their own and their infant's welfare; and it is, consequently, most desirable that we should be able and anxious to give a few sensible directions on the subject. However highly a woman may have been educated, she unfor- tunately finds, when she has no longer to live for herself alone, that her acquirements and accomplishments are but of small service to her; for although she may have gone through a long and expensive course of education, yet she has learnt little or nothing of the most important of her social duties. On consulting those friends and acquaintances of her own age, to whom she can speak unreservedly, she sees that they know but little more than herself; and hence it is often thought necessary to seek advice on this matter from some nurse or other time-worn dame, who, probably, has cer- tain absurd traditional precepts which she delights in promul- gating as immutable laws; as if she believed, with ancient Thomas Hearne, that " when laudable old customs alter, 'tis a sign learning dwindles."* Thus mischief is often caused not from any wilfulness on the part of mothers, but merely from ignorance of the injury they inflict upon their progeny bv carelessness and a disregard of a few common-sense rules as to regimen, &c. The grand rule for a woman to adopt on becoming pregnant *Reliquice Herniana, §c. Collected by Philip Bliss, Principal of St. Mary's Hall. Oxford, 1856. CONDUCT OF WOMEN DURING PREGNANCY. 35 is, to sustain her general health in its highest state of effi- ciency. This is to "be accomplished by attention to diet, clothing, cleanliness, exercise, and moral discipline. 2. The Diet.—This should be simple, light, nutritious and adapted to the requirements of the individual and the condi- tion of the digestive organs. Highly-seasoned or rich food is bad, tea and coffee should be used only in moderation, and alcoholic stimulants are—to say the least—generally un- necessary. It is often erroneously thought that an unusual supply of nourishment is required during pregnancy to support the strength and aid the development of the foetus : consequently, either an increased supply of food is taken, or a change is made from a plain and nourishing diet to full and generous living. Both of these errors are to be avoided: for they will surely either give rise to a state of plethora, as injurious to the mother as to the embryo; or will produce in the former, debility, dyspepsia, nausea, heartburn, &c, and in the latter constitutional feebleness, as of course, the results are the same to the infant, whether the insufficient nourish- ment results from want of food or from inability of the mother's stomach to digest it. Where the digestive powers are good, however, and eating is not followed by oppression or languor, there can be no harm in satisfying the appetite with such food as the patient may be accustomed to, and which she knows from experience agrees with her. A too spare diet is, on the other hand, no less injurious and reprehensible. Un- happily, however, it is less easily avoided; and many of the wives of the laboring classes not only suffer much themselves from their inability to procure a due supply of wholesome food, but, in consequence, give birth to feeble and unhealthy children, who ultimately perish from strumous or tuberculous disease. The craving and capricious appetite from which pregnant women often suffer, most frequently requires but a little self- denial to be controlled, and is. in no instance to be remedied by any excess in food or wine. So also with respect to 36 CONDUCT OF WOMEN DURING PREGNANCY. longings for unusual or extraordinary kinds of food, which should seldom be yielded to. Nothing, indeed, can be worse than pandering to these symptoms of a depraved digestion, and nothing is so likely to perpetuate them, to the risk of the mother and foetus. A gentle laxative—rhubarb and mag- nesia, castor-oil, or a seidlitz powder—with a few hours' abstinence, will often remove them. Alolent medicines, whether purgative or otherwise, are, of course, to be avoided during pregnancy; their exhibition being fraught with equal danger to both mother and child. 3. Clothing.—This should be warm and comfortable; especially avoiding tight bands, and the use of tightly-laced, stiff, unyielding corsets. The breasts and body particularly require to be secured from injurious compression, and the dress and under-garments should be so made that they may adapt themselves to the increasing size of these parts.* To attempt forcibly to compress the abdomen, while Nature is gradually enlarging it for the accommodation and develop- ment of the foetus, is not only most absurd, but dangerous; for the circulation of the blood being impeded, a liability is induced to disorder of the stomach and liver, to uterine haemorrhage and abortion, or to haemorrhoids. Delicate women, especially if they have long been accustomed to corsets, and if their abdominal muscles are relaxed, sometimes derive benefit and support from an elastic bandage or a broad flannel roller applied around the body; it must not be tight, how- ever. Where the circulation of the blood is languid, the lower extremities and feet will be ccld, and will require to be protected by warm stockings and thick boots. 4. cleanliness.—Cleanliness, so conducive to health at all * The origin of the word enciente may serve to remind us that the Roman ladies were wiser, in some matters at least, than many of our country women in the present day: for on the occurrence of pregnancy the tight girdle or cincture, which was at other times worn round the waist, was discontinued. Hence the pregnant woman was said to be incincta, or unbound. CONDUCT OF WOMEN DURING PREGNANCY. 37 times, is remarkably so during gestation. Few things will contribute more to the comfort of the pregnant woman than sponging and tepid bathing. A tepid bath repeated every morning, or every second morning, will soothe nervous excite- ment, ^prevent congestion of the viscera, and promote the healthy action of the skin : a flesh-brush or coarse towel should be used immediately afterwards. 5. Exercise.—One of the simplest means of averting dis- ease, and of contributing to an easy recovery after delivery, is exercise in the fresh air. Hence a walk—which is the best means of taking exercise—should be had daily during the whole period of pregnancy; taking heed, however, as the period of delivery approaches, that too much fatigue is not induced. If, in addition, a ride in an open carriage is desired, it will be useful. Biding on horseback, dancing, and other kinds of violent exertion are to be avoided; as are also late hours, and remaining long in bed in the morning. Care must also be taken that the bed-room is large and well-venti- lated, so that pure air may at all times be breathed. 6. Moral Discipline.—To insure mental and bodily health for her offspring, it is not only necessary that the future mother observes the external and physical laws of health, but she must also regulate her mental constitution, and her moral feelings and affections. Hence she should endeavor to be calm and cheerful, to subdue ill-regulated desires and way- ward fancies, to keep her mind engaged by invigorating occupation and attention to her ordinary social duties, and to look forward to her labor with hope and confidence. If oppressed by a feeling of despondency, or disheartened by an impression that her labor will end fatally, the practitioner should endeavor to correct any derangement of the bodily health which may be present; while, at the same time, he will hardly be exceeding his duty if he gently prompt his patient to put her trust in the fatherly love of Him, who " hath given men skill, that he might be honored in his marvellous works." The pregnant woman should also especially avoid 4 38 CONDUCT OF WOMEN DURING PREGNANCY. all strong mental emotion—as immoderate joy, grief, anger, despair—since the vital functions are much influenced thereby: and for the same reason she should eschew all exciting amuse- ments, as theatres, balls, &c. The children of such ladies in high life as enfeeble their health by late hours, hot and crowded rooms, and irregular diet, are more disposed to con- vulsive affections than the children of those who are regular in their mode of living, and who enjoy the calm tranquillity of a country life.* To show how strongly the happiness of the mother during pregnancy affects the infant, I may mention, that in the chief cities of Europe, the mean proportion of still-born children is one in every twenty-two births; the number being three times greater among illegitimate than among legitimate children.*}" Baron Percy relates, that after the siege of Landau, in 1793, of 92 children born in the district soon after, 16 died at the moment of birth, 33 languished for from eight to ten months and then died, 8 became idiotic and died before they reached the age of five years, and 2 were born with several of their bones fractured;- so that 59 children out of i)2 seems to have died owing to the mother's anxiety and misery, and the results upon her organization.J The philosopher Ilobbes is well known to have ascribed his own excessive timidity and nervous sensibility to the fear in which his mother lived before he was born, owing to the threatened invasion by the Spanish Armada; and which increased to such a pitch on the news of its actual approach, as to bring on premature labor.8 In like manner the constitutional nervousness, the want of "firm resolve," and the extreme aversion to the sight of a drawn sword, always shown by James I. of England was commonly attributed to the constant anxiety and apprehen- * North, On the Convulsions of Infants, p. 14. London, 182G. •j- Quetelet, Sur I'homme et le developpement de ses facultes. Vol i p. 121. Paris, 1835. J Dictionnaire des Sciences Medicates: article—Detonation. \ Dr. A. Combe. Opus cit., p. 24. CONDUCT OF WOMEN DURING PREGNANCY. 39 sion suffered by Mary during the period of gestation; as well as to the brutal murder of Rizzio having been perpetrated in her presence during the same period.* On the other hand, it is a well-known fact that almost all great men have had mothers remarkable for their mental endowments and activity; al- though too much importance must not be attributed to this circumstance, since, it may be said, such parents are precisely those who would pay the greatest attention to the education and early training of their offspring. From these remarks it must not be thought that I agree with those practitioners who regard many of the diseases and deformities of the foetus as due to the unsatisfied longings or the wayward imagination of the mother. The fables of mother-marks, defects of form, &c, are perhaps hardly worth alluding to; but it maybe mentioned, that Dr. William Hunter investigated this subject, at the Lying-in Hospital to which he was attached, and that in 2,000 cases there did not occur a single instance in which there was any coincidence between the fright, or accident, or longings of the mother, and the deformity of the child. There are certainly many curious cases recorded which I cannot venture to explain; but I believe that were all the circumstances known, the mystery would vanish. While writing these pages a case has been brought under my notice which, as it tends to confirm this opinion, may be related. An old patient inquired one day if I had ever seen an infant with two tongues; and as I replied in the negative, she undertook to show me one. Accordingly, in the following week, she sent her sister and child to me; when the former stated, that three or four months before her labor she went into a builder's yard, and was much alarmed by seeing a large dog with its tongue hanging out of its mouth. Some days after her confinement she looked in her child's mouth and saw that it had two tongues: she showed it to her medical man, and he confirmed her opinion. On * The character of this monarch is admirably portrayed by Sir Walter Scott in The Fortunes of Nigel. 40 PECULIARITIES OF THE INFANT STRUCTURE, ETC. examining for myself, I found that the sublingual gland, was well developed, as it often is in infants; and that this had been mistaken for a second tongue. What I wish, however, to impress on my readers is this: that as disease may mutilate or death destroy the child, while still within its mother's womb, so every precaution should be taken to maintain a parent's body in a state of health; and that, as the general condition of the mother's mind has an important influence upon the future mental and perhaps bodily health of her offspring, it consequently follows that all those about her should contribute as much as possible to her comfort'and cheerfulness. This is not to be done by foolish indulgence; but rather by forethought in a thousand little matters which individually may appear trivial; by good- natured equanimity, and by removing or smoothing all sources of care and anxiety. The nervous susceptibility during pregnancy is unusually acute, and hence a little tact and forbearance will be found necessary. SECTION IV.--PECULIARITIES OF THE INFANT STRUCTURE AND CONSTITUTION. In considering the peculiarities of structure and function by which the infant is characterized, and in treating subse- quently of the diseases of infancy and childhood, I shall regard the condition of infancy as extending from the time of birth until the end of the second year, when the first den- tition is generally completed: while the ago of childhood will be supposed to comprehend two epochs; the first, extending from the termination of the second year to the end of the seventh or eighth, the time at which the second dentition is terminated; and the second, reaching from the end of the first epoch to puberty, i. e., consisting of the period of life between about the eighth and fourteenth or fifteenth year, and which is commonly known as girlhood or boyhood. Hence adopting the old Aristotelian division of human life into three PECULIARITIES OF THE INFANT STRUCTURE, ETC. 41 stages—growth, maturity, and decline—we have the first com- prehended under the head of infancy and childhood. The complexity and completeness of man's body, the variety of its parts, the diversity of its functions, and the high facul- ties of sense and intellect with which it is crowned, have in all ages been themes on which writers have loved to dilate; and the ancient opinion, " that man was microcosmos, an abstract or model of the world," seems, on consideration, almost justified. However this may be, it is certainly no poetical fiction to regard the infant as the abstract of the man; for, on examining it at birth, we find that it possesses the same organs as the adult, though these differ in their anatomical structure, and are remarkable for their imperfect development; while the same processes of waste and restora- tion, of growth and decay, are continuously being carried on. The chief structural differences are these: the tissues generally are softer, much more vascular, and more loaded with fluid; the glandular, lymphatic, and capillary systems predominate; the skin and mucous membranes are very delicate, soft, and sensi- tive; the brain is large and vascular, though so soft as to be almost fluid; and there is excessive nervous excitability. The term of infancy being essentially the period of growth, the organs of alimentation are those which are the most fully developed, as they are those which are the most actively em- ployed ; indeed, it may be said that at this age the functions are confined almost exclusively to nutrition. As regards the general appearance of the new-born infant, it may be first remarked, that its length varies from about 16 inches to 22; the average, probably, being between 18 and 19, though Boederer states it to be 20£ inches.* The mean * M. Quetelet's interesting deductions as to the growth of human stature are as follows:—1. The growth is most rapid immediately after birth, amounting in the first year to nearly eight inches. 2. The growth diminishes as the child advances towards the fifth year; thus, during the second year the increase is only half what it was the first, while, during the third year, it is not more than one-third. 3. After 4* 42 PECULIARITIES OF THE INFANT STRUCTURE, ETC. weight is about Tibs, avoirdupois, or one-twentieth of that of the adult. Dr. William Hunter states, that of many thousand new-born perfect infants weighed at the British Hospital in London by Dr. Macaulay, the smallest was about 4 pounds, the largest 11 lbs. 2 oz., while the greater number varied from 5 to 8 lbs. The average weight of 26 children at the natural period, weighed by 1-oederer, was about 6i lbs.; the lightest 5 £ lbs., and the heaviest 8 lbs. The length of male slightly exceeds that of female children, while the difference in weight is estimated by Dr. Clarke at about 9 oz. avoirdupois. In the case of twins, the average weight of each twin is in general less than that of children born at single births, though the combined weight of both is greater. Dr. Clarke found that the average weight of 12 twins was 11 lbs. avoirdupois each pair; the heaviest being 13 lbs., and the lightest 8£ lbs.* The sldn is very vascular, sensitive, and delicate, and usually of a deep-red color; it is covered with an unctuous matter called vcrnix caseosa; and a few days after birth the cuticle desquamates. The limbs and'prominent po.rts of the body are well protected by fat and cellular tissue filled with serum; the tendons and ligaments are imperfect; and the muscles are soft and gelatinous. The bones ure small, chiefly cartilaginous, and deficient in earthy matter; those of the skull and ribs are the most advanced in ossification. The bones of the skull are united to each other by membrane, the sutures not havin<>- be- gun to form. The membranes cover six openings called fon- tanelles, which gradually close until about the fifth year when the bones are found united by suture. The long or cylindri- cal bones contain no distinct medullary cavity, but present in the fourth or fifth year, the stature increases pretty regularly__about two inches annually—until the age of sixteen. 4. After puberty the stature increases slightly—about one inch a year—until the a<*e of twenty-five, when it seems to be completed. The annual growth of the female is less than the male, and her development is completed earlier.—Cyclopaedia of Anatomy: article—Age. * Encyclopaedia Britannica. 8th edition: article—Anatomy. PECULIARITIES OF THE INFANT STRUCTURE, ETC. 43 their interior a soft or loose bony texture : the epiphyses are in the shape of grayish jelly-like matters beginning to present grains of bone. The period at which ossification is finished varies: the epiphyses are rarely firmly united with the osseous cylinder till between the 16th and 17th years. The lower extremities are less developed than the upper; the pelvis is small and looks contracted; the thorax small, flattened at its sides, but prominent in front; while the head and abdo- men are disproportionately large compared with the rest of the body and the size they attain in after life. There is generally some hair on the scalp. The digestive organs are perfectly adapted for producing rapid changes in the food introduced into them, and for thus af- fording a continued supply of the materials for nourishment and growth. The mouth, though apparently imperfect from the absence of teeth, is fully and admirably formed for extracting the food prepared by the mother and conveying it to the pharynx. The stomach is small, long, and somewhat re- sembles the large intestine in form; its anterior or lesser curvature being but slightly arched, while the larger curvature is scarcely developed—an arrangement which shows that this viscus is not suited for receiving much food at a time, or for retaining it for any period. The intestines are also relatively smaller and shorter than in the adult, and their peristaltic actions more rapid; so that all excrementitious matters are quickly got rid of, the infant generally having an evacuation every five or six hours. The mucous membrane of the whole of the alimentary canal is thick, soft, villous, vascular and freely bedewed with mucus: it is very sensitive, and readily irritated by improper food. The salivary glands, the pancreas, the lacteal vessels, and the mesenteric glands are largely developed; the-kidneys are large, and the supra-renal capsules of considerable size, but they soon diminish; the spleen is small. The liver at birth occupies almost one-third of the abdominal cavity, but becomes smaller—especially the left lobe__as the circulation is changed by the obliteration of the 44 PECULIARITIES OF THE INFANT STRUCTURE, ETC. umbilical vein and ductus venosus, and the development of the vena portae. The intestines contain a peculiar dark-colored substance, called meconium; which is the result of accumu- lated secretion. The rcqnratory organs undergo a more remarkable change directly the child is born than any of the other parts of the body ; the lungs, on being permeated by air, becoming in- creased in size, light and vesicular in structure, and of a deep- red color, in the place of being small, dense, and of a brownish color as they were in the foetal state. Occasionally it happens—when from any cause, the function of respiration is established with difficulty—that portions of the lungs re- main solid and unaerated: these portions are then said to be in a condition of atelectasis.* The respirations are quick and forcible, and during the first year range from 35 to 40 in the minute, being nearly double those of an adult; but as growth proceeds, as the infant's weakness is lessened, and as the vital processes are rendered less active, they gradually become slower. In infancy, too, the consumption of oxygen is smaller, and the power of generating animal heat—a function so closely connected with respiration—less, than at later periods. The thymus gland, so large in the foetus that it occupies a consid- erable space in the upper and anterior part of the thorax, soon begins to diminish after birth, though it remains of con- siderable size during the first year : in the adult it can scarcely be recognized. The organs of circulation present many re- markable peculiarities in the early stage of infancy. The volume of the heart is proportionably large; its parietes are softer and paler than in after life, and of nearly equal thick- ness throughout; and the left cavities are larger than the right, instead of the reverse, as they ultimately become. The foramen ovale and ductus arteriosus usually become oblit- erated, or nearly so, before or about the tenth day after birth -f *From atfy^c, imperfect, andtxtfaatj, expansion. The term was first applied by Dr. E. Jorg. | This patent condition of the foramen ovale and ductus arteriosus PECULIARITIES OF THE INFANT STRUCTURE, ETC. 45 after which the walls of the left ventricle quickly increase in thickness, and its cavity begins to diminish in size. The ac- tion of the heart is quick, varying from 120 to 140 beats in a minute. In examining the nervous system we find the brain large, soft, imperfect in structure, and about 10 oz. in weight—the adult averaging from 3i to 4 lbs. The convolutions are im- perfectly marked, as we should expect they would be, if we believe—as most physiologists do—that intelligence is in direct proportion to their extent; while the cineritious or cortical portion scarcely differs in color from the medullary. The meninges are more vascular than in the adult. The structure of the spinal cord and nerves is more perfect than that of the brain, these parts being devoted to the more primitive func- tions of sensation and voluntary motion. The organs of the external senses are all present at birth, and the nerves distributed to them are large. The eye seems fully developed, although for the first few days the child gives but little indication of visual sensation; the ear is imperfect, the new-born infant being probably deaf; the nose is small, and the nasal fossae are wanting; and the sense of touch is very imperfect. The larynx is very small, but increases in size as the infant begins to articulate when from six: to twelve months old: most children speak plainly when from two to three years of age. The genital organs are small, except the clitoris and nymphse of the female, which often appear dispro- portionately large; the evolution of the generative apparatus marks the age of puberty. SECTION V.--PECULIARITIES OF DISEASE IN INFANCY AND CHILDHOOD. During the tender periods of infancy and early childhood there not only exists a predisposition to disease, owing to the continues according to the researches of M. Florens, during eighteen months of extra-uterine life in the human species.—Histoire de la Dtcouverte de la Circulation du Sang, pp. 67, 69. Paris, 1854. 40 PECULIARITIES OF DISEASE weak organization of the system, and the ease with which impressions are made; but the maladies of this time of life arc severe and insidious in their nature, soon give rise to organic change, and run their course with a rapidity of action not seen in the adult. New symptoms, moreover, succeed each other very quickly, and complications soon arise. As might be expected, then, there is more sickness in infancy that at any other epoch. The activity of the vital powers generally, the quickness and force of the circulation, and the abundant way in which blood is supplied to the various tissues, accounts for many of the disorders assuming an inflammatory type, for the readiness with which serum or lymph is effused, and for the reactions being intense and dangerous; while the great sus- ceptibility of the nervous system causes all, even local, affec- tions, to be very severely felt by the whole system. Hence no indisposition in an infant is to be regarded as trifling. At the same time it is indisputable that this activity of the vascular and nervous systems confers an energetic reparative power upon the infant, and most materially aids it in recover- ing from some severe affections, which would often prove fatal to one more advanced in age. The skin and the mucous membranes of the respiratory organs and the digestive tube, being the principal surfaces upon which morbid impressions are received in the infant, are consequently those in which disease usually commences. It seldom, however, long remains confined to these tissues, but sooner or later is reflected upon other and often distant organs; thus either increasing the extent of morbid action, or changing its situation by gradually ceasing at the part where it arose, as it augments in severity in the tissue secondarily affected. In this manner diseases of the skin, alimentary canal, and respiratory organs reciprocally produce each other • and thus we may account for the coexistence and intimate relation between inflammation and irritation of the mucous membrane of the digestive canal, and an analogous state of disease in the brain and its membranes; or for the superven- IN INFANCY AND CHILDHOOD. 47 tion of the latter upon the former, as is often witnessed. The popular dread of the suppression of cutaneous eruptions giving rise to disease of internal organs, is founded upon the frequency with which metastasis is seen to occur in the dis- eases of children. We also find, in the mucous membranes especially, that when morbid action is once set up, it has a great tendency to spread rapidly along the whole of the af- fected tissue, unless promptly arrested by appropriate rem- edies. Thus, it is seldom that inflammations of. the fauces and pharynx are found not to extend some distance into the sesophagus, or more unfortunately into the larynx and trachea; or that the false membranes exuded in croup do not reach to the bronchial tubes. The same remarkable occurrence takes place in the gastro-intestinal mucous membrane; all inflammation of which exhibit a strong tendency to spread downward. The skin being very vascular, delicate, and excitable, is rendered liable to irritating and unsightly—if not dangerous —disease of various kinds, from the simplest rash to the most violent inflammation; and from causes, too, which at a later period would produce no morbid effect. Many of the cutane- ous affections of this period .depend upon a morbid state of the stomach, some are owing to a neglect of cleanliness, others are the result of irritations directly applied to the surface, while the most important—the eruptive fevers—are due to morbid poisons. Most of the exanthematous fevers, but especially measles, are, as a rule, confined to the periods of infancy and childhood, and for the most part occur only once during life. The mucous membrane of the larynx, trachea, and bronchial tubes is liable to inflammation of various grades, though general- ly of an acute character; thus laryngitis, pneumonia, and pleurisy are not unfrequent, while bronchitis and croup are perhaps, of all the severe affections of childhood, those which are most commonly met with. The gastro-intestinal mucous membrane is another common seat of disease at the time of life we are considering; a slight 4S PECULIARITIES OF DISEASE excess of food, or food of an improper nature, or vicissitudes of temperature, or damp or vitiated air, readily producing aphtha;, sickness, purging, flatulence, colic, and even acute or chronic inflammation. Not uncommonly the inflammation extends to the mesenteric glands, or these become affected from constitutional causes rendering the blood unhealthy; enlargement and disorganization of these glands, with great distension of the abdomen, and extreme general emaciation then result, producing the disease known as tabes mesenterica. Owing to the causes already mentioned, the circulation through the brain is readily deranged, and hence we have con- gestion, inflammation, hydrocephalus, and convulsions. Con- vulsive disorders arising from functional disturbance of the brain or spinal marrow are often the result of irritations trans- mitted from the digestive organs, and will only cease upon their removal. I have also known fatal convulsions or dan- gerous cerebral irritation excited by sudden alarm. Epilepsy and chorea occur during the latter periods of infancy and in childhood, rather than in the early months of life. The early extreme development of the lymphatic system causes it readily to become the seat of disease; and we find consequently, that enlargement and inflammation of the lym- phatic glands is not uncommon, that strumous affections show themselves in all their various forms, and that tuberculous affections of the lungs, brain and mesenteric and bronchial glands are rife. According to Sir llobert Carswell, tubercle in the brain is more frequent in young infants and children than at other periods of life, giving rise to acute hydrocepha- lus, with convulsions, paralysis, coma, &c. Infants have also been born with tubercular deposits in different organs of the body, especially in the lungs and brain, and occasionally—ac- cording to Lombard—in the pancreas. Diseases of the urinary organs are neither frequent nor severe, though a disordered state of the urine, or an increased secretion of it, may arise from derangement of the digestive organs, or from the irritation of teething. Incontinence of IN INFANCY AND CHILDHOOD. 49 urine—so often troublesome in childhood—may result from habit, or nervous irritability causing an augmented secretion, or irritations seated in the lower part of the intestines, or pre- ternatural irritability of the mucous membrane of the bladder, or from want of due control over the vesical sphincters. Most of the acute affections of infants and children—as well as the process of teething—are attended with more or less fever, which often assumes the remittent type, having exacer- bations towards the evening or during the night. Young children may also suffer from typhus and typhoid, or from in- termittent fevers, though it is certain that they are much less liable to these affections than adults; but, on the other hand, they are, as we have seen, very obnoxious to the eruptive fevers. The diseases of infancy, then, present many interesting and remarkable features, the peculiarities decreasing as age ad- vances. Thus, although cutaneous diseases are common dur- ing childhood, yet as the skin becomes less sensitive and irri- table, so it also becomes less liable to suffer from slight causes; furunculi, however, or circumscribed phlegmonous inflamma- tions of the skin are not uncommon up to puberty. So again, the mucous membranes readily suffer from inflammation dur- ing youth : while from the great development of the capillary system, and the tendency to hyperaemia and to irritation of the respiratory mucous membrane, there is a liability to hsemorrhages from the nose and lungs. Tubercular disease of the pulmonary organs is often developed during childhood; and scrofulous swellings and ulcerations of the superficial lymphatic glands are of common occurrence. Lastly, the brain, from the great activity of its functions is peculiarly ex- posed to disease as the child grows older; and hence severe headaches and general disturbance of the cerebral circulation are frequent. The direct causes of disease are nearly the same during in- fancy and childhood, as in the subsequent periods of life, though it must be remembered that they act upon the child 5 50 MEDICAL EXAMINATION with much greater severity than upon the adult. Errors in diet, impure air, inattention to cleanliness, intense heat, cold and damp, improper clothing, exposure to the contagion of morbid poisons, excitement of the nervous system from alarm or paroxysms of anger, the irritation of dentition, and the pre- sence of worms in the alimentary canal, together with acci- dents—as blows, falls, &c—are all fertile sources of mischief to the young. Many of the disorders that occur in early life may exist at birth; thus children are occasionally born af- fected with syphilis, small-pox, tuberculosis, scrofula, softening of portions of the stomach and bowels, inflammation of the different organs, &c.; or they may be born convalescent—but very weak—from some disease that has assailed them during intra-uterine life; or there may exist from birth a peculiar condition of the organism, predisposing it subsequently, from the action of slight causes, to a particular form or class of dixases. This condition of organism may exist in all the children of certain families, and would appear, in many cases, to be hereditary—the same diseases prevailing, for many generations, in the same family. * The chief causes of death in children under five years of age may be readily calculated from some valuable tables of fatal diseases, which are to be found in Mr. McCulloch's treatise, f This calculation shows that of 100,000 children born alive 9,112 die of zymotic diseases—such as small-pox, measles, scarlatina, hooping-cough, kc.—within the first five years of life; of convulsions, 4,031; of cephalitis and hydrocephalus, 3,242; of bronchitis, pleurisy, and pneumonia, 5,348; of tubercular consumption, 1,887; of mesenteric disease, 439; of teething, 1,554; of gastritis and enteritis, 863; while 338 are lost from violent deaths. SECTION VI.—THE MEDICAL EXAMINATION OF INFANTS AND CHILDREN. In no case, perhaps, does the practitioner so much stand in * Dr. D. F. Condie, On the Diseases of Children. Page 96. Phila. delphia, 1844. t Opus cit., p. 622. OF INFANTS AND CHILDREN. 51 need of a certain indescribable tact, as in investigating the disorders of childhood; since it is absolutely necessary, to insure success in treatment, that an early and correct diagnosis should be made, while the means of making this diagnosis are in many respects totally different to those which are practised in the diseases of adults. In the first place, it is by no means easy to understand a helpless infant, for his only language is a language of signs, 'which nothing but habit, experience, and patience will enable us to interpret; and in the second place, a sick child is not only peevish and restless, but as medical men, we see him under strange and unusual circumstances, and hence part of his condition at the time of the examination may arise from our alarming, or exciting, or fatiguing him. As Dr. West justly says:—"You cannot question your pa- tient, or if old enough to speak, still, through fear, or from comprehending you but imperfectly, he will probably give you an incorrect reply. You try to gather information from the expression of his countenance, but the child is fretful, and will not bear to be looked at; you endeavor to feel his pulse, he struggles in alarm; you try to auscultate his chest, and he breaks out into a violent fit of crying." * As in most critical positions, however, the difficulties are not insuperable : for by patience and good temper, by a quiet demeanor and a gentle voice, all may be made to go well, and we may accomplish everything that is desirable. One great point is to be careful not to alarm the patient, but on entering the room to be satisfied to gain quietly the previous history of the case from the mother or nurse; taking care to inquire especially into the character of former attacks of sickness, and whether any of the eruptive fevers have been passed through; the circumstances under which the present illness has come on; its early symptoms, and whether these appeared suddenly, or insidiously, or after exposure to contagion; the day of attack; and whether anything strange had been pre- * Lectures on the Diseases of Infancy and Childhood. 3rd ed., p. 2. London, 1854. 52 MEDICAL EXAMINATION OF INFANTS. viously noticed in the child's manners or appearance. Having obtained information on these topics, we inquire the child's sex and age, the nature of its food, and whether it has been weaned, the state of the bowels, together with the nature of the evacuations, and how and to what extent it sleeps; while at the same time, without appearing to do so, we ex- amine the expression of the eye and countenance, the attitude, ■ and the character of the inspirations and expirations, &c. By this time the little sufferer will have become somewhat accus- tomed to our presence, and we may advance to the bedside to examine it more closely. We shall now be able to ascertain if any inflammation exists about the eyes or nostrils, the tem- perature of the surface, whether the body is plump or wasted, and the condition of the skin with regard to dryness, color, and the presence of any rash or eruption ; while by gently applying the index finger over the back of the radial artery without grasping the child's arm, or by feeling the temporal artery, we may learn the nature and frequency of the pulse. The state of the scalp and fontanelles, the presence or absence of abdominal pain or tenderness on pressure, the existence of any hernia, the position of the limbs—whether motionless or tossed about, rigid or relaxed, whether the hands are clenched, the thumb turned in, or the toes bent downwards—may now be ascertained ; and by a little management auscultation may be quietly had recourse to. In practising auscultation, it is worthy of remembrance that immediate is generally to be preferred to mediate auscultation in these cases, since the pressure of the stethoscope frightens, if it does not hurt the child. In employing percussion, care must be taken not to strike too smartly, the variations in resonance being more readily appreciated by a gentle stroke • while it is almost unnecessary to add that mediate percussion must be used, that is to say, the blow must fall on the finger or on an ivory pleximeter, and not on the chest walls. To examine the throat, when deemed necessary, some such manoeuvre as that adapted by the celebrated Golis must be DIAGNOSIS AND PROGNOSIS OF DISEASES. 53 tried. While playing with the infant, pass the little finger between its jaws as far as the base of the tongue : an effort will be made as if to vomit, during which—having previously taken a proper position as regards the light—the physician may seize the opportunity of making the inspection. Lastly, the state of the tongue, the condition of the gums, and the number of the teeth, if any, remain to be ascertained; it being generally better to defer this to the last, since, as Dr. West teaches, it is usually the most grievous part of the med- ical visit. It only remains, before leaving the room, to examine the urine, if it can be obtained; the matters vomited, if any; and the evacuations from the bowels: and the practitioner will then be in .possession of all the materials necessary for forming his diagnosis., The value and import of the symptoms he has observed will be treated of in the next chapter. CHAPTEB II. THE DIAGNOSIS AND PROGNOSIS OF INFANTILE DISEASES. SECTION I.--INTRODUCTION. It is not unfrequently asserted in the way of reproach, that the profession of medieine is merely a conjectural art; and practitioners are reminded how certain of their predecessors have rejoiced at being able to retire from a harassing life, because they were weary of guessing. Allowing that the observation contains a certain modicum of truth, it is never- theless, quite clear that there must be a vast distinction between the conjecture of the scientific physician and that of the rash and ignorant empiric: for whereas the one either surmises by rule and by a slow process of reasoning for each 5* 54 DIAGNOSIS AND PROGNOSIS step of which he can show the why and the wherefore, or by a ready perception acquired only by extensive practice and study, so the other merely makes a haphazard guess which— to say the least—is as likely to be incorrect as correct. More- over, it may certainly be asserted that with regard to the diagnosis of disease in the present day, guess-work no longer prevails; inasmuch as we have the stethoscope, the microscope, and test-tube to aid the educated senses, and often alone to afford us the most trustworthy information. So, again, the knowledge which we now possess of the minute structure and functions of the various organs and tissues of the body, gives us immense advantages in rectifying morbid processes when they occur. As Bacon says :—" This variable composition of man's body hath made it an instrument easy to distemper, and therefore the poets did well to conjoin music and medi- cine in Apollo, because the office of medicine is but to tune this curious harp of man's body, and to reduce it to har- mony."* But not only are we intimately acquainted with the nature of the instrument we have t» keep in order, but we also study—more closely than our ancestors did—disease at the bed-side; and hence we are daily becoming better ac- quainted with the natural history—so to speak—of the latter while we are also learning the true value of remedies. In the following observations the reader must not expect to find more than certain general truths, derived from a scru- pulous and comprehensive survey of disease, briefly expressed • since the extent of my subject renders it imperative that my remarks be confined to succinct assertions, where probably vivid illustrations would be more easily impressed upon the mind. The chief sources from which we derive materials for the formation of our diagnosis and prognosis in the diseases of children, are—the countenance, the gestures and attitude the sleep, the cry, the mouth and breath, the general surface and * Advancement of Learning. Vol. i., p. 42. Bohn's edition. Lon- don, 1846. OF INFANTILE DISEASES. 55 temperature, the respiration, the circulation, and the dis- charges by vomiting and stool. Before examining these seriatim I would briefly offer the following suggestions:— 1. Epidemics vary much in their intensity, being occasionally very mild, and at other times severe. Hence, before forming a prognosis in the case of any zymotic disease, the character of the prevailing epidemic must be taken into consideration. 2. Diseases of the nervous system are very fatal to children, hydrocephalus being especially dangerous, and trismus nas- centium generally fatal. 3. A very guarded opinion should be given in those affections which are due to any hereditary predisposition, as well as in diseases occurring in scrofulous children, and in those disposed to tuberculosis. 4. The symptoms are often masked or complicated by the improper administration of purgatives or of soothing poisons. Some silly mothers, and many bad nurses, are fond of amateur doctoring; while, when they see the resulting mischief, they are not always disposed to confess their delinquencies. 5. Some hours before death a total remission of the symptoms not unfrequently occurs, especially in the cerebral diseases of children; consciousness being restored, and the countenance becoming brighter and more natural. The practitioner who mistakes this change, and gives a favorable opinion from it, will not be likely to increase his reputation. 6. Beware of giving up all hope in any instance, without great caution; for not only do young children often rally from the most severe disorders, but the attendants, regarding the case as hopeless, will cease to administer the remedies, or—as they occasionally say—"'to worry the poor dear." SECTION II.—THE COUNTENANCE. The infant's countenance offers to us one of the most in- teresting and intelligible pages in the book of Nature. In its calm we read the health and ease of all the organs amd functions : in its smile, happiness of body and mind. In its expressions of uneasiness or pain, we first discover the inva- 56 THE COUNTENANCE. sion of disorder or disease. Our attention will probably be first attracted by some undefined change, which it will require a strict- er observation to decipher and associate with its peculiar cause. Four principal indications—speaking roughly—are present- ed by the physiognomy. 1. In general uneasiness, excitement and fever, the whole expression of the countenance is altered: a flushed and heated condition, with occasional wrinkling of the features, being chiefly remarkable. 2. In affections of the brain and nervous system, the expression of the upper portion of the face—as the forehead, brows, and eyes—is especially changed; the forehead being contracted and heavy, the brows knit, and the eyes wild and vacant, or fixed and staring. 3. Morbid conditions of the organs of respiration or circulation affect the features of the middle of the face, the nostrils being rendered sharp and distended, while a dark circle surrounds the mouth and eyes. 4. In diseases of the abdominal viscera a peculiar expression is given to the cheeks, mouth and lips : the cheeks appearing sallow and sunken, the mouth retracted or drawn, and the lips colorless or brown. In acute affections of the brain or meninges, the face is generally flushed, turgid and hot, or the color is inter- mittent—the redness being fugitive and followed by pallor; the eyes are vacant or staring, or the upper eyelid cannot be raised, and the eye is half open, or there may be strabismus; in the early stage the pupil is contracted, but becomes dilated as the disease advances; the upper lip is drawn firmly over the gums, and is of a livid hue; and, at times, there are convulsions of all the features. The deformity produced by hydrocephalus can hardly be mistaken, the disproportion between the size of the cranium and face, with the raised and bulging forehead, at once attracting attention. Diseases of the organs of respiration, as laryngitis, bron- chitis, or pneumonia, produce a dusky-red, swollen appearance of the features; wide dilatation of the nostrils during each * Dr. Underwood's Treatise on the Diseases of Children. 10th ed., p. 106. London, 1846. THE COUNTENANCE. 57 inspiration, and strong contraction with each expiration; knitting of the eyebrows; and lavidity of the lips, which, moreover, are widely opened to facilitate respiration if the breathing be much oppressed. Should the disease assume a chronic form, the features will become emaciated, and present an appearance of decrepitude. The expression of countenance produced by disorders of the abdomen is mostly characteristic; it being difficult to mistake the cause of the peculiar peevish or fretful look, sharp features, sunken eyes, pallor, and dark colour of the lips and skin surrounding the mouth. In severe forms of gastro-intestinal inflammation the face rapidly becomes sallow and emaciated; the lips are stretched firmly over the gums, and are pale, dry, and cracked; the chin seems to project unusually; and the nose looks swollen. In chronic irritations of the bowels from worms the nose and upper lip are often tumid, and the conjunctiva is said to look pearl-like. In weakness and exhaustion from diarrhoea, or from loss of blood, &c, the face is alternately flushed and pale, hot and cold : while, in very extreme cases, the cheeks are pallid, cold, and glistening; the eyelids are half closed; the corneas covered with films of mucus; and the pupils are contracted. It only remains to remark that the countenance is of a yellow hue in icterus or jaundice ; livid, when the blood is improperly aerated ; and of a deep blue or purple in morbus cseruleus, in which affection a malformation of the heart allows of an admixture of the venous with the arterial blood. The lachrymation, redness of the eyes, and swelling of the eyelids, which precede the eruption of measles, will not be forgotten by one who has witnessed these premonitory symp- toms ; and the same statement applies to the brilliancy of the iris and extreme contraction of the pupil caused in the child by a small dose of opium. SECTION III.—GESTURES AND ATTITUDE. ' In infants old enough to be playful and easily amused when awake, the commencement of disease is frequently sig- 58 GESTURES AND ATTITUDE. nalized by their ceasing to be attracted by surrounding ob- jects, by their listlessness and dislike to any movement, and by the difficulty experienced in exciting their smiles or that peculiar cooing sound by which they express their satisfaction or delight when well. As indisposition creeps on, the infant begins to give evidence of its uneasiness by frequent startings and general restlessness : supposing that it has begun to sup- port itself—to hold up its head—its suddenly ceasing to do so, at the same time that it assumes the posture and movements of extreme languor, is clearly indicative of that muscular de- bility which so commonly precedes an attack of acute disease. If a child has arrived at the age of fifteen or eighteen months without being able to hold itself upright, we shall probably find it suffering from rachitis, as indicated by deformity of the thorax, incurvation of the spine, and weakness of the lower extremities. The pain of inflammatory affections often causes the infant to avoid all movement, or, in inflammation of any part of a limb, all motion of the affected member; so in severe abdominal irritation or inflammation the child lies quiet, with the knees bent and drawn upwards, twisting about, however, and uttering loud cries on the sudden accession of pain. An acute spasmodic pain induces immediate contraction of the whole of the muscles, and the infant starts in terror and sur- prise. In convulsions the head is drawn backwards, or one arm becomes rigid, or a leg is drawn upwards, and the child cries violently from pain and fear : at the same time the breath- ing may appear spasmodically affected, and it may be observed that the thumbs and fingers are drawn into the palms of the hands, while the toes are firmly flexed downwards. In great prostration from any cause the child lies motionless, or one side of its body may be paralyzed. There are a few particular gestures which point at once to the seat of the disease : " as the tongue speaketh to the ear, so the gesture speaketh to the eye." Thus, in inflammation ef the brain or its membranes, the hand is frequently raised to the head, attempts are made to tear off the cap, and a quick movement, as of striking the air, is performed, while the head SLEEP. 59 is rolled from side to side as it lies on the pillow: in dis- orders of the tongue or fauces, and during dentition, the child presses its fingers into the mouth, or seizes the nipple roughly and greedily, or rubs the gums with anything it can get hold of: in croup and other diseases producing difficulty of breath- ing it pulls at its larynx, tries to compress it laterally, and by its urgent cries till placed in a sitting posture, indicates the seat of suffering and its painful effect: while, in great prostra- tion from any cause, the hand wanders automatically over the bed, plucking at the counterpane, &c. Lastly, there are the convulsive movements of the muscles of the face so common during dentition, or when any irritation of the digestive canal exists : and the involuntary and tumultuous movements which betray chorea in the more advanced child. These, however, need no description. SECTION IV.--THE SLEEP. The sleep of the healthy infant is tranquil, deep, and pro- longed, its countenance at the time being calm and happy, its breathing slow and occasionally interrupted by deep inspira- tions or sighs, and its limbs relaxed; on awaking it is lively, and seeks the breast. In disease, on the contrary, the rest is disturbed and broken, the respiration is loud and labored, the brow is contracted or the mouth is drawn, there is grinding of the teeth or gums, sudden startings occur, and the child awakes either fretful and peevish, or—if frightened to cry and scream. For the first few weeks after birth infants pass much of their time in sleep, during which the skin is moist and the digestion energetic. As the system is slightly enfeebled during sleep, and the power of maintaining the animal heat lessened, care must be taken to shield them from draughts, cold, &c. Any irritation in the bowels or in the brain, or slight degrees of uneasiness or pain, lessen the ability to rest: there is also very frequently troublesome sleeplessness during convalescence from acute disorders. On the other hand, a 60 CRY. great deal of somnolency is often produced by overloading the stomach, by serious cerebral disease, and sometimes by den- tition. A strong indication of a tendency to convulsive dis- orders is evidenced by a rigid extension of the limbs, with a turning inwards of the great toes and thumbs during sleep. SECTION V.--THE CRY. The first indication which the infant gives of life is to cry, and the more loudly and freely that it does so the better; since it proves that the most important of the vital organs are well formed, and that the child is not deficient in health and vigor. After the first few hours of existence, however, the properly-nursed healthy infant cries but little ; the act of crying being, as it were, reserved to express pain, distress, or hunger. Violent paroxysms of crying are generally produced by great pain; and when prolonged, become injurious, causing congestion of the brain, and sometimes convulsions. In affections of the lungs—especially pneumonia—the cry is said to be laborious, or smothered, i. e., it is rather a groan than a cry: in croup it is hoarse and muffled, and attended by a peculiar ringing sound, or crowing inspiration : in oedematous angina—according to Billard—it is tremulous : in acute cerebral diseases there is sometimes a single, sharp, powerful cry, occurring at rather distant intervals, and which has been termed the hydrocephalic cry : and lastly, in most diseases of the stomach and intestinal tube %the cry is pro- longed and acute, or low and moaning if they have produced much exhaustion. In young children the cries are often accompanied by an abundant secretion of tears, but this is not the case with infants until about the third or fourth month ; since the functions of the lachrymal gland are not brought into play until this time. Hence when no tears are shed, we must consider whether this be due to the age of the little patient or to the functions of the lachrymal gland having been sus- pended by acute disease. M. Trousseau lays it down as an MOUTH AND BREATH. 01 aphorism, as little liable to exception as any aphorism of Hip- pocrates, that when a child sheds tears a favorable prognosis may be delivered, however menacing the symptoms; while on the contrary, when this is not the case in painful diseases, and especially if the eyes are dry and sunken in the orbits, great danger to life exists. The observation applies almost invariably to children under two years of*age, and particularly to those less than one, but may frequently be verified even until seven.* SECTION VI.—THE MQUTH AND BREATH. In health the mouth is moist and pale, the tongue smooth and partially covered with a layer of whitish mucus, the gums red, and the breath free from smell or having only the odor of the mother's milk. These conditions are altered by slight causes : the mouth then becomes hot, red, and dry; the tongue loaded with a white, curdy matter ; and the breath hot, sour, or acid. This is especially the case in fevers, in acute affections of any of the important viscera, in diseases of the alimentary canal, and in painful dentition. In severe cases of small-pox, scarlatina, measles, laryngitis, and croup, the tongue often swells, and becomes covered with a dark-brown fur. In scarlatina, the tongue is loaded with a thick white fur, through which enlarged and prominent papilla3 project;-but as the fur clears away, it becomes clean and preternaturally red, and of a strawberry appearance. Aphthae of the mouth, throat, and tongue, are common in infants ; they may be due to improper food, to impure air, to the irritation of dentition, or to more serious causes. The breath may be rendered foetid by most attacks of fever and by indigestion; it becomes positively foul only in gangrene of the gums or cheek, in gangrene of the lungs, or in severe ulcerations about the nose or throat. * Gazette des Hupitaux. No. 14. Paris, 1848. ' 6 6li GENERAL SURFACE AND TEMPERATURE. SECTION VII.—THE GENERAL SURFACE AND TEMPERATURE. In the healthy infant, the skin should be firm, elastic, and smooth, of a rosy-flesh color—neither too red nor too pale —moist and cool, and uniformly distended by soft sub- cutaneous areolar tissue and fat. Whenever it becomes hot and dry, or pale and flabby, or intensely red or yellow, we may be sure all is not right: moreover, the slightest eruption should attract attention, and, if it be contagious, the parents should be warned. A hot, harsh, dry skin is common to all febrile and acute diseases; a cold, moist one to constitutional feebleness, or to sclerema, or to disorders producing great prostration: in- creased redness is an indication of inflammation, or warns us to look for one of the eruptive fevers : a pale, doughy, or puffy condition, with emaciation, bids us take defensive measures against scrofula and tuberculosis: intense blueness may arise from any cause interfering with the oxygenation of the blood, or from cyanosis : yellowness, from some affec- tion of the liver : while a dirty, sallow hue may be pro- duced by diarrhoea, or any protracted disease of the abdominal viscera. The " tache meningitique, ou tache cerebrale," has been pointed out by M. Trousseau as a red mark or stain, easily produced by pressure upon the skin of hydrocephalic children. This mark is most readily made upon the face, neck, or chest; and though most common in cases of hydrocephalus, yet it has also been observed in congestion of the brain, pneumonia &c. Dr. Baines suggests that it is due to some altered rela- tion between the supply of nervous power to the capillaries and the circulation, allowing of a ready dilatation of the superficial vessels when any irritation is applied to the skin.* The temperature of the body often furnishes indications of disease, though it must be remembered that the heat proper to young children varies as much as their constitution, vital * Medical Times and Gazette. London, 6 December, 1856. RESPIRATION. 63 powers, &c. Speaking generally, however, it may be said that the normal temperature varies from 88° to 96° Fah.: and that when it is above 100° Fah., fever may be considered as existing; and when below 88°, some exhausting disease, as sclerema—hence termed by M. Boger, algide oedema. Ac- cording to M. Boger, pneumonia and typils fever are the diseases attended with the greatest rise of temperature. Thus, if the pulse and respiration be quickened, and the temperature raised to 106°, inflammation of the lungs may be diagnosed; while the same degree of heat, with a moderate pulse, is peculiar to typus. In peritonitis or enteritis the temperature is said seldom to reach 104°. Bigors do not occur in young children, not even when suffering from intermittent fevers. M. Bouchut states that he has observed the commencement of an attack of intermittent fever in several children under two years of age, and not one experienced shivering; the cold stage being only outwardly betrayed by a considerable paleness of the face, decoloration of the lips, and a manifest bluish tint beneath the nails.* SECTION VIII.—THE RESPIRATION. The new-born infant breathes instinctively, without method or regularity : when about two years of age, the respirations become more regular. The younger the child, the less the chest dilates during inspiration, and the more freely do the muscles of the abdominal wall and the diaphragm act; hence the respiration is said to be abdominal. The respiration is most tranquil during sleep, is repeated twenty to thirty times a minute, and the movements of inspiration and expiration succeed each other without effort. On awaking, the breathing is altered; for a time being calm and easy, then intermittent and hurried, and again free and tranquil. The chests of children at the breast are but slightly reso- nant on percussion: on auscultation, the respiratory bruit is * The Diseases of Children. Dr. P. H. Bird's Translation, p. 121. London, 1854. 64 CIRCULATION. heard, hard and feeble, owing probably to the incomplete dilatation of the air-cells. After this period, as the rarefac- tion of the pulmonary tissue becomes greater, the resonance increases ; while the respiratory murmur becomes sonorous and roaring—puerile respiration. All diseases of the glottis, larynx, and trachea are attended with difficult and noisy respiration; they are also accom- panied with cough, which is hoarse and spasmodic in inflam- mation of the glottis, ringing in laryngitis, and crowing in croup. In bronchitis, pleurisy, and commencing pneumonia, the breathing is merely hurried, the cough hacking and dry, and unaccompanied with expectoration : as the severity of the inflammation increases, however, the rapidity of the breathing becomes augmented, so that, in confirmed pneumonia, the respiration may be termed panting, from sixty to eighty inspirations being made in the minute. At the same time there is rapid dilatation and contraction of the nostrils, violent moist cough, and copious expectoration; the matters expectorated being generally swallowed, so that we are unable to aid the diagnosis by their examination. When the pain in pleurisy is acute the respiration has the peculiar character of being restrained, i. c, it is suddenly stopped at each effort by a kind of convulsive spasm. In peritonitis, also, the inspirations are short, jerking, and difficult, owing to the pain to which all movement of the abdominal muscles gives rise. As regards the value of auscultation in the pulmonary affections of children, I need only here mention that in many cases it is useless; while in all, much less reliance must be placed upon the signs derived from its practice than in the diseases of the adult. SECTION IX.--THE CIRCULATION. Authors who have paid attention to the frequency of the pulse in children at the breast have not all arrived at the DISCHARGES BY VOMITING AND STOOL. 65 same conclusions. Thus, Haller fixes the number of beats at 140 a minute; Soemmering, at 130 or 140 the first year, 120 the second, and 110 the third; Billard observed a minimum of 80, and a maximum of 180, in thirty-nine infants from one to ten days old; while M. Trousseau found a minimum of 96, and a maximum of 152, in children of from fifteen to thirty days. From a careful examination, however, of much that has been written upon this subject, I think I am justified in deducing the following observations:— 1. In young infants, no signs can be deduced from the fullness or hardness, the strength or weakness of the pulse, since generally these distinctions cannot even be recognized. 2. The pulsations are often irregular, without any disease being present. 3. They are very frequent, the normal quickness varying from 110 to 150 a minute; the mean number being 130. 4. They diminish gradually as the period of weaning ap- proaches, continuing to do so until adult age, when they are about 75. 5. Sex has no influence until the age of seven years, after which the female pulse becomes slightly quicker than that of the male. 6. Sleep lowers the frequency by about eighteen or twenty beats per minute. In estimating the value of the indications derived from the pulse it must be remembered that the heart's action is more variable in infancy than at any other period of existence, and that moral impressions quicken the pulsations as much as fever or inflammatory disease. SECTION X.—DISCHARGES BY VOMITING AND STOOL. Infants frequently vomit from mere repletion, a greater quantity of milk having been sucked than the stomach can 6* 60 URINE. digest. In such cases the milk is brought up unchanged, or partly coagulated. Any disturbance of the process of digestion will induce sickness. Bepeated vomiting, however, shows that the cause is more than temporary, and should be sought for. It may be due to improper food, to disease of the stomach or intes- tines, or to disease of the brain. Some of the eruptive fevers —especially scarlatina—are ushered in by vomiting; so is infantile cholera. The paroxysms of hooping-cough are fre- quently terminated by a fit of vomiting. As children usually swallow matters expectorated from the bronchial tubes, these expectorations are often ejected with the contents of the stomach. During the whole period of infancy and childhood the evacuations from the bowels are more frequent than in after life. Diarrhoea, however, is readily induced by any excess in the quantity of the nourishment, or by improper food, or by any irritation or inflammation of the alimentary canal, or by the irritation of dentition. The first stools after birth—the meconium—are of a dark- green or black color, very viscid, and have an odor resembling that of the perspiration. Subsequently they become of a light- brown or yellow hue, of a curdy consistence, and free from odor. Frothy, acid evacuations, of a pale-green color, indi- cate some disturbances of digestion : discharges of slimy mucus are common during dentition, or when worms are present in the intestines: thin, foetid, dark-brown stools signalize chronic diarrhoea: and, lastly, a dark-green color of the discharges generally indicates serious disease of the stomach or intestines. Constipation is not common in infancy. It may arise from the quality of the mother's milk, from the exhibition of sooth- ing syrups containing opium, or from some derangement of the liver preventing the free secretion of bile. SECTION XI.—THE URINE. The examination of the renal secretion not only affords but little information in the diagnosis of the disorders of the GENERAL REMARKS. 67 period of life under consideration, but it is obtained with such difficulty that nurses are seldom able to show a speci- men. Hence it is only necessary to mention that, in all febrile affections, it is scanty, high-colored, of high specific gravity, usually very acid, and often deposits a sediment; in intestinal irritation from worms, &c, and in cerebral dis- turbance, it is white and thick, and sometimes loaded with phosphates; in indigestion, and during dentition, it may be pale, limpid, and abundant; while after scarlatina—on the supervention of acute desquamative nephritis—it may be- come scanty, of a dark smoky color, and loaded with albumen. CHAPTEB III. INFANTILE THERAPEUTICS. SECTION I.--GENERAL REMARKS. The great aim and object of the physician being the relief of pain and suffering and the cure of disease, too much attention can hardly be paid to the nature and properties of the various agents with which he has to work. To form a correct estimate of many classes of medicines, however, is by no means an easy task; since in addition to the well-known fact that several worthless articles still encumber our materia medica, it is also undeniable that well-founded doubts are beginning to be enter- tained concerning the value of certain particular drugs which during many years have been deemed absolutely necessary for the relief of peculiar morbid conditions. For example, few practitioners even in the present day would think of treating pericarditis or iritis without mercury; yet more than ten years have elapsed since Dr. John Taylor's valuable contribu- tions to clinical medicine were published, in which it was clearly shown that the opinions then current on this subject 68 general remarks. required revision.* Thus of the several instances of disease on which this excellent physician founded his observations, four got well without any treatment; in twelve, ptyalism was not followed by any abatement of the pericarditis; in six, ptyalism was followed by pericarditis; in three by endocar- ditis; in two, by extensive pleurisy; in four, by pneumonia; in one, by erysipelas and laryngitis; in one, the pericarditis and pneumonia both increased in extent after ptyalism; while in only one instance was salivation followed speedily by relief, and in two or three by a gradual diminution. Again, Mr. Dixon asserts that in syphilitic iritis our chief reliance must be placed upon mercury; though he adds that the best cures are effected where the gums are not made tender in the slightest degree.f Yet a great authority, Dr. Mackenzie, tells us that in syphilitic inflammation of the iris the constitu- tion must be thoroughly mercurialized, and the gums made distinctly sore, since he has known many cases in which little effect was produced until pretty profuse salivation was estab- lished;! while Dr. Pereira states—speaking of the effects of this metal generally—that without salivation the curative influence is not usually observed.§ These contradictory statements on really essential points lead naturally to the supposition that mercury may not be necessary at all in the treatment of iritis, and prepare us to learn, without surprise that Dr. Henry W. Williams has cured sixty-four cases (of every degree of severity, including its idiopathic, traumatic rheumatic, and syphilitic varieties) without a dose of this agent; the treatment having chiefly consisted in sustaining the general system, in relieving pain by narcotics, and in keeping the pupil dilated by belladonna. || * Lancet, from 17 May, 1845 to 31 October, 1846. f The Practical Study of Diseases of the Eye, p. 137. London 1855 \ Diseases of the Eye. 4th ed., p. 547. London, 1854. \ Elements of Materia Medica. 3d ed. Vol. i. p. 824. London, 1849. || The Boston Medical and Surgical Journal. Vol. lv., pp. 49, 69 92. 1856. GENERAL REMARKS. 69 Owing to this want of correct knowledge as to the proper- ties and modus operandi of particular medicines, as well as on account of the extreme susceptibility of the young to most drugs, we must not only exercise great caution in prescribing, but must also closely watch the results produced. The follow- ing rules may be advantageously borne in mind :—1. That many of the diseases of early life may be arrested by very simple treatment, if promptly applied. 2. That drugs are frequently unnecessary, for articles of diet may often be made to serve as medicines. Moreover, drugs sometimes do great harm, e, g., purgatives in intestinal obstructions; hence the practitioner should learn when to abstain from ordering physic. 3. That a marked disposition exists in infants and children to be affected by medicines, especially by those which exert their influence on the nervous system, as by narcotics and irritating stimulants. 4. Those remedies only should be employed, the composition, effects, and modes of action of which are best known; while of those which are suitable, the least irritating and the most simple are to be chosen. 5. Bemember that the bulk of the remedy should be small, as the medicine must be given in the form of a liquid or powder. And 6. Make the dose as palatable as possible, not only from motives of kind- ness, but especially because the forcible administration of nauseous physic to the young often does great harm. In addition to attending to these points, the practitioner will not fail to pay due regard to the mode of accession, sup- posed cause, and the duration of the symptoms; to the general aspect, nutrition, vital power, and constitution of the little patient; to the conditions—air, temperature, &c.—by which the child is surrounded; and to the nature of the diseases pre- valent at the time. Moreover, while subsequently watching the progress of the disorder, he should be careful not to attri- bute too much of the improvement to the action of the reme- dy • for it may not have been administered, or its active ingre- dients may be so adulterated as to be useless, or it may not have been absorbed into the system, or the result may be due to the vis medicatrix naturae. 70 GENERAL REMARKS. No rule that will be applicable under all circumstances can be laid down as to the exact dose of a medicine which a child will require, compared with an adult, Still, although the proportion cannot be stated with arithmetical precision, we can form some general opinion on the subject, and the follow- ing table—a translation of that contained in the Pharmacopoeia of Guy's Hospital—though not to be implicitly followed, may serve as a valuable guide :— Maximum Dose. One Ounce—3j. One Drachm—3j. One Scruple—3j 1 Month 3 " 6 " !) " 1 Year 2 " 3 " 4 " f> " 6 " 7 " S " 10 " 12 " 13 " In " 18 " 20 " 21 " 5 ss. 5 ss. S ij. :•) ij. 5j. r, ij. 5 iiss. 3 iij. 5 iiiss. 3 ss. 5 ivss. 3 v. 5 vss. 3 vj. 5 visa. 5 vij. gj. gr. iij. iv. vj. vij- viij. x. xij. XV. xviij. XX. XXV. 5 ss. gr. xxxv. xl. xl. xlv. xlv. 1. 5j. gr. J. J- ij- U- i'j- iv. iv. v. vj. vij. viij. J) ss. gr. xij. xiv. XV. xvj. xvij. xviij. 9j- Lastly, the infant during its illness must be supported by suitable nourishment, given at short intervals. Should the breast milk be found too stimulating—as it has sometimes been said to be during fevers and some inflammatory diseases —it must be diluted with water, or exchanged for thin gruel arrowroot, or barley-water. On the contrary, in disorders of a lowering nature, and in convalescence from acute affections more nourishing food than usual may be wanted; and I have frequently seen the best results ensue from giving beef-tea or the yolk of an egg beaten up in milk, or even from a small quantity of port wine well diluted. Diluents and refrigerants as water or slops containing a small quantity of nutriment should be freely allowed in febrile disorders, and in most cases when the child eagerly desires cold drinks; they diminish CHANGE OF AIR. 71 the specific gravity of the blood, distend the blood corpuscles (Hewson,) augment the secretion of the kidneys, and promote exhalation by the skin and lungs. On the contrary, we withhold these fluids when it is necessary to increase the specific gravity of the liquor sanguinis, as in aneurism, when we wish to promote the coagulation of the blood; in diabetes, when it is desirable to repress excessive secretion; and in affections characterized by a watery condition of the blood (spaiKsmia, Simon,) as anaemia, morbus Brightii, &c. SECTION II.—CHANGE OP AIR. No practitioner in the present day will expect to cure disease in a close, over-crowded, or ill-ventilated apartment, since he knows that he will be looking for an impossibility. Fresh, cool air is of itself medicine; and we must take care that it is freely supplied to the sick child, whose room should seldom be heated beyond 65° Fah. Independently, however, of a pure atmosphere, we have a valuable remedy in change of air; protracted cases of infan- tile disease being frequently benefited even by mere removal from one room to another. This is especially true in fevers, chest affections, and abdominal diseases; while in affections of the head the good to be derived is more doubtful, always supposing that the room already occupied is quiet, free from damp, and well ventilated. One of the best remedies, perhaps, which we possess for diseases in which debility is the chief and fundamental character, is sea-air. This can hardly be wondered at when we compare the atmosphere of large towns with the pure invigorating air of the sea. Dr. Glover is of opinion that the latter, besides containing minute quantities of chlorine, bro- mine, and iodine, has also In its composition more oxygen and ozone than the air of inland districts.* Scrofulous chil- dren who remain unbenefited by all the drugs in the Pharma- copoeia, improve surprisingly from a residence on the coast; * On Mineral Waters, p. 36. London, 1857. 12 BATHS. and the same takes place in pale, irritable children, who, without being positively ill, are always languid and pining. In children between three and four years of age, and particularly between five and seven, threatened with hydro- cephalus or mesenteric disease, or disposed to glandular enlargements, or to membraneous inflammation—bronchitis, croup, gastric and intestinal irritation, &c.—Dr. Evanson recommends removal for the winter months to the genial climates of the South of France or Italy ; having himself seen such children pass the whole winter in those countries with- out one day's illness, whereas previously they had seldom been out of the sick-room. " The places on the Continent best suited as winter residences for children are Nice or Bome, but in the commencement of the season, Naples is equally eligible; and for those with whom a soft, but rather moist atmosphere is calculated to agree, Pau is a convenient place to select."* For feeble, delicate, and strumous children, the dry, invigora- ting air of Nice is the best; for such as are liable to acute inflammatory attacks, or to bronchial affections of a dry, irri- tating kind, or who have an excitable nervous system, the mild, soft, relaxing climate of Bome is to be preferred. In either case, a residence should be selected in a good quarter of the town, and the aspect of the rooms should be southerly. SECTION III.--BATHS. 1. The Warm Bath may often be employed with great advantage in the diseases of infants and children; for it will soothe irritation, subdue pain, lessen fever, promote perspira- tion, and induce sleep. The water should not be very hot 95° Fah. is a good temperature : about sixteen gallons will be required for an infant, thirty for a child three years old and forty at seven. The child should remain in the bath, with the water up to the chin, from five to fifteen minutes, accord- ing to its age; and should be quickly and carefully dried on * Maunsell and Evanson, On the Diseases of Children, p. 114. 5th ed. Dublin, 1847. BATHS. ry.o being taken out, and th^n put to bed. The forms of disease in which warm bathing is required are infantile convulsions, chronic cutaneous disorders, eruptive fevers in which the eruption is slow to come out or has receded, dropsy following scarlet fever, chronic inflammatory affections, infantile cholera, and some cases of continued fever. Immersion of the feet and legs in hot water, while ice or cold water is applied to the top of the head, often does good in inflammatory affec- tions of the brain and its membranes, and in convulsions. " In abdominal affections of a chronic character, as peritonitis, enteritis, protracted diarrhoea, &c, &c, we have seen," says Dr. Evanson, " the best effects from leaving children for hours together in a tepid bath, the temperature of which, as well as the time for remaining in, being regulated by the feelings of the patient. This practice is an imitation of the method so successfully pursued with some mineral baths on the Continent, and from which we have witnessed the happiest results. Warm bathing is similarly Tecommended in chronic pulmonary affections, particularly pneumonia, and its benefits are highly spoken of by some German writers, as Siefert, Horn, &c* The bath is to be used frequently in the day (at least twice;) the temperature of the water varying from 95° to 98°, that of the apartment not being below 65°; and the child is to be left in the bath as long as possible. The practice is doubtless worthy of imitation, but we have our- selves seen so much mischief done by the abuse of hot baths in pulmonary inflammations, that we confess to feeling some prejudice on the subject."f The warm bath will often, also, act beneficially as a cooling agent, in fever, pneumonia, &c, when the temperature of the body is higher than that of the water employed. A moment's consideration shows that this must be the case; since, as water is a good conductor of heat, * " Many children," says Horn, who has had most extensive oppor- tunities for observation, "whose cases seemed hopeless, have been indebted to this means for their life."— Ueber die Erlcenlniss und Heilung der Pneumonic t ®Pm cit-> P- 16°- 7 74 BATHS. it follows, that if the bath has a temperature of 96° and the patient's body of 104° or 106°, the latter must, on being immersed, rapidly part with heat to the former. 2. The Vapor Bath.—The effects of this bath are very similar to those of the hot-water bath, except, perhaps, that it is more derivative to the surface, more diaphoretic, and rather more lowering. It may be employed in chronic, scaly, cuta- neous affections; in rheumatism; and especially in that fatal disease of new-born children—sclerema, or induration of the skin and areolar tissue. In the latter case it must be promptly resorted to; and its application should be repeated every six or eight hours, until the skin becomes moist and soft, and until the tightness and hardness have disappeared. The heat of the vapor should be between 98° and 100°, and not above 105°. 3. Medicated Baths consist of water impregnated with v; rious substances, and are valuable and powerful therapeutic agents. In using them care must be taken that none of the water gets into the child's eyes, as severe irritation would often be caused. The warm artificial salt-water bath is a useful means of stimulating the functions of the skin, and im- parting tone and vigor to the system : hence it is employed in glandular enlargements, in the strumous diathesis where the cutaneous circulation is languid, and in some chronic skin diseases. It is made by adding—according as the age varies from one to seven—from half a pound to two pounds of com- mon salt to the water at a temperature of 90° or 92° : it should be used once a day for twenty minutes. Alkaline baths stimu- late the skin, promote the functions of absorption and secre- tion, and relieve spasm and convulsion. For infants and young children they may be made by adding from a quarter to half a pound of soft soap to the water; but for children above six years of age, and in cases where we wish to make a more powerful impression on the nervous system, from half an ounce to six drachms of the carbonate of soda or potash to each gallon of water will be required. Sulphureous baths— BATHS. 75 made by adding half a drachm of sulphuret of potassium to each gallon of water—are more powerfully stimulant and alterative than the preceding. Hence they are mostly used in obstinate skin diseases, as psoriasis and lepra; in scabies, when it is extensive; and in some nervous diseases, as chorea. In some forms of scrofula Iodine baths, repeated two or three times a week, are said to be valuable; they may be prepared in a wooden tub, by adding from eight to ten grains of iodine, and twenty to thirty grains of iodide of potassium—according to the age—to each gallon of water. Lastly, Ferruginous baths may be employed in children of a relaxed frame, where the internal use of tonics is objectionable. They can be promptly prepared by the addition of half an ounce of the tincture of the sesquichloride of iron, or two drachms of sulphate of iron, to every ten gallons of water. 4. The Cold Bath is a powerful stimulant and tonic of great efficacy, when judiciously used. It is indicated in delicate and strumous children, where there is weakness and languid absorption, without much irritability of the nervous system; and in the latter stages of convalescence from acute affections. No form of it is more efficacious than sea-bathing, especially when used in the middle of the day, during the summer months. We must, however, be careful not to pre- scribe it rashly, since it is by far too stimulating a remedy for infants, as well as for children prostrated by disease. . Moreover, when it is ordered, directions should be given to discontinue it, if it gives rise to much alarm, and unless a proper reaction—indicated by an agreeable feeling of warmth and refreshment—follows its use : since only harm can result if the child remain cold and shivering, fatigued and pros- trated, heavy and oppressed, for hours afterwards. Where, from any cause, bathing in the open sea is inapplicable, the use of the shower-bath will be found attended with many ad- vantages especially in children subject to nervous or con- vulsive affections. Only a small hand-bath, such as is made purposely for children, or a very large sponge need be used; 76 BATHS. the water at first must be tepid; and the body should be afterwards well rubbed with a piece of flannel, or a coarse towel. Cold sponging is a convenient and grateful method of mode- rating the excessive heat of simple fever, small-pox, scarlatina, &c; or of any disease—excepting, perhaps, pneumonia. It is, however, more likely to produce catarrh, and is less efficacious than the Shallow bath; which is a most valuable means of reducing fever in children and women, when the heat of the body is above the normal standard—i. e., above 96° or 98° Fah., as measured by the thermometer—and when it is not contra-indicated by any visceral inflammation, or by the presence of general perspiration, or by too great irritability of the nervous system.* The cold affusion so successfully practised by Dr. Currie in the treatment of typhus and since recom- mended by Dr. Armitage, is too powerful a remedy—as a general rule—for children. Still many German physicians, as Heim, Harder, and others, have attested its utility in the exanthemata, in typhus, in spasmodic croup, and in acute hydrocephalus, when other measures have failed. To practise it, the child is kept naked in an empty bath or tub, while a * " The Shallow Bath is a bath about six feet long, with a depth of water varying from five to twelve inches. The temperature of the water varies from G0° to 80° Fahr. In this the patient is placed in a sitting position, with the lower extremities consequently covered by the water. They are constantly rubbed by an assistant, while water from the bath is poured gently over the head and trunk from a pitcher. This operation is occasionally interrupted, and the trunk is well rubbed by an assistant, who wets his hands in the water of the bath. The patient is kept in the water a variable time, until he is sufficiently cooled, which must be decided by the physician, according to his ap- pearances during the bath. The immediate effect on the three great symptoms of fever—the temperature, frequency of pulse, and of re- spiration, is the same (they are diminished) as that observed after Currie's affusion, but this bath is not so stimulating, and the amount of stimulation can always be regulated, as the colder the water the greater the stimulus, and vice verta." Page 58. Hydropathy as ap. plied to Acute Diseases. By T. B. Armitage, M. D. London, 1852. BLOOD-LETTING. 77 pailful of water, at 40° or 50° Fah., is poured in a stream over the head and chest, from a height of one or two feet. "The affusion acts," says Dr. Armitage, in speaking of its use in adults, "as a stimulant to the nervous system, but differs from all internal stimulants in common use, by acting at the same time as a cooling agent, whereas they increase the heat and fever. It really is what the ancients would have called a true ' Excitans frigidum,' and is therefore applicable in all conditions of fever in which a stimulating method is indicated; while at the same time, it is desired to diminish the intensity of the fever."* SECTION IV.—BLOOD-LETTING. The abstraction of blood from the system acts in four prin- cipal ways:—1. It diminishes the quantity of blood in the system. 2. It impoverishes the blood by increasing its watery constituent, and diminishing its fibrin and globulin. 3. Loss of blood weakens the heart's action. And 4. It causes general debility, with mal-nutrition of the various viscera and tissues. The tolerance of blood-letting is admitted by all to be diminished in the very young, the old, and the feeble. We have only to consider its effects upon the very young; and, with regard to them I may at once assert, as the results of my own experience and all that I have witnessed in the practice of others, that not only do they bear bleeding badly, but that I believe abstraction of blood is very seldom neces. sary in the treatment of their diseases. Indeed, I ought to say that the only infantile diseases in which I have found it necessary to take away blood during the last ten years, have been a very few in which some obstruction to the due circula- tion of the blood has existed,—as in certain cardiac affec- tions : and, in three or four instances, to relieve the pain caused by mischief resulting from mechanical injury. When, however, I refer to authorities on these matters, and find full * Opus cit., p. 57. 7* 7S BLOOD-LETTING. directions given for opening one of tbe brachial veins, or one of the veins on the dorsum of the foot or back of the hand, or—these failing—instructions for getting blood from the jugular vein ; when I read that cupping may be advan- tageously practised on infants less than a month old, and that leeches may be applied, and their bites allowed to bleed until exhaustion—indicated by great pallor, stupor, or convulsions —ensues; and when I remember that the mere mention of the words meningitis, laryngitis, croup, pneumonia, peritonitis, &c, almost makes the practitioner instinctively feel for his lancet: I say, that when I consider these things, I am almost tempted to fear, either that my experience has been too small, to enable me to form a correct opinion ; or, that I may have been misled, owing to my patients having been chiefly amongst the poorer classes, and all of them residents in London.* However, as the opinion I have expressed is my deliberate and conscientious persuasion, I think it better only to make one or two brief remarks ; more especially as, in subsequently speaking of each disease, I shall show clearly the plan of treatment which I am in the habit of adopting, and shall also often allude to that which I find recommended in books. * Dr. Rush, in his "Defence of Blood-letting," makes the following statement:—"I could mention many more instances in which blood- letting has snatched from the grave children under three and four months old, by being used three to five times in the ordinary course of their acute diseases."—Medical Inquiries and Observations. Vol. iv. p. 300. Philadelphia, 1798. The late Dr. J. B. Beck—though much opposed to the copious bleedings recommended by Dr. Rush—says, "the physician who dis- cards this agent (blood-letting) understands but poorly his profession, or the duty which he owes his patients. The proper use of a remedy, however, is one thing, the abuse of it is another; and I must express the opinion, founded on no small observation, that it is frequently re- gortedto in children when it is unnecessary—when necessary, it is often carried too far—and that in its general use, there is frequently an absence of precision and care, which, in many cases, renders it a most dangerous remedy."—Infant Therapeutics. 2nd ed., p. 99. New York 1855. BLOOD-LETTING. 79 First, then, let me say, that no child should, under any cir- cumstances, be bled without the most anxious reflection; nor without a strong conviction than no other plan of treatment will be as efficacious; nor without remembering that, though the circulation in childhood may be active, yet at this period of life slight causes produce great results; and that children, when greatly lowered, rally with difficulty. Secondly, should it be determined that blood must be lost, I am convinced that leeches will effect all that can be re- quired. They should be applied over some part where pressure can be resorted to, and in the presence of the practi- tioner, who should not leave the house until the bleeding from the bites has ceased.* Where there is any difficulty in stopping the haemorrhage, the application of pressure, or of dry powdered starch, or of a small piece of glazed card, or of matico-leaf, or of the nitrate of silver, will generally suffice to do so : but these means failing, a fine needle should be passed under the bite, and a thin ligature twisted around it, much in the fashion adopted for the obliteration of varicose veins. Thirdly, in deciding upon the quantity of blood to be removed, the practitioner must not be led away by the idea that children suffering from acute disease bear the loss of blood well. Moreover, he must remember that all the strength which they may have at the commencement of an attack will be certainly required to carry them through it. Fourthly, during the first six weeks of life, the loss of about * " I have twice known children bled to death in this way in hospital practice, the nurses having labored under a common preju- dice among their craft, that leech-bites cannot bleed too much."—Dr. R. Christison's Dispensatory, p. 493. 2nd ed. Edinburg, 1848. "The loss of blood from a single leech-bite has caused the death of an in- fant."—ify;~>° Fah., being from 3° to 5° less than that of the adult; while the heat of infants born prematurely is still less. Supposing that the infant appears healthy and active, it may be forth- with washed, placing its body and extremities in a basin of warm water, while the head rests on the nurse's left arm; the white, unctuous, tenacious substance, denominated the vernix caseosa, being gently removed with a fine sponge. When any difficulty is experienced in removing this matter, it should be allowed to remain rather than use any force; for it will readily scale off in a day or two, or come away in subse- quent washings. If soap be used, that known as glycerine soap will be the least injurious. The washing being finished, the body is to be dried with a warm, soft napkin; and a little violet-powder—powdered starch scented—may then be lightly dusted over the surface, especially about the axil he, groins, knees, as the eyelashes are agglutinated together by this matter, the eyes cannot be opened without great pain until the parts are freely bathed with warm water. This secretion, moreover, with the inflammation causing it, produces great local irrita- tion ; a frequent discharge of tears, which drop over on the cheeks instead of being conducted along the edges of the lids to the puncta lachrymalia; and frequently numerous little ulcers at the roots of the eyelashes. Should the inflammation extend to the conjunctiva lining the lids, a sensation of rough- ness—as of sand in the eye—will be complained of; together with heat, redness, soreness, and intolerance of light. The general health always suffers; the functions of the skin and digestive organs are impaired; and there is often strumous enlargement of the lymphatic glands, tumid abdomen, &c. Inversion of the eyelashes—trichiasis; shortening of one or other eyelid, so that the eye cannot be completely covered__ lagophthalmos; excoriation of the edges of the lids—blear eyes —lippitudo; and obliteration of the Meibomian apertures may result from long-continued ophthalmia tarsi. Causes.—It often results, secondarily, from other forms of ophthalmia, from strumous inflammation of the conjunc- tiva, from affections of the eyes occurring during small-pox measles, &c. When primary, the common causes are cold damp, impure air, insufficient and improper food, and sexual excesses. Treatment.—The patient must be directed to bathe his eye- lids well with warm water, and to soften the concreted puru- 17* 198 DISEASES OF THE EYELIDS. lent matter with glycerine or some oleaginous material, before attempting to open the eyes in the morning; afterwards fomenting the parts with decoction of poppy capsules for half an hour or more. If the inflammation runs high, a bread-and- water poultice may be laid over the eyelids at night; the pal- pebral conjunctiva should be scarified; and astringent or emollient collyria frequently applied, according as either the discharge or the pain appears to predominate. The applica- tion of sulphate of copper to the edges of the lids often does good;, or the unguentum hydrargyri nitratis of the Pharma- copoeia, diluted with two or three parts of lard, may be used twice in the day. In employing ointments, great care must be taken to insure cleanliness; for a salve smeared over a dried purulent secretion does more harm than good. The oxide of zinc ointment, if carefally used at night, will tend to prevent the edges of the lids adhering in the morning. A cure will seldom be effected without attention to the general health. Quinine, steel, the mineral acids, and other tonics often do great good; cod-liver oil is frequently bene- ficial; alteratives, as iodide of potassium, or small doses of mercury, may be required; and purgatives must be used if necessary. The diet is to be regulated: nourishing food, capable of being easily digested, should be allowed; and a little wine or beer may be ordered. Moreover, warm clothing, warm bathing; exercise in the open air, and early and regular habits, will do much to hasten the cure. 7. Epiphora.—Epiphora consists of an over discharge of tears—excessive lachrymation—from some irritation or disease of the secreting lachrymal organs. It may arise from the pre- sence of some mechanical or chemical irritant, as a particle of dust, an inverted eyelash, the vapor of ammonia, &c; or it may be produced by some constitutional cause, as disordered diges- tion, intestinal worms, and such like ; or it may be a symptom of some other disease of the eye, as of strumous ophthalmia. Epiphora must not be confounded with Stillicidium lachry- marum, in which there is merely some incapability in the DISEASES OF THE CONJUNCTIVA. 199 excreting parts of the lachrymal organs to remove the tears and the mucus of the conjunctiva. The tears are very irritating; and when from any cause they run over the cheek for any length of time, they give rise to inflammation and excoriation. The practitioner must be sure, however, that the mischief is from the tears; for in a supposed case of this kind in Glasgow it was afterwards found that the deep lines of excoriation which ran down the child's cheeks were the effects of a deliberate application of sulphuric acid by the nurse.* Treatment.—Remove the cause, when possible. If the con- junctiva be very irritable, a drop or two of a solution of nitrate of silver (gr. ij.—iv. to 3j.,) Put in the eye once or twice a-day, will do good. Some cases are benefited by the vapor of warm water, impregnated with opium: a teaspoonful of laudanum is put into a cupful of boiling water, and the eye held over it. Small blisters on the temples are recommended by several surgeons. The diet must be regulated; tonics will often be needed; and purgatives should be employed to main- tain a healthy condition of the secretions and regular action of the bowels. section ii.—diseases of the conjunctiva. 1. Foreign Substances adherent to Conjunctiva.— Particles of dust or coal, small insects, the germs of grasses, &c, cause great annoyance- by "getting into the eye;" sensi- tive children especially, sometimes suffering severely from these slight causes. The foreign body will generally be found under the upper lid, on everting which over a probe it can readily be removed. Should a particle of lime fall into the eye, it may produce most extensive mischief unless speedily removed; and even a troublesome ulcer may then result. Where pain is ex- perienced after the removal of the irritating substance, it may be allayed by painting the eyebrows and lids with extract of belladonna, moistened with a little water; since this agent * Mackenzie. Opus cit., p. 106. 200 DISEASES OF THE CONJUNCTIVA. acts as an excellent anodyne on the branches of the fifth pair of nerves. 2. Catarrhal Ophthalmia.—This form of ophthalmia is generally regarded as the type of inflammation of the conjunc- tiva; the morbid action being almost—if not entirely—confined to the conjunctiva and Meibomian follicles. It is the most common of all the diseases of the eye in the adult: it occa- sionally occurs in children : and it usually affects both eyes, but one more severely than the other. Symptoms.—The eyelids are stiff, red, and slightly swollen; the eye is bloodshot; the natural secretion from the conjunc- tiva and Meibomian follicles is increased in quantity, and becomes puro-muculent; there is slight intolerance of light —photophobia; and an occasional discharge of tears gives temporary relief. The pain is slight; the patient complaining more of stiffness and dryness, and of a feeling of pricking or roughness—as if sand or broken glass were under the upper eyelid—than of acute suffering. This sensation arises from the presence of flakes of puriform mucus, and especially from the rubbing of the sensitive eyelids over the enlarged vessels of the sclerotic conjunctiva. These vessels are seen to be large, of a bright-scarlet color, and irregularly arranged; differing thus from the appearance of the vessels in sclerotitis, in which they 'are minute, of a pink hue, and disposed straight and regularly, like radii in a circle. The constitutional disturb- ance is slight; headache is complained of; and there is com- monly exacerbation of the symptoms towards night. Causes.—Exposure to cold and wet, vicissitudes of temper- ature, &c. Blows and injuries may also give rise to it. Oc- casionally, conjunctivitis appears to prevail epidemically; and probably the discharge is contagious. Treatment.—Catarrhal ophthalmia readily yields to treat- ment. The child is to be kept quiet, put on mild diet, and purged with a dose of calomel and jalap. Local astringent remedies then effect a cure : a large drop of a solution of ni- trate of silver (gr. iii.— iv. to gj. of distilled water)'is to be DISEASES OF THE CONJUNCTIVA. 201 allowed to fall into the eye about twice a-day. A. piece of lint, soaked in tepid water, may be kept applied over the eye; or a bread-and-water poultice, in a muslin bag, if found more agree- able ; or a fomentation of warm decoction of poppy capsules may be used if the pain is at all severe. 3. Ophthalmia of New-born Children.—When only a few days old, infants are liable to be affected with an inflam- mation of the conjunctiva, usually known as ophthalmia neo- natorum, or the purulent ophthalmia of infants. Symptoms.—About the third day after birth, it is noticed that the upper eyelid is slightly swollen, that the infant keeps the eyes closed, and that the lids are slightly gummed to- gether by inspissated muco-purulent matter. On separating the eyelids,* the conjunctiva lining them is found very vas- cular and tumid, and a drop of thick white fluid escapes. As the inflammation extends to the conjunctiva covering the eye- ball, the swelling of the lids increases; the lachrymal caruncle and semilunar fold are enlarged; there is chemosis; the dis- charge becomes more abundant and decidedly purulent; and the infant appears restless, fretful, unwilling to suck, and feeble. Hitherto the transparent parts of the eye have not been involved. At the end of eight or ten days, however, if * To examine an inflamed eye in a young child, some little skill and tact is required; together with gentleness, for the organ is deli- cate and highly sensitive. Mackenzie, Wharton Jones, Tyrrell, and others, recommend some such plan as the following:—The practi- tioner to seat himself on a chair, with a long towel laid across his knees. Opposite to him the nurse sits in such a way that when she lays the child in her lap, its head may be held between the knees of the surgeon. The hands and arms of the child being confined by the nurse, the surgeon dries the eyelids with a piece of soft linen, and then separates them by applying the point of the forefinger of one hand to the border of the upper eyelid, and the point of the thumb of the other hand to the border of the lower lid. The eyelids being opened, they are readily kept so during the examination, by the com- mand which the tips of the finger and thumb, resting against the edges of the orbit, have of their borders. If necessary, the lids may be easily everted, to learn the condition of the palpebral conjunctiva. 202 DISEASES OF THE CONJUNCTIVA. the case has been neglected or improperly treated, the cornea becomes the seat of ulceration or purulent infiltration; either of which processes, by extending rapidly, destroys the texture of the cornea, so that the iris becomes exposed, the humors bulge through the pupil, and the sight is completely lost. Both eyes commonly suffer; either at the same time, or within an interval of a few days. Causes.—There can be but little doubt that this disease may arise from inoculation of the conjunctiva by leucorrhoeal dis- charge during parturition; or that its worst forms may be due to the application of gonorrhceal virus in the same way. Hence, when called upon to attend a woman who may .be suffering from severe leucorrhcea or from gonorrhoea, we should take care frequently to use injections of tepid water, or of water containing a little carbonate of soda, during the first and second stages of labor; and should also direct the nurse to wash the infant's face freely with plain warm water directly it is separated from the mother. Sometimes the inflammation can only be attributed to ex- posure to cold air, or to a very bright light, or to the intrusion of soap or some such irritant into the eye. M. Trousseau states that when puerperal fevers are prevalent in hospitals, new-born infants are very liable to suffer from an ophthalmia which at first seems simply catarrhal, but which in three or four days ends in the perforation of the cornea.* The disease may be propagated to adults or children by the discharge, which is highly contagious. Prognosis.—If the disease is recent, and the cornea? free from ulceration or purulent infiltration, the sight may be saved. The signs of the disease yielding are, a diminution in the swelling of the lids, a lessening of the chemosis and redness of the conjunctiva, and a decrease of the quantity of the puru- lent discharge. If ulceration or infiltration of the cornea has occurred, the prognosis must depend on the extent of the mischief; for if * Gazette Medicate de Paris, p. 52. 24 Janvier, 1852. DISEASES OF THE CONJUNCTIVA. 203 the ulceration be extensive, or the infiltration complete, the cornea will be thrown off by ulceration or sloughing, and pro- trusion of the iris and humors will result. Treatment.—Great cleanliness must be enjoined : three or four times, at least, in the twenty-four hours, the eyelids are to be separated, the purulent discharge removed with a piece of sponge, and the edges to be washed with a weak solution of alum or of bichloride of mercury,—F. 99 or 100. After each cleansing, a solution of nitrate of silver (gr. ij.—gr. x. to 5J.) is to be applied by means of a camel's-hair pencil to the surface of the inflamed conjunctiva; a weak solution sufficing in all recent cases. To prevent agglutination of the eyelids, Dr. Mackenzie recommends the application of the red precipi- tate ointment along their edges, whenever the infant goes to sleep ; but probably the use of lard will be equally efficacious. The little patient's bowels are to be opened by castor oil, mag- nesia, or a few grains of grey powder and rhubarb; the breast only is to be allowed; and the nurse's diet should be regula- ted, by restricting the quantity of animal food, and forbidding . the use of wine, beer, or spirits. When this plan of treat- ment is adopted sufficiently early, a cure is usually effected in a few days. In some very few obstinate cases, perhaps, a blister behind the ear may be needed; or it may be advisable to administer small doses of calomel; or if there be great chemosis of the conjunctiva, free incisions may be made into it. Some practitioners also recommend the application of leeches; but I believe that anything like antiphlogistic treat- ment will only do harm. When the cornea is affected with ulceration, the treatment varies; it being then necessary to omit the use of the nitrate of silver, and to quickly get the eye under the influence of belladonna by painting the lids with the moistened extract, and by adding two grains of the sulphate of atropia to the corrosive sublimate collyrium,—F. 98. * The efficacy of this treatment depends, not upon its causing dilatation of the pupil, * Mackenzie. Opus cit., p. 471. 204 DISEASES OF THE CONJUNCTIVA. but upon the anodyne influence of the belladonna inducing a healing action in the cornea. At the same time, great benefit will result from -the administration of calomel and quinine,— F. 44 ; or if the child appear very depressed, from the employ- ment of quinine alone,—F. 08. When the active symptoms have completely ceased, the conjunctiva sometimes remains red and relaxed. This condi- tion can be usually overcome by the use of the vinum opii diluted with an equal part of water; one or two drops being employed at intervals of two or three days. 4. Conjunctivitis Aphthosa.—Aphthous or pustular ophthalmia is a frequent consequence of some cutaneous erup- tion, and especially of either of the exanthemata; that which follows small-pox being the most severe and dangerous. The conjunctiva becomes affected with one or more aphthous ulcera- tions, which form near the edge of the cornea : the symptoms are often slight, resembling those of catarrhal ophthalmia: and a cure is readily effected by an astringent eye-wash, one or two doses of purgative medicine, and a generous diet. 5. Conjunctivitis Phlyctenulosa.—Phlyctenular, or scrofulous, or strumous ophthalmia, is a disease of the con- junctiva and cornea, to which children are very liable; so much so, that it has been estimated that, of 100 cases of oph- thalmia occurring in children between one and eight and nine years of age, 90 will be examples of strumous conjunctivitis. This affection is often the first manifestation of a scrofulous taint, although it may occur in patients having no tendency to scrofula; it is very tedious and troublesome; it mostly occurs between the period of weaning and the eighth or tenth year; and it may affect one or both eyes, or it may pass from one to the other. Symptoms.—These are, for the most part, very character- istic; consisting chiefly of great intolerance of light, very slight redness, and phlyctenular which form at the edge of the cornea, and degenerate into small ulcerations. The excessive intolerance of light—photophobia—is most DISEASES OF THE CONJUNCTIVA. 205 distressing, and occasionally is the only. symptom present. The child cannot open his eyes in the ordinary daylight; the attempt to do so producing a gush of hot tears, and spasmodic contraction of the orbicularis palpebrarum. Consequently, he hides himself in a dark corner of the room, or sits with his head buried in his lap until the evening, when this symptom seems to remit. With all this suffering, the redness of the conjunctiva is very slight; sometimes a few enlarged vessels being visible, though frequently none are perceived. When the disease has existed some time, the palpebral conjunctiva is often found more vascular. The phlyctenulae or small pimples, which form on the surface of the eyeball, are most numerous at the edge of the cornea; they sometimes become absorbed, but usually suppurate, burst, and give rise to small ulcers. Darting pains in the eye occur at night, and cause distress; which is augmented by the irritating tears producing excoria- tion of the cheeks. In almost every case the general health is found affected; the digestive organs are disordered; the secretions are vitiated; and frequently other signs of scrofula—as enlarge- ment of the lymphatic glands, eruptions about the head, swelling of the upper lip, tabes mesenterica, &c.—may be detected. Causes.—The primary cause—as a rule—is a strumous constitution; the secondary, any circumstance which dete- riorates the general health, as deficient food, impure air, want of exercise, and insufficient clothing. The disorder may be excited and kept up by the irritation of teething, or by the exanthemata, or by irritants applied to the eye. Treatment.—The disease does not readily yield to treat- ment. In the first instance, the digestive organs are to be brought into a healthy condition by alteratives and mild laxatives; such as a few small doses of hydrargyrum cum creta, rhubarb, or calomel and scammony,—F. 4, 10, 11, 13, &c. An emetic of ipecacuanha or antimony—F. 24—is often useful in the early stage, when the skin is hot and the pulse 18 206 DISEASES OF THE SCLEROTIC AND CORNEA. quick. Tonics—especially quinine, in grain or half-grain doses thrice daily—then act most beneficially; their action being favored by good nourishing food, warm clothing, warm baths, and fresh air. Cod-liver oil is very efficacious; so are the different preparations of steel; and 1 have found a combination of iron, iodine, and quinine—in the form of a syrup—very valuable. As regards applications to the eye itself, it may be stated that astringents and caustics in the acute stage are very mischievous; but that sedatives, especially belladonna—F. 98 —give great relief. Steaming the eye with the vapor of hot water impregnated with belladonna or opium, and warm fomentations may be recommended. When the acute symp- toms have subsided, a drop of the vinum opii placed in the eye once daily often hastens the cure; or the employment of a solution of nitrate of silver (gr. ij. to gj.,) or of the red precipitate ointment—F. 88—has the same effect. Lastly, the child should not be allowed to lie in bed during the day; he should be taken out into the open air as often as the weather will permit; a broad hat, or a green or black shade should be worn; and when the practitioner wishes to examine the eye, he may judiciously save the patient much suffering by gently narcotizing him with the vapor of cholo- form or sulphuric aether. 6. Pterygium.—Pterygium consists of a thickened and elevated triangular portion of the conjunctiva; the base of the triangle being towards the caruncula lachrymalis, while the apex advances over the edge, or even as far as the middle of the cornea. It is probably sometimes caused by strumous, or other varieties of ophthalmia. Treatment.—Should the application of the vinum opii, or of the solid nitrate of silver, fail to effect a cure, the pterygium must be extirpated. SECTION III.—DISEASES OF THE SCLEROTIC AND CORNEA. 1. Sclerotitis Idiopathica.—Sclerotitis, or rheumatic ophthalmia may be defined as an inflammation of the sclerotic, DISEASES OF THE SCLEROTIC AND CORNEA. 207 or fibrous tissue of the eye excited by cold. As, however, it is a disease of the middle period of life, probably never occurring in children, it need not be described in these pages; and the same remark applies to— 2. Catarrho-Bheumatic Ophthalmia—or inflammation of both the sclerotic and conjunctiva—which is a severe disease, characterized by a combination of the symptoms of conjunctivitis and sclerotitis. It may here be mentioned that, though ophthalmic surgeons speak of conjunctivitis, scle- rotitis, corneitis, &c, it must not be supposed that the inflam- mation is confined to the particular texture indicated by these names; but merely that the morbid action has its origin and chief seat in these parts, while all the neighboring tissues are more or less invovled. 3. Scrofulous Corneitis.—The cornea often suffers in the affections previously noticed. Keratitis scrofulosa, or scrofulous inflammation of the cornea, is however, a pecu- liar chronic disease, lasting for months, or even years; occurring chiefly in strumous subjects between the ages of eight and eighteen; and commencing in the conjunctival layer -of the cornea, but gradually extending to the deeper tifJatK •i&ymptoms.—The prominent symptoms are—slight sclerotic redness, most apparent in that part of the tissue immediately surrounding the cornea; dilatation of the pupil; haziness or trifling opacity, and more convexity than natural of the cornea; tenderness of the whole globe; and lachrymation, with photophobia. The change of figure in the cornea is due to an increased secretion of the aqueous humor—hydroph- thalmia. The constitutional disturbance is slight; but gene- rally feverishness, loss of appetite, and headache, are not un- commonly complained of. Treatment.—This must be much the same as that recom- mended in phlyctenular ophthalmia. I have seen the best results from the long-continued use of the iodide of potassium, sarsaparilla, and cod-liver oil; with warm anodyne fomenta- 208 DISEASES OF THE IRIS. tions locally. Quinine and iron are also very valuable remedies in this affection, particularly where there is much debility. When the inflammation has been quite arrested, the clearing of the cornea will, perhaps-, bo promoted by the employment of the bichloride of mercury collyrium,—F. 98 or 100. In cases where an ulcer has formed upon the cornea, without going on to perforation, we must endeavor to heal it by the administration of tonics with good nourishing food; whilst the local application of a drop of olive oil twice daily will at least prove a soothing remedy. section iv.—diseases of the iris. 1. Iritis.—Inflammation of the iris is such an interesting disease to the physician and to the pathologist, that a brief account of it will hardly be deemed out of place; though it must, fortunately, be allowed that it is a very rare affection in childhood. Suspended—like a curtain with a circular aperture near its centre—between the cornea and crystalline lens, and bathed on both sides by the aqueous humor, the iris serves to regulate the quantity of light admitted to the retina. By it, the cavity containing the aqueous hu^c m is divided into an anterior and a posterior chamber, lirihig which is a serous membrane, forming a shut sac analogous to the peritoneum; consequently, in iritis, the inflammation is similar to that of other serous membranes; that is to say, is of the adhesive kind—is attended with the formation of coagulable lymp. It must not be thought that in iritis the iris only is affected. This is indeed the focus of the abnormal action; but the retina, the membrane of the aqueous humor, the crystalline capsule, the sclerotic, .and the conjunctiva, are involved. Diagnosis.—Now, from whatever cause iritis may arise, its principal symptoms are the same. They are thus clearly enumerated by Dr. Mackenzie:—1. Zonular sclerotitis; fine hair-like vessels, running in radii towards the edge of the DISEASES OF THE IRIS. 209 cornea. 2. Discoloration of the iris. If naturally blue, it becomes greenish ; if dark colored, reddish. This is the result of increased vascularity, or of effusion of lymph into its sub- stance or on its posterior surface. 3. Contraction, irregularity, and immobility of the pupil. 4. Effusion of coagulable lymph into the pupil and posterior chamber, and occasionally into the anterior. 5. Adhesions of the iris, apd especially of its pupillary edge, to the capsule of the lens; in some rare case, to the cornea. 6. Tubercles, pustules, or small abscesses of the iris. 7. Opacity of the lens or its capsule. 8. Dimness of sight, and sometimes total blindness. 9. Pain in the eye of a pulsatory character, and nocturnal circum- orbital pain. The practitioner is not to suppose that in every case all these symptoms will be met with; but rather, that a certain number of them will be found sufficient to render the diagnosis certain. The constitutional disturbance is well marked, though it is not generally very severe. If the inflammation be not checked, it creeps on, involves the choroid coat and retina, and spoiling the delicate texture of the latter, destroys the sight for ever. Causes.—The causes of this affection are :—injuries and wounds, producing traumatic iritis; exposure to cold and wet, giving rise to rheumatic or idiopathic iritis; syphilis and gonorrhoea, causing syphilitic iritis; and certain conditions of the constitution, especially the scrofulous, inducing strumous iritis. Iritis arising as one of the secondary effects of syphilis, though rare, is perhaps the most common form of this disease in-the young; it may be accompanied with the other effects of constitutional syphilis, such as copper-colored eruptions, wast- ing, tenderness of the limbs, and aphthous ulcerations about the mouth and fauces. Without laying too much stress upon the local peculiarities of syphilitic iritis, it may be mentioned that, at first, the redness is much less severe than in the rheu- matic form; that the iris often assumes a rusty color, especial- ly near its pupillary edge; and that the pupil is occasionally 18* 210 DISEASES OF THE IRIS. apt to be displaced, to be drawn upwards towards the root of the nose. Lastly, Dr. Taylor has related the history of an in- teresting example of iritis in an infant, which he believed to be due to the irritation of teething.* Treatment.—Mercury, blood-letting, and belladonna are the three supports on which we are taught to rely; and so strong- ly have these remedies been recommended, that it will be dif- ficult to persuade many practitioners of their inutility. But that the first two agents may be often advantageously dis- pensed with is, I think, proved by the sixty-four cases of Dr. W. H. Williams; all of which were cured by sustaining the general health, relieving pain with narcotics, and keeping the pupil dilated by belladonna, "f" Hence, I would advise that in the treatment of inflamma- tion of the iris the patient be kept very quiet in a darkened room; that hot fomentations, with poppy capsules, be applied; that the bowels be kept regular by mercurial purgatives, or enemata; that small doses of opium be given to relieve the pain ; and that the diet be plain but nourishing, and free from stimulants. If there be depression, ammonia and bark, or quinine, may be advantageously given. In infantile syphili- tic iritis I would also recommend the iodide of potassium. Moreover, during the treatment, from the commencement to the termination, it is generally advised that the pupil be kept dilated, in order to prevent the iris from forming adhesions with the capsule of the crystalline lens. This may be done by belladonna, or by a solution of atropine—F. 99. No as- tringent or other collyria should be employed. Oil of turpentine has long been recommended in iritis where the use of mercury is contra-indicated. Mr. Guthrie speaks favorably of its effects in some few instances in which he employed it in adults. Should the practitioner be unwill- ing to trust too much to Nature, he can try its effects. 2. Congenital Imperfections of the Iris.—A congeni- * Medical Times and Gazette, 6 March, 1852. t See Chapter III., Section I. CONGENITAL CATARACT. 211. tal malformation which sometimes occurs is an incomplete formation of the iris, or even a total absence—occasionally spoken of as Irideremia—of this membrane. Children thus unfortunately formed are painfully impressed by the too great influx of light into the eye; and consequently they depress their eyebrows, and keep the eyelids half closed. When the child becomes old enough, the suffering may be partly ameliorated by wearing a dark plate, with a small aper- ture in it, in front of the eye; thus forming a rude kind of artificial iris. In Albinos there is a deficiency of black pigment in the choroid and uvea; this deficiency imparting a pink hue to the pupil and iris, and causing the affected person to suffer from intolerance of light. SECTION V.—CONGENITAL CATARACT. The infant may be born with cataract—opacity of the crys- talline lens or its capsule. Occasionally, a few days after birth, an attack of ophthalmia is experienced; on the subsi- dence of which, cataract is discovered. In such cases it can- not be positively determined, from the want of previous ex- amination, whether the opacity existed at birth, or came on during the inflammation. Both eyes are usually affected. Congenital cataract appears to be generally owing to an original imperfect formation of the crystalline lens : some- times several children in the same family are born with it. When opacity involves the whole lens, the eye should be operated on before teething commences. The reasons for the early performance of the operation are thus stated by Mr. Wharton Jones :—" As the infant cannot see, its eyes are not fixed on objects, but roll about in a heedless manner. This being allowed to go on the infant loses command over the eyes, or, rather, does not acquire command over them; and even if sight be afterwards restored by an operation, the power of directing the eyes properly and steadily towards objects may never be fully gained. It is also to be observed 212 AMAUROSIS. that good sight is more likely to be restored by an early operation. Moreover, the important opportunity of education of and by the sight is secured.''* The operation usually performed at this period of life is that known as Division. The effect of this proceeding is to divide the cataract into fragments; which, becoming dissolved in the aqueous humor, disappear by absorption. SECTION VI.—AMAUROSIS. General Description.—The term amaurosis—from d^owpou, to obscure or darken—is used to express partial or complete loss of vision arising from defective sensibility of the optic nerve. The transparent tissues and humors of the eye may all be healthy, but the nervous matter which should receive and convey impressions, and render them perceptible to the mind is affected. As Dr. Mackenzie says, if the retina be incapable of receiving with correctness impressions of ex- ternal objects through the medium of light, if the optic nerve be unable to convey to the sensorium the impressions made upon the retina, or if the brain be incapable of receiving the impressions conveyed by the optic nerve, the indvidual must be affected with an obscurity in vision, or suffer a total deprivation of sight, according to the degree of inability in these several parts to execute their functions. Even when he goes no further than this, the pathologist must see the necessity of distinguishing different cases of amaurosis according as the retina, the optic nerve, or the brain, is the part first and principally affected. Now the affections of either of these three parts which may cause amaurosis are pressure and structural change, such as inflammation, suppu- ration, induration, ramollissement, hypertrophy, atrophy, &c. "In children," remarks Mr. Dixon, "the occurrence of Tubercle in the brain would suggest itself as a probable cause of blindness coming on without apparent disease in the eyes themselves. The occurrence of fits or paralysis would * Defects of Sight, $c, p. 121. London, 1856. AMAUROSIS. 213 strengthen the suspicion; although blindness may, for a long time, be the only manifestation of such cerebral affection. During the progress of Hydrocephalus, loss of sight inva- riably takes place; and in the later stages of the disease, the pupils become dilated to their fullest extent, and quite immovable."* It must also be remembered that slight structural changes are probably sometimes produced by remote causes. Thus, amaurosis may arise from the presence of worms in the intestines; the intestinal irritation being sufficient, in an extreme case, to excite a morbid condition of some part of the optic apparatus. So, again, the irritation of teething may produce temporary amaurosis in the same manner. Symptoms.—In examining an amaurotic patient, the first points that attract attention are his gait and expression of countenance. He walks with an air of uncertainty; and his eyes, instead of being directed towards surrounding objects, have an unmeaning look—appear to be staring at nothing. In complete amaurosis, the movements of the iris are slug- gish and the pupil is dilated; in total blindness, the pupil is greatly dilated and the iris immovable. When both eyes are affected, they are often unnaturally prominent and of an unhealthy color; the sclerotica being frequently of a yel- lowish hue, and covered with varicose vessels. In the commencement, the failure of sight is only expe- rienced occasionally, as after long-continued exertion of the eyes, reading by candlelight, &c. Sometimes it begins with indistinct vision, or amblyopia; or objects appear double, diplopia ; or only one-half of an object may be seen, hemiopia. At the same time there is frequently headache, and occular spectra become visible; the patient complaining of black specks or flies floating in the air—muscce volitantes—or of flashes and scintillations of light—photopsia. Treatment.—It is difficult to lay down rules for the treat- ment of this disease, for since the causes upon which it * The Practical Study of Diseases of the Eye, p. 186. London 1855. 214 ENCEPHALOID FUNGUS OF THE EYEBALL. depends are various and opposite, so, consequently, are the means of cure numerous and unsatisfactory. In all instances, however, attention must be first directed to the general health. Each case is then to be studied in all its bearings, especially with reference to the cause of the affection. When it manifestly results from inflammation, mercury, or iodide of potassium will be necessary ; when from vascular exhaustion or nervous debility, the preparations of iron, cinchona, good diet, sea air, and tepid or cold bathing are indicated; when from the presence of intestinal worms, anthelmintics are to be resorted to; and when, from the irritation of teething, sedatives, lancing the gums, and gentle stimulants, will often effect a cure. Children sometimes feign amaurosis to escape from school, &c. The assumed disease may be detected by the history, by not showing any suspicion of the imposition, and by practising a little artifice when the patient is off his guard—such as sud- denly directing his attention to something curious in the room. SECTION VII.--ENCEPHALOID FUNGUS OF THE EYEBALL. Encephaloid fungus of the eyeball—soft cancer—or fungus haematodes, occurs more frequently in early childhood than at any other period of life. It has its origin generally in the retina; though it has often been found to arise in the optic nerve before its entrance into the eye, as well as in every tissue of the eyeball, except the lens and cornea. Symptoms.—In encephaloid originating in the retina, three stages are usually recognized. In the first, the eyeball is of its natural size and general appearance, except that the pupil is more or less dilated, and through it a brilliant reflection from the bottom of the eye can be seen. In the second, the diseased growth, though still confined within the tunics, has advanced towards the anterior part of the eyeball, which has become bloodshot, and more or less enlarged and misshapen from distension. In the third stage the tunics have given way and the tumor protrudes in the form of a fungus. STRABISMUS. 215 Diagnosis.—In the early stage the diagnosis between en- cephaloid fungus of the eyeball and scrofulus deposit within the globe is very difficult; and in the majority of instances it is almost impossible to give a correct opinion upon the nature of the case until the globe bursts and the contents escape. We -then find—if the affection be scrofulous—that a chronic discharge takes place from the opening, until the tissues gradually collapse and form a small shrunken mass. But in encephaloid disease, a vascular fungoid growth soon sprouts out, which grows rapidly, and speedily assumes all the characters of an ulcerated cancer. Treatment.—Very mild alterative courses of mercury, espe- cially of the bichloride; bark and cod-liver oil; sedatives, with anodyne applications locally; and careful regulation of the bowels, regimen, and diet, constitute the only treatment which experience shows is admissible. Extirpation has been so generally unsuccessful that, according to Mr. Wharton Jones, little is to be hoped from such an operation.* SECTION VIII.—STRABISMUS. Strabismus, or squint, is a deformity, consisting in a mal- direction of one or both eyes, or a want of power to move them together harmoniously, so that their axes shall always be directed at the same time to the same point.-j" The chief forms of squint are the convergent or inward, and the divergent or outward; single convergent strabismus being by far the most common. Symptoms.—If an individual affected with strabismus con- vergens be directed to look at an object placed at some little distance in front of him, the squinting eye will be turned in- wards towards the nose, while only the sound eye is directed to the object; and however the position of the object may be * Ophthalmic Medicine and Surgery, p. 216. 2nd ed. London, 1835. | For this definition and for many of the subsequent remarks, I am indebted to the excellent course of lectures on the Pathology and Treatment of Strabismus, published by Mr. Holthouse. 216 STRABISMUS. varied, the effect will be the same—viz., that the sound eye gazes at it, while the affected eye disregards it. But if the patient be desired to close the sound eye, ho can then direct the other to any object he wishes, though perhaps to a less extent outwards than in other directions. Moreover, if both eyes are closed, and the lid of each then gently raised, the squinting eye will be found turned to the inner canthus. In strabismus divergens there is the same want of harmony in the movements of the two eyes, so that in looking at an object placed directly before them they never converge to the same point; the sound eye alone being directed to it, while the squinting one is more or less everted. It is not very uncommon for both convergent or divergent strabismus to be combined with a slight upward or downward squint; while much more rarely the cornea is neither inverted nor everted, but directed upwards—strabismus sursumvergens, or downwards—s. dcorsumvergens. Double convergent strabis- mus, in which both eyes are habitually more or less turned in at the same time, is also sometimes met with; as well as alter- nating convergent strabismus, in which, on covering the habit- ually well-directed eye, it squints, while the previously affected eye becomes straight. The vision of a squinting eye is generally imperfect: an early symptom, of which the patient does not long continue sensible, is double vision: the distorted eye is either some- what more or less prominent than its fellow: and the pupil of the affected eye is frequently less obedient to the stimulus of light, and hence more dilated than the other. Causes.—Strabismus commonly arises in early life—usually, perhaps, between the fifth and ninth years of age. It is some- times merely temporary, depending on some functional dis- order; more commonly it becomes permanent. Occasionally it is the first sign of acute hydrocephalus. The chief remote causes to which it is attributable are— defective vision, disease of the brain, convulsions during in- fancy, difficult dentition, the exanthemata, hooping-cough, STRABISMUS. 217 epilepsy, intestinal worms, injuries to the head, fright, imita- tion ophthalmia, and a habit of misdirecting the eyes while in many instances no reason can be assigned for its occurrence. The proximate cause is some affection of the orbital mus- cles ; by which one has become stronger, or weaker, or shorter than the others, owing, probably, to perverted nervous action. Treatment.—In every recent case of strabismus, the prac- titioner should first endeavor to ascertain the cause, in order to lessen or remove it; and when in children this is not evident, no harm can arise from paying attention to the general health, regulating the diet, and insuring proper action of the bowels. The squint persisting for two or three months, we may be sure that it will neither disappear spontaneously nor from constitutional treatment; and the question arises—are we to recommend an operation ? Mr. Haynes Walton places the argument so fairly before his readers that I cannot do better than quote his words:—"An operation is contra-indicated when certain causes are present, such, for instance, as inflam- mation of the eyeball or its appendages; when there is an opacity of the cornea, so that the obliquity is a provision for enabling the patient to see—the other eye being lost; or when caused by tumors, cicatrices from wounds, contractions after abscess, or indeed any accidental mechanical means that pushes or draws the eye from its axis. After it has been ascertained that the case is a proper one for operation, I cannot see that there is any advantage in delay, for preparatory treatment is not called for. When I have advised an immediate operation, I have frequently been asked if there is not a chance of a child outgrowing the deformity. There is certainly a feeling both in and out of the profession that an operation should be de- layed till after puberty; but there is much to be said against, and nothing that I am aware of for the postponement, for increase in age does not remove a squint, and imperfection of vision, when a result of the obliquity, may be improved or actually removed by an early operation."* * Operative Ophthalmic Surgery, p. 278. London, 1853. 19 218 OTALGIA. The operation consists in effectually dividing the tendinous expansion of the affected muscle—usually the internal rectus; the little patient being narcotized by the vapor of sulphuric fether or chloroform. There is seldom any bleeding; the wound in the conjunctiva heals kindly; and no special after- treatment is necessary. Should it happen, as it sometimes will, that the sound eye becomes somewhat inverted after the deformity of its fellow has been rectified by operation, it will be necessary to treat it in the same way as if it had been originally the faulty eye. CHAPTER X. DISEASES OF THE EAR. SECTION T.—OTALGIA. Otalgia, or earache, may be symptomatic of inflammation of the ear, or of the presence of foreign bodies, or of ton- sillitis, or of disorder of the prima via, or of rheumatism of the head, &c; or it may be idiopathic, that is to say, true neuralgia of the ear. In the latter case, the pain is most severe on its invasion; and, unlike the pain in otitis, does not increase in severity, is unattended by fever, and often disap- pears suddenly. When the pain is very severe, it frequently shoots through the nervous filaments distributed over the same side of the face and bead, causing much suffering and restless- ness. When the affection is symptomatic, the treatment must be directed to the primary disease; when idiopathic, mild pur- gatives, a blister behind the affected ear, or the application of chloroform or the tincture of aconite, will be useful. Any carious teeth must be extracted or stopped. Children not unfrequently poke peas, beads, grains of corn, pieces of slate-pencil, and other foreign bodies into the exter- nal meatus. To remove such, the ear should be carefully OTITIS. 219 syringed; but this treatment failing, the extraneous substance should be laid hold of by means of a small pair of forceps and gently extracted, or it may be removed by cautiously passing a curette or scoop over it. In all cases, before attempting extraction, the surgeon should convince himself by careful examination that a foreign body is really present. An accu- mulation of hard, dark-brown wax in the auditory passage sometimes acts as an irritant, causing uneasiness, buzzing, and deafness. It may be dislodged by careful syringing with warm water; or if firmly adherent may be lifted away with the currette, all rude force being avoided. SECTION II.—OTITIS. Otitis, or inflammation of the ear, may affect the external and internal ear at the same time, or it may be confined to either. External Otitis, or inflammation of the membrane lining the meatus auditorius externus, is at first characterized by dryness, itching, and heat of the part, gradually increasing to a dull aching, and eventually to an acute pain, generally increased at night, causing great agony, sleeplessness, fever, and even delirium. The lining of the meatus is swollen, dry, and pinkish; in a short time a muco-purulent or purulent discharge takes place, and relief is experienced. Attendant upon these symptoms and appearances, there is a sensation of , soreness of the head upon the affected side; while sneezing, moving the jaw, &c, increases the suffering.* Internal Otitis, or inflammation of the lining membrane of the cavity of the tympanum, is a most severe disease; being generally combined with inflammation of the membrana tyni- pani—the myringitis of Wilde. Though frequently a disease of youth, it may occur at any time of life; cold is a frequent cause of it, especially in debilitated or strumous individuals. It commences with violent headache, tinnitus aurium, and impaired hearing; followed by intense, acute, and gradually * Practical Observations on Aural Surgery, §c. By W. R. Wilde, p. 194. London,1853. 220 OTITIS. increasing pain in the ear, and loud or beating noises; until after a short time a sense of bursting or distension in the car is experienced. The eyes become injected, the countenance anxious, the skin hot, pulse frequent, and the functions of the kidneys and bowels disordered. Delirium is often present; or, in children, Convulsions. Many of the violent fits of scream- ing with which children awake out of sleep, are caused by otitis; a sudden accession of excruciating pain in the middle of the night being a frequent symptom of this affection, even when it exists in a subacute or chronic stage. Facial paraly- sis, caused by the inflammation extending to the bony canal in which the portio dura passes round the tympanum, may occur. The disease terminates in one of three ways: either by resolution, the symptoms gradually subsiding, and hearing being restored; or by suppuration, the pent-up pus bursting through the membrana tympani, and so discharging itself; or by the inflammatory process spreading either through the mastoid cells internally, and so producing necrosis, exfolia- tion, and cerebral disease,—or extending externally by the bony meatus to the periosteum covering the mastoid process.. Peculiar forms of otitis have been well described by Mr. Harvey, such as the rheumatic and gouty, which, however, need only be here mentioned : as well as exanthematous otitis, which, according to Mr. Wilde, frequently follows scarlatina and measles, and if neglected gives rise to unmanageable otorrhcea, destruction of the ossicula, incurable deafness, and even loss of life. * * Dr. Theophilus Thompson has recorded an interesting case of gangrenous abscess of the brain induced by exanthematous otitis. The patient had been affected with deafness and discharge from the right ear, the result of scarlatina, for more than twenty years. All at once, violent sickness came on, followed in a few hours by coma, and death. The case is remarkable for the long continuance of the dis- ease of the ear before it extended to the brain, for the insidious way in which serious disease of this organ involved the brain, and for the suddenness of the fatal issue after the first occurrence of alarming symptoms.—Transactions of the Pathological Society, vol. vii., p. 16- London, 1856. OTORRHOEA. 221 Treatment.—The treatment of otitis must be prompt and decided. In many cases, "where the fever runs high, and the suffering is acute, antimony in nauseating doses will be called for; alterative doses of mercury must also be administered; active purgatives are necessary; and the patient must be re- stricted to low diet. Hot fomentations sedulously applied, poultices, and holding the ear over the steam of hot water, usually give great relief. On the subsidence of the acute .symptoms, counter-irritation behind the ear may be useful. Should the pain continue, both Wilde and Harvey recom- mend that a free incision be made over the mastoid process, down to the bone; this proceeding being especially needed, if it can be determined that pus has formed under the perios- teum, or if it be thought that the inflammation has extended to the osseous tissue. At the same time the system may 'be gently got under fhe influence of mercury. When the mem- brana tympani has been ruptured, the inconvenience which arises must be subsequently obviated by the application of a thin layer of moist cotton wool as recommended by Mr. Years- ley, or by the use of an artificial membrane as suggested by Mr. Toynbee. SECTION III.-—OTORRHEA. Otorrhea—a purulent or muco-purulent discharge from the ear—is, properly speaking, only a symptom of certain dis- eases of this organ ; as of inflammation, polypus, granulations on the surface of the membrana tympani, &c. It occurs very frequently, however, without any appreciable cause, in young children—especially in strumous subjects—about the time of dentition, or on the subsidence of any of the exanthemata, or on the sudden cessation of purulent ophthalmia. It is com- monly neglected, or treated with purgatives and any " drops" that the fancy of the nurse suggests : no proper examination is made : and a loathsome, obstinate discharge is established. Thus, that which might have been cured in a short period by appropriate treatment, is allowed to become a chronic affection; 19* 222 OTORRHCEA. in which case it may continue for years, destroying in the course of time the membrana tympani, the ossicula auditus, and producing caries of the bony walls of the meatus and tym- panum. The disease may even extend to the cells of the mastoid process of the temporal bone; or in the opposite di- rection along the petrous portion of the same bone, until the brain and its membranes becoming involved in the unhealthy action, rigors, fever, and masked cerebral symptoms show themselves, and the case ultimately terminates in convulsions, coma, and death. Treatment.—The first step must be to syringe, and then to carefully examine the meatus auditorius externus by means ' of an ear speculum. A simple conical silver tube, well polished internally so as to transmit the light, is the simplest and best form of instrument. If the discharge be not severe, K and no cause, as polypus, &c, be found to account for it, a cure may often be effected by daily dropping into the ear a N solution of alum, zinc, or tannin, of the same strength as the ' various collyria (gr. iv.—x. to gj.) When these means fail, the surface of the canal should be painted with a solution of • nitrate of silver (gr. vj. ad §j.,) with a camel's hair pencil: this must be repeated every second day, the ear being frequently syringed in the interval with tepid water by means of an elastic bottle, or common syringe. The application of gly- cerine, as recommended by Mr. Thomas Wakely, may also be beneficial after the use of the astringents. Where the patient's general health is bad, tonics and change of air will be necessary; in scrofulous cases iodine, cod liver oil, &c, should be tried; and in all instances a generous diet is invaluable. No mischief whatever can ensue from curing either recent or long continued otorrhoea, as was at one time—and is still by the vulgar—feared. The evils which result from these dis- charges are due to their being neglected; for, so long as they are present, we never can tell how, when, or where they will terminate, or what serious disorganization they may lead to. DEAF AND DUMB. 223 SECTION IV.--THE DEAF AND DUMB. Although the subject of deaf-dumbness is not usually treated of in works like the present, yet I trust the importance and interest which naturally is attached to the most desperate of human calamities may plead as sufficient excuse for intro- ducing a few lines on the matter. It can hardly be necessary to observe that the incapacity of speech which exists in such as are designated deaf and dumb, results entirely from the want of the sense of hearing, and not from any physical. imperfection in the organs of speech. All who are deaf from birth must be dumb; for how can they use language, the sound of which they have never had the perception of, and which they consequently cannot attempt to imitate ? ' By the Census of 1851 in Great Britain, 12,553 persons (6,884 males and 5,669 females) were returned as deaf and dumb, or 1 in every 1,670 of the inhabitants. According to the most recent returns, the average proportion of the deaf and dumb to the population of. Europe generally, is found to be 1 in every 1,593 persons. Deaf-mutism is also found to be more common in agricultural and pastoral districts than in towns. Causes.—In some cases there has been no appreciable organic defect; in others the cause of the deafness has been either some organic change in the auditory nerves, or some lesion at their origin, or an alteration at the base of the brain or about the medulla oblongata, or effusion into the fourth ventricle, or imperfect development of the ear itself, or disease of the ear occurring during early infancy. Some authorities also assert that many of the cases of deaf-dumbness originate in convulsions occurring during the first dentition. Education.—Children who are born deaf differ but little from other children during early childhood; and it 'is not usually until a rather advanced period that the parents will allow themselves to be convinced that there is a positive defect of hearing in one who is, probably, more than com- 224 DEAF AND DUMB. monly engaging and affectionate, and who—from the expressive play of his features and the readiness with which he apprehends the slightest look or gesture—has, perhaps, been regarded as more than ordinarily intelligent. Experience having shown the almost complete impossibility of curing the deafness, it becomes a matter of the utmost importance early to commence the education of the other senses; so that the hapless being who is debarred from the chief avenue to knowledge at the most critical period of his intellectual growth may, nevertheless, not remain uneducated. The system of instruction for deaf mutes consists of:*— 1. Pantomime, which maybe divided into the employment of such natural, imitative, or descriptive signs or expressions of thought by gesture and pantomime as all mute persons acquire; or those arbitrary and conventional signs used by teachers and others in the habit of communicating with the deaf and dumb. The former are common to all mutes, and vary but little; the latter are generally sounded upon some special plan, the method of one teacher differing from that of another—all of which shows the necessity of adopting some universal system by which the mutes of countries speaking different languages may communicate their ideas. The use of pictures, models, and similar illustrations may be classed under this head. 2. Dactology, or finger-writing by either the double or single-hand alphabet; the former being that chiefly taught in this country; the latter that used on the Continent, in America, &c. 3. Writing and Reading. 4. Lip-reading, by which a mute understands what is said by merely watching the motions of the lips of a speaker; those, however, who acquire this faculty being generally such as heard and spoke originally, but who, by accident or disease, became totally deaf and subsequently mute. 5. Articulation, or the pronun- ciation of words and sentences. To what extent the true congenital deaf person can ever be taught to speak is still * The paragraphs which follow are taken almost verbatim from the Appendix to Mr. Wilde's treatise. DISEASES OF THE SKIN. 225 undetermined—only a few of the most intelligent and anxious are at all susceptible of such teaching, and even in these the effort at vocalization is, from want of hearing, harsh and inharmonious, and seldom turned to much account in their intercourse- in life. In most of the schools in this country, the system has been abandoned; the teachers conceiving that the time spent in acquiring this mechanical form of speech may be more usefully employed in other descriptions of education. As regards the industrial education of deaf mutes it is only necessary to say that they are probably as capable of acquiring a practical knowledge of the mechanical and industrial arts, as hearing and speaking persons in their own rank of life. CHAPTER XI. DISEASES OF THE SKIN. SECTION I.—CLASSIFICATION, &C. It is an opinion very generally entertained by medical practitioners, that the subject of cutaneous pathology ought to be viewed as a distinct branch of medicine; since it is not only thought that the diagnosis of cutaneous diseases is extremely difficult, but also that the treatment of these affec- tions requires special study. I believe that such ideas are very erroneous and mischievous; the various phenomena presented by each class of these disorders being generally strikingly characteristic and always appreciable by the eye, while their treatment is by no means difficult in the majority of cases, and often remarkably simple. Moreover, it must be remembered that the greater number of cutaneous affections are very common, very irritating, and very unsightly; and that—speaking generally—they are merely local manifesta- 226 DISEASES OF THE SKIN. tions of a constitutional disorder. How then can he be a sound or successful practitioner of medicine who is not fully acquainted with them in all their bearings ? In dealing with the symptoms, diagnosis, and treatment of these diseases, it is necessary to adopt some classification : for although all such classifications are—like the Linnasan classi- fication of the vegetable kingdom—entirely artificial, yet they cannot be dispensed with. The systematic arrangement which it is proposed to follow in these pages, is that of Willan, considerably modified; and as infants and children are liable to the same skin diseases as adults, this chapter must contain an account of them all, at the same time that the description is qualified so as to apply specially to these affections as they occur in early life. Order 1. Exanthematous or Erythematous Eruptions.— The diseases of this group are characterized by the appearance of variously formed superficial red patches, varying in intensity and size, disappearing transiently under pressure, and termi- nating in resolution or desquamation. They are frequently complicated with gastro-intestinal irritation or inflammation, and with cerebral or pulmonary diseases. This order includes Erythema, Erysipelas, Boseola, and Urticaria. Order 2. Hcemorrhagic Eruptions.—In this order the chief feature is the presence of crimson spots of variable size, caused by the rupture of capillary vessels : hence, as the blood is extravasated, the redness is unaffected by pressure. When the haemorrhagic spots are very small they are termed jyetechice ; when large, vibices or ecchymoses. Two diseases belong to this class, viz., Purpura and Scurvy. Order 3. Vesicular Eruptions.—A vesicle is a slight ele- vation of the epidermis,. containing a serous fluid—generally transparent, but occasionally opaque or sero-purulent. The fluid may be absorbed; or it may become effused upon the surface, causing 'excoriation and small thin scabs or incrusta- tions. Vesicular eruptions are occasionally preceded by fever, but often appear imperceptibly: they give rise to a peculiar DISEASES OF THE SKIN. 227 appearance, as if drops of water had been- scattered over the surface of the skin. In this order are placed Sudamina, Herpes, and Eczema. Order 4. Bullous Eruptions.—As a general rule, bullae differ from vesiculae merely in being larger, and hence it is almost unnecessary to separate them into two orders : they are superficial tumors, varying in size from a quarter of an inch to two or three inches, and are produced by effusions of serum beneath the epidermis. Pemphigus and Rupia are the two eruptions which come under this class according to Willan; but Dr. Burgess has judiciously added Button Scurvy. Order 5. Pustular Eruptions.—The pustular affections of the skin are characterized by the formation, between the cuti- cle and cutis vera, of small tumors called pustules, containing purulent fluid. Three kinds of pustules are sometimes spoken of by authors, viz., psydracice, or such as are small, irregular- ly circumscribed, and but slightly elevated above the skin; phlyzacia', or those which are of some size, elevated, have in- flamed bases, and end in small brown scabs; and achores, or such as are small, have comparatively large inflamed bases, and form thick large scabs which somewhat resemble incrustations of honey. The genera of this order are Ecthyma, Impetigo, and Equinia. Order 6. Parasitic Eruptions.—The order Parasitici must be divided into two groups, according as the parasite belongs to the vegetable or animal kingdom. The cutaneous diseases depending on a parasitic plant are, Tinea Tonsurans, Tinea Favosa, Tinea Decalvans, Tinea Sycosis, Plica Polonica, and Chloasma; while.the disease produced by a parasitic insect is Scabies. All are contagious. Order 7. Papular Eruptions.—A papula or pimple is a small, solid, acuminated elevation of the cuticle, resembling an enlarged papilla of the skin; generally terminating in reso- lution, or in slight desquamation, and sometimes in ulceration of its summit. Papular eruptions are usually preceded by itching; are rarely accompanied by fever; slowly developed; not contagious; appear on any part of the body; and vary in 228 EXANTHEMATA. their duration from a week to several months. Lichen and Prurigo are the diseases of this class. Order 8. Squamous Eruptions.—The term squanue is ap- plied to the scales of degenerated, thickened, opaque, dry epi- dermis which cover minute papular elevations of the skin : they are readily detached, and are reproduced by successive desquamations for a length of time. The scales or scurf are the result of a morbid secretion of the epidermis : their forma- tion gives rise to merely slight constitutional disturbance, and to local heat and troublesome itching. None of the squamous diseases are contagious, but they are very chronic in their duration. Lepra, Psoriasis, Pityriasis, and Icthyosis are the diseases included in this order. Order 9. Tubercular Eruptions.—This order is divided into the following genera:—Elephantiasis, Molluscum, Acne, Lupus, Frambcesia, and Keloid. These affections are charac- terized by the formation of small hard tumors or tubercles, more or less prominent, circumscribed in form, and persistent: the tumors may become ulcerated at the summit, or they may terminate in suppuration. Tubercular diseases are slowly de- veloped, are very chronic, are more severe in tropical than temperate climates, and their symptoms are so characteristic, that their diagnosis is easy. Order 10. Maculce.—This order of cutaneous diseases is characterized by certain changes of color in parts of the skin —giving rise to spots of various appearance and size—or in the whole of the cutaneous envelope. The maculae are seated in the rete mucosum, and depend on some alteration of its coloring matter : they are generally incurable, and unattended by any derangement of health. They may be divided into two classes, those attended by change of. color—Nigrities, Lentigo, Ephelis; and those marked by absence of color— Albinismus and Vitiligo. SECTION II.—ORDER 1. EXANTHEMATA. 1. Erythema is a non-contagious, superficial inflammation the skin; characterized by slight red patches of variable EXANTHEMATA. 229 form and extent, and most frequently seen on the face, chest, and extremities. Its duration varies from a week to a fort- night : it is seldom preceded or accompanied by febrile symp- toms : it causes but little local heat, and no pain: it terminates by slight exfoliation of the epidermis: and the prognosis is always favorable. Species.—There are several varieties of erythema, as E. Fugax, in which the red patches are evanescent and fleeting, subsiding at one part to break forth on another, and producing heat and dryness of the surface. It is symptomatic of some visceral derangement. E. Circinatum appears in the form of small, round, and slightly elevated patches of redness, which increase at their circumference, while the central portions assume their natural color; thus a series of red rings are formed. E. Intertrigo occupies the folds of the skin, and is induced by the friction or chafing of one surface upon another. It is often met with in the axillae, groins, and between the buttocks of infants who are not kept clean and dry. And, lastly, we have E. Nodosum, in which the eruption is confined to the fore part of the leg; taking the form of one or more large oval patches, running parallel to the tibia, and rising into painful protuberances, much resembling nodes. It occurs commonly in young women when badly nourished or over- worked. Treatment.—This is very simple. A few doses of some mild saline aperient; warm baths ; attention to the digestive organs; light diet; and tonics, especially quinine, or the compound tincture of bark, or the mineral acids, are sufficient for the cure of all forms of this affection. 2. Erysipelas—popularly called in Scotland the rose, in this country St. Anthony's fire—is a diffused inflammatory affection of the skin, and very commonly of the areolar tissue, characterized by the affected part becoming of a deep- red color, hot, painful, and swollen. No portion of the surface is exempt from attacks of it; but the integuments of the face and head are most commonly the seats of the idiopathic 20 2^0 EXANTHEMATA. erysipelas—that which arises from internal causes; while traumatic erysipelas—that which follows a wound—may occur on any part. Symptoms.—Idiopathic erysipelas resembles the eruptive fevers, inasmuch as it is preceded by fever and general constitutional disturbance. It often sets in with chilliness, followed by distinct rigors; sore throat is an early and fre- quent accompaniment of it; there is great mental depression; disturbance of the cerebral functions; and nausea, vomiting, and diarrhoea may also be present. Then, on the second or third morning from the rigor, reduess and swelling appear on some part of the skin, frequently on one side of the nose, spreading to the rest of the face, and often extending over the scalp, neck, and shoulders. The lips swell, the cheeks enlarge, the eyes become closed by their puffy lids, and all traces of the natural features are completely lost; while there is frequently great fever and debility, with very weak pulse, brown and dry tongue, and low muttering delirium. After three or four days the redness fades, the swelling subsides, and the cuticle desquamates. In most cases the inflammation is merely superficial; occasionally it affects the subcutaneous areolar tissue—phlegmonous crysip>elas—and is then apt to be followed by suppuration and sloughing. Terminations.—Erysipelas may prove fatal by the exten- sion of the inflammation to the brain or its membranes giving rise to effusion and coma. The same result may occur from the mucous membrane of the glottis becoming affected, so that the chink gets closed, and the patient dies unexpectedly from suffocation. In other cases death is owing to failure of the vital powers. Causes.—Erysipelas may arise from contagion. When it prevails epidemically, as it sometimes does, insufficient food, foul air, and trifling injuries favor its occurrence. Treatment.—This must be conducted on the principal that we cannot cut short the disorder, but only lead it to a safe termination. At the commencement an active purgative, such EXANTHEMATA. 231 as a dose of the neutral salts, will be beneficial; and when the tongue is much coated-and the breath foul, an emetic does good. In the country, when the patients are young and vigorous, bleeding is commonly considered necessary; in London such a practice would invariably be bad. In the cases which have fallen under my own notice, there has always been marked evidence of debility, and I have consequently followed the practice of those physicians who adopt a tonic mode of treatment as the great rule in idiopathic erysipelas. The late Dr. Robert Williams, of St. Thomas's Hospital, gave all his adult erysipelatous patients milk diet, sago, very gentle purgatives, and from four to six ounces of port wine daily, from the very first appearance of the disease, irrespective of the symptoms or the part affected; and he says, in his admirable work on Morbid Poison, " I have pursued this system for several years, and I hardly remember a case in which it has not been successful." The sesquicarbonate of ammonia, in doses of one to five grains, according to the age, will often prove an excellent substitute for wine; or it may be administered alternately with wine every three or four hours. Of all the local applications which have been recommended, that which gives the most relief is the fomentation by flannels wrung out of a hot decoction of poppy-heads, assiduously ap- plied. Linseed-meal poultices are sometimes useful; flour freely dusted over the inflamed part has often a soothing, cooling effect in mild cases, but as it imbibes the cutaneous transpiration it is apt to form a crust which is removed with pain and difficulty; and sedative lotions, or water dressing— the temperature being regulated by the feelings of the patient —are frequently of much service. In the phlegmonous form of the disease, when suppuration has taken place, and pus has become infiltrated through the areolar tissue, free incisions must be made to give it exit. Infantile erysipelas most frequently occurs about the region of the umbilicus, frfjm whence it may extend over the entire surface of the abdomen. It may be due to some mismanage- 2S2 EXANTHEMATA. ment of the remains of the funis. The strength must be sup- ported: if the mother's milk be deficient in quantity or quality, a vigorous wet-nurse should be obtained. Cordials, as white-wine whey, wine and water, &c, should also be given. 3. Roseola is a mild, non-contagious inflammation of the skin, characterized by rose-colored spots or transient patches of redness, of small size and irregular form, distributed over more or less of the surface of the body; its duration varies from twenty-four hours to six or seven days. The eruption, at first brightly red, gradually subsides into a deep- roseate hue, and slowly disappears. It is accompanied by slight fever. Young children frequently suffer, especially in hot weather, from a peculiar form of roseola—R. Infantilis—which from its resemblance to rubeola, is commonly known as false measles. It may be distinguished by the constitutional disturbance being very slight; by the eruption being confined to one limb, or to one portion of the trunk; and by the absence of that crescentic arrangement of the spots so generally present in measles. But little treatment is usually necessary. Simple diet, diluents, and a few warm baths, are often all that is required; perhaps mild alteratives, laxative, and tonics may be needed in some few cases. 4. Urticaria.—Urticaria or nettle-rash, is a transient and non-contagious exanthematous eruption; characterized by long prominent patches or wheals, either red or white, of irregular shape, and of uncertain duration. The spots or wheals closely resemble those produced by handling nettles. It is accom- panied by intense heat; a burning and tingling in the affected spots, with great itching; and it is associated with more or less irritation of the gastro-pulmonary mucous membrane, and fever. There are two varieties : one in which' it is acute, running a short, rapid course; another in which it is chronic, very HiEMORRHAGIA. 233 obstinate, and either persistent or intermittent. Both forms attack individuals of all ages and constitutions. The chronic intermittent variety is the urticaria evanida of Willan; it sometimes lasts for months, or even years. Urticaria may attack young infants, and prove very troublesome. The child, perhaps, is put to bed apparently quite well, but in the middle of the night it awakes and screams; the cause of which rest- lessness is at once explained when the large wheals are found on the lower part of the body and legs. Urticaria is caused by the irritation of dentition ; by pul- monary irritation; by exposure to cold or heat; and by pe- culiar derangement of the digestive organs, arising from the use of improper food. Treatment.—This must consist in • the administration of emetics and purgativ.es, where the disease depends upon stomach derangement. In the chronic form, a simple diet, without stimulants of any kind, must be rigildy adhered to; laxatives, antacids, and warm or tepid baths, forming the remaining chief remedies. SECTON III.—ORDER 2. HEMORRHAGED. 1. Purpura.—This disease arises from a morbid condition of the blood and of the capillaries. The blood is deficient in fibrinous elements, while the capillary vessels are softened; and there is a want of tone in all the tissues. Hence extravasa- tions of blood into the tissues readily occur; either from pres- sure, or from the force of the circulation. Symptoms.—The spots or patches vary in color, being either red, purple, livid, or reddish-brown; they often bear a great resemblance to bruises; pressure does not efface them; they sometimes persist for months; and they are aggravated by impure air, insufficient food, deficient exercise, &c. The constitutional symptoms indicate debility; varying from slight depression, to hectic feverishness, constant faintness, oedema of the lower extremities, and the most complete pros- tration ending in death. 20* 234 ILEMORRHAGIA. Species.—Four varieties are commonly enumerated:—Pur- pura simplex, in which the spots are small, the symptoms of mal-assimilation prominent, and the languor and lassitude distressing, but not dangerous: P. Hemorrhagica, the local and constitutional symptoms being those of purpura simplex, in a very aggravated form, with the dangerous complication occasionally of internal haemorrhage: P. Urticans, which commences with the formation of slight elevations or rounded wheals like the eruption of nettle-rash, although the irritation of the latter affection is absent: and P. Senilis, which occurs frequently in elderly women from some local irritation. Diagnosis.—This disease must not be confounded with scurvy, which it sometimes resembles. It differs, however, inasmuch as it often appears suddenly; is not owing to any want of vegetable food; and is not .attended with a. livid, spongy state of the gums. Treatment.—As purpura is a disease of debility, the treat- ment must consist in the use of good diet; the removal of any irritant secretions contained in the alimentary canal; tonics, especially quinine and iron, and the mineral acids; and a sojourn at the sea-side during convalescence. The oil of turpentine, in small, frequently repeated doses, has been strongly recommended:—F. 43. 2. Scurvy.—Scorbutus, or scurvy, is a peculiar disease caused by long-continued deprivation of fresh succulent ve- getables. It does not often occur during childhood. Some authors speak of land scurvy and sea scurvy as if they were two different complaints. I believe them to be identi- cal. The same authorities have also regarded land scurvy and purpura as one and the same affection; there is little doubt but that they are very dissimilar. The symptoms of scurvy show themselves gradually, com- mencing with lassitude, mental anxiety, and difficulty of breathing on the least exertion. The countenance becomes sallow and of a dusky hue; the gums swell, are spongy, of a livid color, and ble§d on the slightest touch; the teeth VESICUL.E. 235 loosen, and the breath becomes very offensive. As the disease advances the debility increases; the dyspnoea often becomes most urgent; the gums frequently slough, and haemorrhages occur from them, as well as from the mouth, nose, stomach, and intestines. Ecchymoses or effusions of blood beneath the skin also appear, especially on the lower extremities and trunk; and many parts of the body become discolored with bruise like marks, so that the patient appears as if he had been severely beaten. The legs swell; the skin is dry and rough; the urine is scanty; in some instances there has been sponta- neous salivation ; and there is generally constipation. Unless relieved, the patient dies from exhaustion. Dr. Garrod believes that in scurvy the blood is deficient in potass, and that this deficiency is indeed the cause of the disease. He shows that all substances which act as anti- scorbutics contain this agent, and he has rapidly cured cases by the use of some of its salts. These views have been con- firmed by Dr. Hammond, who has cured and prevented the disease by the bicarbonate of potash, when fresh vegetables could not be obtained.* Treatment.—That usually adopted, consists in the admin- istration of those vegetables, which are remarkable for their antiscorbutic qualities, such as oranges, lemons, potatoes, lime-juice, &c. If we believe in the soundness of Dr. Garrod's opinions, as indeed we are bound to do, we shall employ the tartrate, chlorate, or phosphate of potash :—F. 37, &c. SECTION IV.—ORDER 3. VESICULAE. 1. Sudamina.—In the progress of many acute and chronic diseases attended with sweating, crops of small transparent vesicles make their appearance. Thus in acute rheumatism, typhoid fever, &c, sudamina are frequently found upon the trunk and extremities; especially in the latter stages of these affections. Some persons speak of Miliaria as a distinct fever "arising * American Journal of Medical Sciences, vol. Ii. January, 1853. 206 VESICULJE. from constitutional causes, and as differing from sudamina produced by copious sweating. The distinction—if it exist— is unimportant; since the vesicles in both cases resemble each other, and disappear spontaneously without requiring any treatment. 2. Herpes.—Herpes, or tetter, is a transient, non-contagious affection, consisting of clusters of globular vesicles upon in- flamed patches of irregular size and form. The eruption runs a definite course, rarely continuing for more than two or three weeks; it is not usually severe, nor is it accompanied by any constitutional symptoms. Care must be taken not to mistake its nature, since herpes proputialis has been actively treated as syphilis, and herpes circinatus—when occurring on the scalp— as tinea tonsurans, or ringworm. A singular species of this disease is known as herpes zoster, or zona, or the shingles, in which the inflamed patches with their clustered vesicles arc arranged in the form of a band, encircling half the circum- ference of the body; in nineteen cases out of twenty the zone will be found to occupy the right side of the body. Treatment.—Gentle laxatives, warm baths, and a plain, unstimulating diet will alone be called for. The local irrita- tion should be relieved by an emollient lotion, or by the ap- plication of the zinc ointment, or the diacetate of lead cerate of the Pharmacopoeia. 3. Eczema.—Eczema, crusta lactea, humid tetter, or seal I., is a non-contagious disease, consisting of an eruption of small vesicles on various parts of the skin, closely crowded together, and often running into each other, so as to form, on being ruptured, superficial moist excoriations. Species.—There are several species of this disease. When the eruption consists of minute vesicles on different parts of the skin, without any inflammation, it is called eczema simplex; when the skin in inflamed, and there are heat and swelling, eczema rubrum. Eczema impetiginodes is a severe degree of eczema rubrum. AVhen arising, as it sometimes does, from the effect of great heat, especially from the heat of the sun, it vesiculae. 237 is called eczema solare; when as a result of the use of mer- cury, eczema mercuriale. But the form of this eruption which most concerns us now is that form known as eczema infantile; inasmuch as infants at the breast and young children are peculiarly subject to it. This variety I shall now describe. Symptoms.—Eczema infantile, like eczema adultorum, origi- nates in mal-assimilation, and is often due to a faulty secretion of milk on the part of the mother. When it once attacks an infant, it gives rise to the greatest trouble, since it seems to excite all the cutaneous eruptions from which the little patient can possibly suffer. The general health also is likely to be greatly affected by the cause of the disorder, as well as by the intense itching and burning heat of skin which, accom- panies it; and the sufferer becomes pale, weak, anaemic, and emaciated. " The eruption usually commences," says Mr. Erasmus Wilson, in his graphic description of this malady, " as a patch or blotch of slightly-raised pimples; the patch is itchy, is rubbed, increases in size, becomes more inflamed, the cuticle is raised in more or less defined vesicles, which are usually broken by friction; the surface becomes excoriated, somewhat swollen, and pours out an ichorous secretion, varying from a mere oozing to an excess that wets through everything that is applied to it. With the increase of irritation consequent on the excessive secretion and the congestion which gives rise to it, the patch spreads; where the eruption commenced by several blotches, they probably run into one; the ichorous discharge also increases the local disease, by irritating the parts over which it flows. The case up to this time is one of inflammatory eczema, or eczema rubrum. The state of eczema simplex has hardly existed, and is only to be seen occasionally; but the disease still runs on, its violence increases, and the morbid secretion, from being a transparent and colorless icho, like water in appearance, becomes slightly opaque (tinea mucosa,) milky, then yellowish and semi-purulent, and the case is transformed into eczema 238 VESICUL2E. impetiginodes; or the discharge may take on a still more decidedly purulent character, while small postules arc deve- loped on the red and tumefied skin around the patch, and then the case is one of impetigo. Thus the plus or minus of those pathological conditions is irrespective of the cause or essential nature of the disease; in other words, the disease being the same, it may, according to the temperament or constitution of the child, be an erythema verging upon eczema; an eczema rubrum; an eczema verging on impetigo, or eczema impetiginodes: or, the pustular element being in excess, it may be an impetigo. Again, as I have before said, whatever the predominating character may be, whether erythema, lichen, eczema, or impetigo, there will always be present, in a greater or less degree, some or the whole of the other forms sprinkled over the body; a simple erythema here, an erythema with strophulous or lichen there; a few scattered vesicles of eczema in a third place, or a few congre- gated psydracious pustules of impetigo in a fourth."* Sometimes the whole of the body, from head to foot, is covered with these eruptions; the excoriations and scabs being most irritating, and the ichorous discharge from them disgust- ingly offensive. The hair also becomes matted and entangled with friable crusts resembling particles of mortar; the ears are swollen; the face is bloated; the features are distorted by the discolored scabs, which sometimes form a huge, unsightly mask; and the child becomes worn out and exhausted with the agony it experiences. Occasionally the danger is in- creased by the occurrence of diarrhoea; or of congestion or inflammation of the mucous membrane of the air-tubes, lungs, &c. Treatment.—In attempting to cure eczema infantile—as also indeed the other obstinate varieties of this disease—three great indications are to be fulfilled, viz., elimination, alle- viation of local distress, and restoration of power.^ * Diseases of the Skin, p. 171. 4th ed. London, 1857. f Mr. Wilson. Opus cit., p. 17G. VESICULiE. 239 For elimination, calomel and grey powder is to be adminis- tered ; one grain of calomel with one of white sugar being the dose for the youngest infant; for a child of one year old, a grain and a half; for a child two years old, two grains. The object being to stimulate the liver, and to obtain a perfect clearance of the stomach and bowels, the dose must be repeated according to circumstances—once, twice, or thrice a week as the patient's condition may indicate. To alleviate the local distress, the benzoated oxide of zinc ointment, rubbed down with spirits of wine—F. 84—is to be abundantly and gently applied over every part of the eruption, night and morning. To insure the permanent application and non-disturbance of this dressing, Mr. Wilson orders a little shirt to be made of old linen, which is to be worn constantly, night and day, and for a week together, if necessary. It is intended as a mere envelope or dressing to the inflamed and irritated skin; and its saturation with ointment only contributes to its greater utility. Where the eruption is chiefly confined to the arms or legs, linen sleeves will be sufficient for the purpose. On the face no other covering than the ointment is necessary, but the latter should therefore be used the more largely. When the oxide of zinc ointment is thus employed, the formation of crusts on the eruption is prevented, in conse- quence of the exclusion of the atmosphere and the consequent absence of desiccation. And when crusts are already formed, the object to be attained is to soften them by saturating them thoroughly with the ointment, and then by gentle friction to displace them and substitute a thin stratum of the ointment in their place. The inflamed skin is not to be washed; but the exudations are to be gently removed with a soft napkin. On the scalp, the ointment should be applied in the direction of the hair to avoid matting; and as soon as the oozing of ichorous discharge has somewhat subsided, the hair should be gently brushed. The third indication, restoration of power, is fulfilled by 240 BULLiE. correcting the mal-assimilation, and restoring the blood to its normal condition. The chief agent for effecting this, is that valuable alterative tonic, arsenic, which is a most effective and harmless remedy for the youngest infant. The dose of Fowler's solution, for an infant from one month to a year old, is two minims thrice daily. In many cases it may be bene- ficially conjoined with iron, cod-liver oil, &c.—F. 40. Should diarrhoea, or inflammation of either of the mucous tracts su- pervene, the use of the arsenic must be suspended. The diet of the child must be wholesome and nutritious; milk, strong beef-tea, cod-liver oil, &c, being very valuable. SECTION V.—ORDER 4. BULLiE. 1. Pemphigus.—This affection is characterized by the ap- pearance of large bulla), two or three inches in diameter, upon one or more regions of the body. The eruption is generally preceded for twenty-four or forty-eight hours by slight general indisposition, fever, and itching of the skin; small red cir- cular patches then form, gradually increase in extent, and become covered with bulla), which either fade away on attain- ing their full size, or burst, and are replaced by thin, brown- ish-colored incrustations. The duration of this disease is usually from one to three weeks, although it occasionally becomes chronic and prolonged for months. Young infants—particularly such as are brought up in the dirty, ill-ventilated dwellings of the poor—sometimes suffer severely from this disease. Pemphigus infantilis may also be due to over-feeding, to teething, or to some gastric or intes- tinal irritation. 2. Pompholix is merely a variety of pemphigus, unat- tended with fever. It runs its course in about eight or ten days; it is very uncommon, especially during childhood. A kind of artificial pompholix may be produced by the application of cantharides. I remember a girl in King's College Hos- pital who deceived her physician for a short time by rubbing powdered cantharides into various parts of her person, and thus raising numerous small blisters. BULLiE. 241 Treatment.—Tonic and alterative medicines, warm bathing, with generous diet and fresh air, appear to be the remedies called for both in pemphigus and pompholyx. 3. Rupia may be considered as a modification of pemphi- gus, occurring in persons of debilitated constitutions. It is characterized by the eruption of small flattened bulla), con- taining at first serous fluid, which soon becomes purulent or sanguinolent, and concretes or dries into dark, black, rough crusts. When the crusts fall off, they leave circular ulcers, of various sizes, indisposed to heal. It is sometimes dependent upon syphilis, when it is known as syphilitic rupia. Most forms are obstinate, often lasting for weeks or months. Rupia occasionally attacks strumous children, or the off- spring of unhealthy parents. When it occurs previous to the infant being weaned, the nurse's state of health should be carefully inquired into, so that, if necessary, a new and strong nurse may be obtained. In older children a nutritious diet should be ordered; with tonics, cod-liver oil, and mild altera- tives. Change of air—particularly to the sea-coast—will also do good in all instances. 4. Button Scurvy.—Ecphyma globulus, or button scurvy —as it is popularly misnamed—is a singular cutaneous dis- ease prevalent in the middle and southern counties of Ireland. • "This disease," says Dr. Burgess, "is characterized by an erup- tion of one or more scattered excrescences on different parts of the body, each of which in form resembles a convex button— hence its name—and varies in size from four or five-tenths of an inch to an inch and a quarter in diameter. It is highly contagious (through the medium of the fluid secreted by the excrescence,) and is described by some writers, erroneously, as confined to the cuticle. It is not a syphilitic disease; although sometimes bearing a resemblance to the syphilitic condylomata described by Fricke."* It is ordinarily unat- tended by constitutional symptoms; being merely a local * Burgess's translation of Cazenave's Manual on Skin Diseases. 2d . od., p. 160. London, 1854. 21 242 PUSTULE. affection, as is clearly proved by the case with which the application of the nitrate of silver generally cures it. SECTION VI.—ORDER 5. PUSTULiE. 1. Ecthyma.—This disease may be defined as an acute inflammation of the skin; characterized by large, round, pro- minent pustules, occurring upon any part of the body, though very rarely on the face or scalp. The pustules arc usually distinct, seated upon a hard inflamed base, and terminate in red stains or in thick dark-colored scabs, which leave super- ficial ulcers, followed by cicatrices. This disease not unfre- quently occurs in badly-nourished, weakly children; being generally significant of some irritation of the gastro-intestinal mucous membrane. Ecthyma infantile often terminates in desquamation; the pustules, after threatening to suppurate, gradually diminishing and disappearing. Treatment.—This must consist in the use of gentle laxa- tives, with alteratives, slightly acid drinks, and spare diet. Water-dressing, or the lotio plumbi, or the unguentum zinci, may be applied to the pustules. 2. Impetigo.—Impetigo, or running tetter, is a severe non- contagious inflammation of the skin; characterized by an • eruption of small hemispheroidal or flattened pustules, most frequently grouped in clusters, and forming thick, rough yel- lowish scabs or incrustations. From beneath the incrustations a discharge takes place; the crusts become thicker and larger; and they fall off, leaving a raw surface. The mode of distri- bution of the pustules has caused a division of the disease into two varieties—impetigo figurata and impetigo sparsa. The first occurs generally on the face, especially on the cheeks; it is attended with constitutional disturbance; and as the pus- tules burst and form greenish-yellow crusts, resembling patches of dried honey, the heat and itching become intolerable. In children the impetiginous eruption sometimes covers the face like a mask, and is called crusta lactea. The second form merely differs from the first, inasmuch as the pustules are PUSTULvE. 2 13 more scattered, being sometimes sprinkled—as it were—over an entire limb, or even over the whole body. The constitutional symptoms are generally very slight, las- situde and headache being the most prominent: but when this troublesome and offensive disease is prolonged, a state of debility is induced. Treatment.—During the inflammatory-stage sedative fo- mentations and water-dressing give relief Subsequently, the benzoated oxide of zinc ointment rubbed down with spirits of wine or glycerine, freely applied night and morning, docs great good; or a lotion of equal parts of olive oil and lime- water will be found soothing. The constitutional treatment must consist in attention to diet, the exhibition of mild laxa- tives, with salines or alkalies; and afterwards «the use of tonics, especially the bitter infusions and tinctures of gentian, calumba, cinchona, or quassia. When stubborn it may be necessary to resort to Fowler's solution of arsenic, in two or three minim doses thrice daily; or to the liquor hydryodatis arsenici et hydrargyri—known as Donovan's solution—in rather larger quantities. 3. Equinia.—Equinia, Farcinoma, Farcy, or Glanders, is attended by symptoms somewhat similar to those of glanders in the horse; viz., by fever, great debility, pa*!ns in the limbs, profuse offensive discharge from the nostrils, and the forma- tion of a number of pustules and tumors in different parts of the body, which have a great tendency to suppurate and be- come gangrenous. The pustular eruption does not appear until about the twelfth day; it is accompanied by profuse foetid sweats, and sometimes by the formation of black bullae. The disease generally proves fatal before the twentieth day. It occurs for the most part in grooms, stablemen, &c. There is abundant proof of the transmission of the glanders from the horse to man. No treatment seems hitherto to have been of any service. I can only recommend stimulants, and a trial of the salts of potass, especially the chlorate. 244 PARASITICI. SECTION VII.—ORDER 6. PARASITICI. 1. Tinea Tonsurans.—Tinea tonsurans,porrigo scutulata, dV, vulgarly, ringworm, is a chronic contagious disease, caused by a parasitic mucedinous plant—the Tricophyton tonsurans. It occurs in circular or oval, and slightly-elevated patches, each patch having the appearance of a thin layer of scurf. There is slight itching; and as—when the disease affects the head—the hairs are rendered dry, discolored, and brittle by this affection, they are readily broken off at variable distances from the scalp. In the early stages there is no discharge, and frequently none appears during the whole progress of the complaint: but in some the irritation of the scaly crusts pro- duces such itching that the rude attempts constantly made to relieve their annoyance give rise to inflammation of the skin, followed by an ichorous discharge. The patches spread at their circumference, and the rings sometimes assume consider- able dimensions. In almost all instances we shall find symp- toms of deranged nutrition : the child is languid, pale, and— in short—out of health. The most frequent seat of the disease is the head, but it is often seen on the neck, arms, and other parts of the body. Mr. Erasmus Wilson does not believe that it is contagious: my own experience inclines to an opposite conclusion, and I think most practitioners will support this opinion. When this disease breaks out in a school, it is for the time a great nuisance. 2. Tinea Favosa—termed porrigo favosa by Willan and Bateman—most commonly affects the scalp, in tho form of small cup-shaped, dry, bright-yellow crusts; each containing a hair in its centre, and somewhat resembling a piece of honeycomb. The scabs gradually increase in size, and are highly contagious. At first the small yellow pustules are dis- tinct, but soon they become confluent, and form continuous scabs; they produce troublesome itching; and on removal of the scabs eroded surfaces are left. The parasitic plant causing PARASITICI. 2lo or accompanying this offensive and troublesome disease is the Achorion Schonleinii. 3. Tinea Decalvans—or Porrigo decalvans—is readily diagnosed by the perfectly smooth bald patches which result from the hair falling off on one or more circular spots; these spots varying in size from a sixpenny piece to five or six inches in circumference. The parasitic vegetable is Microsporon Audouini. 4. Tinea Sycosis—the last species of tinea—is character- ized by inflammation of the hair-follicles, causing successive eruptions of small acuminated pustules, occurring most fre- quently upon the chin and other parts occupied by the beard ; it rarely occurs on the scalp, and rarely affects women. It is called mentagra by Willan and Bateman, and sycosis by Cazenave. The parasite is the Microsporon mentagrophytes. Treatment.—This is the same in all the varieties of tinea. Great attention must be paid to cleanliness, daily washing with common yellow soap and water being attended with great advantage. Shaving, the head is seldom necessary, but the hair must be kept short. Should there be any scabs or incrustation they must be removed by poultices or water- dressing. We then attempt to cure the disease by destroying the spores of the parasitic plant. This may be effected in many ways. Having always been successful with a lotion of sulphurous acid, as first recommended by Dr. Jenner*—F. 93 —I always resort to this agent. Other practitioners employ acetic acid; or a lotion of sulphuret of potass—3j. to water Oj.; or they paint the affected parts with the acetum cantha- ridis; or they apply a stimulating ointment, such as the diluted unguentum hydrargyri nitratis, or a mixture of equal parts of the unguentum hydrargyri ammonio chloridi and the un- guentum picis liquidae. In all cases the local treatment must be conjoined with con- stitutional remedies, since the spores of these microscopic plants find their most congenial nidus in weakly children. * Medical Times and Gazette, 20 August, 1853. 21* 240 PARASITICI. Hence, the child should be taken away from its books; allow- ed to be much in the open air; fefl. well upon plain nourishing food; warmly clothed; and be strengthened by tonics, espe- cially quinine and steel. 5. Plica Polonica—or Trichosis Plica, or Polish ring- worm—is a disease of the hair little known in this country. It is characterized by tenderness and inflammation of the scalp; the hairs become swollen and imperfectly formed; and the hair-follicles secrete a large quantity of viscid, reddish-colored fluid, which glues the hairs together, uniting them into a mass. It is caused, or accompanied, by two parasitic plants —the Trichophyton tonsurans and Trichophyton sporuloides. As regards the treatment of this disease little is known, but it is usually recommended that the diseased hairs should not be cut. I should myself resort to the use of the sulphurous acid lotion, so beneficial in analogous diseases. 6. Chloasma.— Chloasma, pityriasis versicolor, or liver- spot, makes its appearance generally on the front of the chest or abdomen, in the form of small spots of a dull-reddish color, which gradually increase in size, and assume a yellow tint. It may last from a few days to many months or years. It is contagious. According to Eichstedt, this disease is caused by a cryptogamic plant—Microsporon furfur. It may be cured by the use of the sulphurous acid lotion, or by a lotion of bichloride of mercury in water (gr. ij. to §j.,) applied night and morning. Mr. Startin considers that it is apt to return, if an arsenical course be omitted. I have, however, cured cases by the mercurial lotion alone, continuing its use for a short time after the disappearance of the eruption. 7. Scabies.—Scabies, or psora, or the itch, is a contagious disease—contagious in that sense which implies contact—con- sisting of a vesicular eruption, presenting a number of watery heads, attended with violent itching. It may occur on any part of the body, but it is most frequently found in the flex- ures of the joints—especially on the fingers. An opinion pre- vails that scabies never attacks the face; but this seems to be PAPULiE. 247 incorrect, for I am told that at the Hospital for Diseases of the Skin, cases of its occurrence in this locality, are not un- common. The cause of the disease is an insect called the Acarus scabiei; which is to be found about a line from, but not in, each vesicle. * Treatment.—Scabies never disappears spontaneously. It is readily cured by killing the insect, and perhaps no agent does this so readily as sulphur. Hence, after a good washing, the affected parts are to be well covered with sulphur ointment, or a sulphur bath may be used. As the patient's clothes will probably be contaminated, they must either be destroyed, or at all events thoroughly fumigated with sulphurous acid gas, which may be procured by igniting a rag dipped in melted sulphur. When scabies is complicated with other eruptions, it must be cured before attempting the relief of the latter. SECTION VIII.--ORDER 7. PAPULiE. 1. Lichen.—This is a papular affection readily recognized by the minute, hard, red elevations of the skin which it pre- sents, together with the annoying pruritus. There are three forms:— Lichen simplex, in which the eruption consists of small ag- glomerated papulae, rarely larger than a millet seed. Lichen strophulus, or red-gum, tooth-rash, &c, which gen- erally attacks infants at the breast; and is characterized by an eruption of minute, hard, sometimes slightly-red pimples, at- tended with itching, and appearing upon part or the whole surface of the body. And Lichen agrius, in which the papulae are more inflamed, and developed on an erythematous surface, which appears hot and painfully distended. The itching is very intense, and the duration of this form is often very prolonged. Treatment.—Tepid baths, mild laxatives, and acidulous * For a description of this little parasite, the reader may be referred to the Author's Manual of Clinical Medicine, p. 285. London, 1855. 94 s PAFUL.E. drinks will cure most forms of lichen. The irritation is best relieved by a weak lotion of the liquor plumbi diacetalis, to which a little hydrocyanic acid may be added. 2. Prurigo.—Prurigo—itching—is a cutaneous disease characterized by an eruption of small papula) or pimples, of the natural color of the skin. It is a chronic affection lasting for months or years, and causing great discomfort, not to say misery. Patients afflicted with it scratch and tear themselves constantly till the blood flows; their sufferings are aggravated by warmth. Willan describes three varieties—prurigo mitts, prurigo formicans, and prurigo senilis. The first is the mild- est form ; in the second, the itching is combined with a sensa- tion like the creeping of ants or the stinging of insects; while the third occurs in old persons, and is the most obstinate, often continuing for the rest of the patient's life. Diagnosis.—The itching arising from prurigo must not be confounded with that caused by insects. I may here mention that the human body is infested with four kinds of lice, viz., the Pediculus vestimenti, or clothes' louse; the Pediculus capitis, or head louse, which lives in the hair; the Pediculus ciliorum, or louse of the eyebrows ; and the Pediculus pubis, or crab louse, which infests the hair of the pubes. They are all destroyed by mercurial ointment, or by dusting the parts with calomel, or by washing them with infusion of tobacco. Treatment.—Alkaline, or sulphur, or plain water baths should be used daily; the temperature should not exceed 70° Fah. The local applications which give the most relief are vinegar, lime water, a weak solution of bichloride of mercury, a dilute solution of creosote, a lotion containing prussic acid, tar ointment, an ointment containing a small quantity of aconitine, &c. The general treatment must consist of a light and cooling regimen, the avoidance of stimulating food or drink, and the use of laxatives, sarsaparilla, acid tonics, or even the liquor potassae arsenitis. Dr. Bowling, of Kentucky, says in a letter to Dr. Watson, SQUAMA. 249 that he has cured numerous cases of prurigo senilis thus:— " I direct that the affected parts be sponged for a minute or so with good apple-vinegar, and then be allowed time to dry. After this they are to be smeared over with citrine ointment {unguentum hydrargyri nitratis.) The applications are to be made twice a day. The cure is usually effected in a week." SECTION IX.--ORDER 8. SQUAMAE. 1. Lepra.—Lepra, or lepra vulgaris, is perhaps the most obstinate and troublesome of all cutaneous diseases : but it is very rarely seen in children. It is a non-contagious chronic eruption; consisting of red, scaly, circular patches, of various dimensions, scattered over different parts of the body, but most frequently found in the neighborhood of the joints, especially near the knee and elbow. By degrees, the patches increase in size and number, and extend along the extremities to the trunk. When the patches are small, white, and of long standing, the disease is termed lepra alphoides; when copper colored, and the result of syphilis, syphilitic lepra. Treatment.—All local applications, with the exception of alkaline baths, or the simple warm bath are useless. Liquor potassae, in large doses, thrice daily, is often beneficial; or the liquor potassae arsenitis; or the triple compound of iodine, arsenic, and mercury, known as Donovan's solution, may be cautiously given with the greatest advantage. Where these remedies fail, the decoction of dulcamara, or decoction of sar- saparilla and bichloride of mercury, tar capsules, tincture of cantharides, or the iodide of potassium, may be tried: mer- cury will generally cure the syphilitic form. The Harrowgate waters have been recommended. At the same time, the diet must be very simple, and all stimulating food or drink avoided. During an arsenical course, all acids, fruits, and vegetables should be abstained from. 2. Psoriasis.—Psoriasis, psora, leprosa, or dry-tetter, is a 250 SQUAM.E. chronic, non-contagious inflammation of the derma; charac- terized by the development of patches, of various extent and form, slightly raised above the level of the skin, covered by thin, whitish scales of altered epidermis, and accompanied by rhagades or fissures of the skin. The eruption may be local, or it may be diffused over the whole body. The local varieties consist of psoriasis palpebrarum, psoriasis labialis, psoriasis pneputialis, psoriasis scrotalis, psoriasis palmaris, and psoriasis unguinum. The general varieties are psoriasis vulgaris, psoriasis gyrata, and psoriasis invetcrata. Psoriasis is closely allied to lepra in its appearance, and general pathology : in the former disease, the patches are irregular, and not depressed in the centre; in the latter, they are circular, and depressed in the centre, with elevated mar- gins. Both affections are sometimes hereditary, and both re- quire the same treatment. 3. Pityriasis.—This disease is a chronic inflammation of the skin, attended with redness and itching, and characterized by the production of minute white scales or scurf in great quantity. It may attack any region, but the scalp and parts covered with hair are the most common seats of it. The des- quamation takes place copiously and incessantly. Treatment—Some tonic infusion, an occasional purgative, and the use of alkaline lotions to the affected part. Occa- sionally the unguentum hydrargyri nitratis mitius does much good, applied daily. When the head is the part affected, the hair should be cut off close to the scalp, with a pair of scissors. Great cleanliness is, of course, essential. It is very often re- bellious to treatment. 4. Icthyosis.—Icihyosis, the fish-skin disease, is charac- terized by the development, upon one or more parts of the integuments of thick, hard, dry, imbricated scales of a dirty- grey color, resting upon an uninflamed surface, and unat- tended by heat, pain, or itching. It is said to be a congenital disease, and to last during life. Simple warm and alkaline baths may be used as palliatives • TUBERCULA. 251 no other treatment seems of any use. Donovan's triple solu- tion might be tried. SECTION X.—ORDER 9. TUBERCULA. 1. Elephantiasis.—There are two species of this disease; viz., Elephantiasis Grcecorum, and E. Arabucum. Elephantiasis Grcecorum is a terrible and dangerous affec- tion; non-contagious, hereditary, and generally incurable. It is characterized by the appearance of patches of a purplish color; succeeded by elevated tumors, having the same tint, irregular in shape and size, soft, smooth, and insensible to the touch, and which generally—after a certain time—become the seat of unhealthy ulceration. It is not met with in temperate climates, but. there is found to be a disposition to it as we ap- proach the polar regions on the one hand, and the tropics on the other. Males suffer from it more than females. It is designated by the Jews tsaraath. Elephantiasis Arabicum is characterized by great swelling and induration of the skin and of the subjacent areolar and adipose tissues, producing marked deformity. It frequently attacks one of the lower extremities, causing great swelling so that the limb becomes double its natural size; hardness ; severe pain; and an appearance resembling—it is fancifully said— the leg of an elephant. It is uncommon in Europe, occur- ring principally in the West Indies ; it generally continues for life; causes alarming constitutional disturbance; is neither contagious nor her Mr.uy; ^.rthat no ^o actions can take place in the Sll,ne constitution, nor in the same part, at one and the same time; the operations of the body are similar in this respect, to actions or naotions in common matte, It natural y VARIOLA, OR SMALL-POX. 257 body at the same time, is proved to have no real foundation, there seems little reason to doubt that an individual exposed to the contagion of both poisons may suffer from a hybrid disorder compounded of the two fevers. Moreover, Mr. Marson, in a paper on the coexistence of variola and scarlatina, adduces several instances of the simul- taneous occurrence not only of those two fevers, but also of variola and rubeola, variola and pertussis, variola and vaccinia, rubeola and scarlatina, rubeola and vaccinia, rubeola and per- tussis, varicella and vaccinia, and pertussis and vaccinia. * SECTION II.—VARIOLA, OR SMALL-POX. Variola, or small-pox, may be defined as a contagious and infectious fever; commencing with lassitude, headache, stupor, mental depression, rigors, heat of skin, vomiting, and pain in the back and loins; and succeeded on the third day by an eruption of pimples, which in the course of a week inflame and suppurate. In many instances it is accompanied by a similar affection of the mucous membrane of the nose and mouth; in some, by swelling and inflammation of the subja- cent cellular tissue; and occasionally, by affection of the ner- vous system. When the vomiting and pain of the back are violent, they are generally the precursors of a severe form of the disease. The period of incubation, or the time which elapses from the hour of infection to the establishment of the fever, is twelve days; during which the patient's health is apparently perfect. It is curious that, when the disease is received into the system by inoculation, only seven days elapse between the reception of the virus and the appearance of the fever. There is no contagion so powerful or so certain as that of small-pox; results from this principle, that no two different fevers can exist in the same constitution, nor two local diseases in the same part, at the same time." Vol.iii.,p. 4. Hunter's Works. Palmer's edition. London, 1837. £ Medico-Chirurgical Transactions, vol. xxx. p. 129. London, 1847. 22* 258 VARIOLA, OR SMALL-POX. the period when transmission is most likely to happen is during the suppurative stage. As a rule, the susceptibility of the constitution to the action of the poison is exhausted by one attack; but cases of recurrent small-pox have occurred, though rarely. The peculiar eruption of pimples or papule always begins to show itself on the third day of the fever; first appearing on the face, the neck and wrists, the trunk, and, lastly, on the lower extremities. The papulae then gradually ripen into pustules, the suppuration being complete by the ninth or tenth day; at which time the pustules break, and crusts or scabs form. In four or five days more these scabs are falling off. The fever of the small-pox is remarkable; inasmuch as it remits entirely when the eruption comes out, but reappears about the end of the eighth day of the disease in the distinct, and on the eleventh day in the confluent form. Now the severity of small-pox almost always bears a direct relation to the quantity of the eruption. When the pustules are few, they remain distinct and separate from each other; when very numerous, they run together, coalesce, and lose their regularly circumscribed circular form. We thus have a division of this disease into two varieties—variola discreta and variola conjluens. The former is seldom attended with danger; the latter is never free from it. The eruption on the face may be of the confluent form, while it is scanty elsewhere; still the disease is of the confluent kind. Sometimes the pustules are so numerous that they touch each other, but nevertheless do not coalesce; the disease has then been said to be of the cohering or semiconjlucnt form. In variola discreta, the eruption, in the words of Willan, is papular. On the third day a small vesicle, with a central depression, appears on each papula, containing some thin transparent lymph; around this an inflamed areola forms. About the fifth day of the eruption, or the eighth of the dis- ease, the vesicles lose their central depression, become turgid, and hemispheroidal. Suppuration has occurred, and the vesi- VARIOLA, OR SMALL-POX. 259 " cles have become pustules, containing yellowish matter. A peculiar disagreeable odor now begins to emanate from the pa- tient, which once smelt cannot be forgotten; from it alone the disease may be diagnosed. About the eighth day a dark spot appears on the top of each pustule, the cuticle bursts, the matter oozes out, and the pustule dries into a scab. In about four or six days more the crusts fall off, leaving a purplish-red stain, which slowly fades; or where the pustule has gone so deep as to destroy a portion of the true skin, that permanent disfigurement—-the so-called pitting or pock-mark—results. Variola confluens is usually ushered in by more violent fe- ver, greater sickness, and more intense pain in the back, than in the discrete variety. The eruption comes out earlier; the eyelids swell, so that by the fifth day the patient is often unable to see; the parotid glands become affected; there is salivation also; and the limbs swell. The vesicles on the face run together into one bleb, containing a thin brownish ichor; the face is pale and doughy. The vesicles on the trunk and extremities, though often not confluent, have no areola, and are pale. On the breaking of the pustules, large black or brown scabs arc formed, exhaling great foetor; pulse rapid; great debility; and restlessness. The mucous membranes become involved; those of the nose, mouth, larynx, and trachea are the seat of an eruption; tongue and palate covered with vesicles; throat is very sore; there is difficulty of swallowing; hoarseness; dyspnoea; cough; the glottis often becomes narrowed, and suffocation may ensue. Delirium fre-, quently occurs; usually of a low muttering kind. When to the foregoing symptoms malignancy and putrescency are added, the disease becomes malignant smallpox. But the greatest difference between variola discreta and variola confluens is in the secondary fever; which sets in usually about the eighth day of the disease in the former,' and on the eleventh in the latter. In variola discreta this secondary fever is generally slightly marked; the patient being merely hot, restless, and uncomfortable. But yi variola * 260 VARIOLA, OR SMALL-POX. confluens, the fever is intense and perilous; the pulse is weak and rapid, the tongue brown and dry, there is great prostration, general tremors, coldness of the extremities, col- lapse of the features, and generally delirium. Occasionally the fever at once proves fatal, the system appearing to be overwhelmed by the virulence of the poison. In all cases the greatest care and the most attentive nursing will be required. Should any complications arise—as erysipelas, phlebitis, pneumonia, inflammation of the urinary organs, ophthalmia, &c, the danger will be much increased. Prognosis.—This disease is seldom fatal to young people between seven and fourteen years of age: it is, however, very dangerous to infants and delicate children. The more con- fluent the eruption, the greater the danger; the more perfect the maturation of the pustules on the fourth day, the less the danger. The more abundant the eruption, the greater the danger: for inasmuch as the pustules eliminate the morbid poison existing in the blood, and arc thus essential to the cure, so their quantity also indicates the extent to which the blood has been poisoned. The provident action by which these small abscesses are so beneficial, has been denominated by Dr. Addison "cell-therapeutics."* Of those who die, nearly one-half do so between the seventh and eleventh days of the eruption. Delirium, a suppression of the perspiration, scanty urine, hajmaturia, great hoarseness, a sudden sup- pression of diarrhoea when present, are dangerous symptoms : . the formation of abscesses or sloughing sores, the occurrence of convulsions, of erysipelas, or of other combinations, arc circumstances which increase the probability of a fatal termi- nation. Treatment.—In the treatment of small-pox, as of the other eruptive fevers, the practitioner must not attempt too much; ' and especially must he endeavor to aid, and not to thwart Nature. There are three rules to bear in mind:—1. To moderate the fever, when it is violent, by salines, mild laxa- * On Cell Therapeutics, by W. Addison, M.D., &c. London, 1850. VARIOLA, OR SMALL-POX. 261 fives, cooling drinks, and cool or tepid sponging. 2. To support the vital powers when they flag, by stimulants, nourishing broths, and milk. 3. To combat any complica- tions that arise with great caution; remembering that anti- phlogistic remedies are badly borne by a system already pros- trated by a debilitating poison. Distinct small-pox requires but little treatment; and if the young patient is doing well, no medicine whatever should be given, notwithstanding the wishes of the parents or nurses to the contrary. I say this, because a popular belief still exists that drugs can cut short this affection; and old women—of both sexes—are very fond of doing something. Consequently the practitioner will be contented with ordering a plain, unstimulating regimen; he will watch the child to detect any complications as early as possible; he will direct the «ick-room to be kept cool, and the bed-linen to be light and often changed; and if thirst is complained of, he will allow plenty of water, or milk and water, or lemonade, or the juice of ripe subacid fruits. Supposing the case does not proceed as favorably as could be wished, the prominent symptoms must claim attention. Thus, if the bowels are confined, mild vegetable purgatives may be administered; when there is great heat of skin, the surface should be sponged every three or four hours with tepid or cold water, and effervescing salines or soda-water freely given; where there is great irritability, I have seen opiates in small doses act very beneficially; and when the throat is affected, emetics and gargles of sulphate of zinc— gr. v. to water £j.—or of the compound infusion of roses, afford relief. Should the maturation of the pustules go on tardily, good broths and a little wine and water, or ammonia in camphor mixture, will be called for; at the same time that the condition of all the internal organs is carefully looked to. In treating the secondary fever, attend to the bowels; administer sedatives if there be much irritability; and support the system by a nourishing but digestible diet, such as strong 262 VACCINIA, OR COW-POX. beef-tea, milk, the yolk of one or two eggs daily, &c. Sloughy and gangrenous sores demand the application of poultices or fomentations; the liberal administration of wine and brandy or of cordial medicines; and when they occur on the b;ick or nates, the patient should be placed on a water-bed, or on one of Hooper's large water-pillows. With regard to the prevention of pitting, several means have been recommended, though I know of none entitled to much confidence. The agent in which I have most faith for this purpose is the calamine cerate; which can do no harm, at all events, when freely applied. Further evidence is wanted of the utility of covering the face with gold-leaf, or with mercurial ointment, or with a solution of corrosive sublimate, or with the tincture of iodine, or with a strong solution of nitrate of silver, before advising any such applica- tions. To relieve the intolerable itching of the pustules, they may be smeared with the calamine cerate diluted with olive oil, or with cold cream, or, what is better, carron oil.—F. 85. When the pustules have burst, some dry powder, as the oxide of zinc, or powdered starch, should be freely applied, to absorb the matter. SECTION III.—VACCINIA, OR COW-POX. Since the discovery of Vaccination by Jenner,* towards the close of the eighteenth century, the fatality of small-pox has * Edward Jenner, the son of the Rev. Stephen Jenner, vicar of Berkley, in Gloucestershire, was born 17 May, 1749. "While serving his apprenticeship to Mr. Ludlow, a surgeon at Sodbury, near Bristol, a young woman came to the house, and the conversation happening to turn upon small-pox, she said: "I cannot take the disease, for I have had the cow-pox." This observation made a great impression upon Jenner's mind: but did not bear fruit for some years. After completing his professional education in London, during two years of which time he resided with John Hunter, he went to Berkley to pi'actise; and seems often to have thought over the possibility of demonstrating the preservative powers of the cow-pox against small- pox. It was not, however, until he had taken his doctor's degree at VACCINIA, OR COW-POX. 263 been most considerably diminished; so that whereas for the ten years ending 1800 the average annual mortality from this disease within the Bills of Mortality was 1,780 in a popu- lation of 261,233, this number was reduced to an average '-VA St. Andrew's, in 1792, that he had leisure thoroughly to investigate the subject; and in 1795, he persuaded fourteen persons who had previously had the cow-pox to be inoculated for the small-pox, not one of whom—as he had hoped and anticipated—took the infection. His experiments were continued, and in 1798 he published the results and came to London. During the three months he remained in town, he could not induce a single person to be vaccinated; and the paper wbich he wrote for the Royal Society was declined by this learned body. After he had returned home, Mr. Cline wrote and advised him to settle in London, assuring him of a practice of 10,000/. a-year. Here is Jenner's reply: " It is very clear, from your representation, that there is now an opening in town for any physician whose repu- tation stood fair in the public eye. But here, my dear friend, is the rub. Shall I, who, even in the morning of my days, sought the lowly and sequestered paths of life—the valley, and not the mountain—shall I, now my evening is fast approaching, hold myself up for fortune and for fame? Admitting it as a certainty that I obtain both, what stock shall I add to my little fund of happiness ? My fortune, with what flows from my profession, is sufficient to gratify my wishes. Indeed, so limited is my ambition, and that of my nearest connections, that were I precluded from future practice, I should be enabled to obtain all I want; and as for fame, what is it ?—a gilded butt, forever pierced with the arrows of malignancy. The name of John Hunter stamps this observation with the signature of truth." However, it was abso- lutely necessary that Jenner should come to ^ondon to explain his views. He did so ; he succeeded in satisfying the profession and the public that he had indeed been intrusted with " the mighty and re- sponsible effice of shutting one of the great gates of human death;" and his triumph was ultimately complete. In 1807, Parliament voted Dr. Jenner 30,000Z. as a reward for his discovery: in 1808, the National Vaccine Establishment was formed: in 1823, Jenner died: in 1840, a Bill passed the legislature for the extension of vaccination, and another declaring the practice of inocu- lation illegal: in 1853, compulsory vaccination was first established: and in 1858, it is to be hoped, that the statue to Jenner's memory— already completed—will be erected in Trafalgar-square. 26-1 VACCINIA, OR COW-POX. annual amount of 821—for the fourteen years ending 1S55— with a population of above 2,250,000. / .•;. '. 1 •'/•- When vaccination has been successfully performed on a healthy child, an elevation may be felt over the puncture on the second day, accompanied by slight redness ; on the fifth, a distinct oval or circular vesicle is formed, having an elevated edge and depressed centre; on the eighth, it is of a pearl color, and is distended with a clear lymph. This vesicle is composed of a number of cells, by the walls and floor of which the lymph is secreted. An inflamed ring or areolar now begins to form round the base of the vesicle, and to increase during the two succeeding days; about the eleventh day it fades; and the vesicle, which has now burst and acquired a brown color, has by the end of the second week become converted into a hard round scab. This falls off about the twenty-first day; leaving a circular, depressed, striated cicatrix, which is usually permanent in after life. The constitutional disturbance which accompanies vaccina- tion is generally very slight: about the eighth day the infant is rather restless, the bowels are perhaps confined, the skin is hot, and the sleep is disturbed. These symptoms, however disappear spontaneously in two or three days. Some interesting experiments lately made by Dr. Gustav Wertham, of Vienna, tend to show that the frequency of the pulse is permanently increased by the process of vaccination. Thus, a man aged thirty-eight, and a woman aged thirty- three, neither of whom had suffered from small-pox, were vaccinated for the first time; the pulse, in both cases, in- creased in frequency up to the six.th day after vaccination, when it began to decline; never declining—not at least for the four months during which the observations were continued —as low as it was before the introduction of the vaccine virus. For example, before the vaccination the man's pulse was on average 66; afterwards the average was 78. In practising vaccination, it is better to use recent lymnh which should be taken from the vesicles between the fifth and VACCINIA, OR COW-POX. 265 ninth days, the seventh or eighth being probably the best. Three or four small punctures must be made with a sharp lancet on either arm, and' the vaccine lymph inserted deep enough to come in contact with the absorbing surface of the cutis vera. According to the Act of Parliament, passed in 1853, parents and guardians are obliged to have every infant vaccinated ■ within, at furthest, four months from birth; unless, indeed, the child's state of health renders it necessary to postpone the operation. With regard to re-vaccination at the period of puberty it / must be recommended ; for although in probably the majority of cases where vaccination has been properly performed during infancy it may prove unnecessary, yet in some in- stances the protection which has been afforded does certainly seem to die out, and hence requires renewal. Moreover, it is certain that re-vaccination can do no harm; while it will doubtless, increase the patient's feeling of security. When small-pox occurs after a child has properly taken cow-pox, as it sometimes will, the disease is much milder and shorter, is unaccompanied by secondary fever, and is less likely to lead to disfigurement or permanent impairment of the constitution; it is called modified small-pox. But the protection afforded by vaccination is within a fraction as great as that given by inoculation; -while the former is unattended with any danger, and does not—like the latter__ tend to keep alive and propagate the disease. At the Royal Military Asylum, Dr. Balfour has shown that out of every 1,000 boys admitted protected by previous variola, 6-15, and out of every 1,000 protected by vaccination, 7-06 were attacked subsequently by small-pox : while it is very remark- able that whereas the deaths from secondary small-pox amounted to 2-05 per 1,000 of those attacked, not one fatal case occurred in those affected with modified variola.* More- over, from records kept at the Small-Pox Hospital, Mr. * Medico-Chirurgical Transactions, vol. xxxv., p. 403. London, 1852 23 266 VARICELLA, OR CHICKEN-POX. Marson proves that the mortality from small-pox in persons well vaccinated, and having more than two cicatrices, was less than 1£ per cent.; in persons reputed to be vaccinated not more than 3 or 4 per cent, under favorable circumstances, and not more than 7 under unfavorable; while the mortality of the natural small-pox varied from 20 to 35 per cent.* SECTION IV.—VARICELLA, OR CHICKEN-POX. Varicella, or chicken-pox, is a trifling complaint almost peculiar to infants and young children. After a short incu- bation—probably four days—an eruption of transparent vesicles appears, the bases of which are surrounded by a slight inflammatory blush. The eruption generally commences on the shoulders and breast, affects the scalp, but generally spares the face, and is accompanied by slight pyrexia. Dr. Gregory states that when the vesicles are abundant the body presents the appearance of having been exposed to a momentary shower of boiling water, each drop of which has produced a small blister. There are no constitutional symptoms of any importance; the disease occurs but once to the same person; it is conta- gious ; it runs its course in six days; and it requires no treat- ment beyond attention to the diet, and confinement to the house until the desiccation of the vesicles is completed. SECTION V.—RUBEOLA, OR MEASLES. The Measles (Cullen,) Rubeola (Willan,) Morbilli (Syden- ham,) are terms employed synonymously to designate a dis- ease, the distinguishing characters of which are—a continued contagious fever, accompanied by an eruption, and frequently attended with inflammation of the mucous membrane of the respiratory organs. Symptoms.—After a period of incubation, varying from * See an interesting paper by Dr. E. C. Seaton on the Protective and Modifying Power of Vaccination in the Journal of Public Health. London, January, 1857. RUBEOLA, OR MEASLES. 267 ten to fourteen days, during which there is but little disturb- ance to the general health—perhaps a feeling of languor, with a cough—symptoms of fever with catarrhal implication begin to show themselves, followed by rigors; the conjunctivae, Schneiderian membrane, and membrane of the fauces, larynx, trachea, and bronchi becoming affected. In a day or so there is swelling of the eyelids; eyes suffused and watery, and in- tolerant of light; sneezing; dry hollow cough, with hoarse- ness and dyspnoea; drowsiness; a tendency to delirium; great heat of skin; and frequent and hard pulse. The eruption comes out at the end of the third or beginning of the fourth day of the disease, seldom earlier, often later. It consists of small circular spots, like flea-bites, which gradually coalesce into blotches; these are of a dull dingy-red color, present frequently a crescentic or horse-shoe shape, and are slightly raised above the surface of the skin. The rash appears first on the forehead and face, and gradually extends downwards : it begins to fade on the seventh day in the same order, and without producing that marked desquamation which is such a striking feature in scarlatina and erysipelas. The diarrhoea, which often sets in as the rash declines, is for the most part beneficial. It is worthy of notice that the fever does not abate—though the cough often ceases—on the appearance of the eruption, as in small-pox; nor does the severity of the attack at all depend upon the quantity of the rash. The contagion of measles is strong; being most powerful during the eruptive stage, and especially during the early part of this period. Some ob- servers have stated that rubeola is most contagious at the time of desquamation; but this was clearly disproved during an epidemic of measles which broke out in the Faroe Isles in the year 1846. Prognosis.—This must depend upon the mildness or severity of the chest symptoms: the complications most to be feared are severe ophthalmia, laryngeal and croup affections, or bronchitis and pneumonia. In the great proportion of fatal 2i')H SCARLATINA, OR SCARLET FEVER. cases, death is due to pneumonia. There were 864 deaths from measles in London during the year 1855 ; while in 1856 the number was increased to 1,445. Probably one case in fifteen is fatal. Treatment.—Exposure to cold to be carefully avoided. The patient should be confined to bed, in an apartment moderately warm. Low diet, mucilagiuous drinks, gentle aperients, and mild diaphoretics must be had recourse to. A draught con- taining one drachm of the liquor ammonia; acetatis, ten or twenty drops of the spiritus jetheris nitrici, and half an ounce of camphor mixture, may be given to a child six years old every four or six hours. When the cough is very troublesome a little syrup of poppies should be given at bed-time. If the diarrhoea prove exhausting, one or two grains of Dover's pow- der will help to check it; if there be much debility, nourish- ing broths, and wine or cordial draughts, will be called for. The state of the three great cavities must be carefully watched, especially towards the decline of the eruption. Should any complications arise, they must be treated accord- ing to the rules which will be laid down in speaking of each affection. After the disease has subsided, the patient should be warmly clad, and not allowed to go out of doors too early. SECTION VI.—SCARLATINA, OR SCARLET FEVER. Scarlatina, or Scarlet Fever, is an infectious and contagious febrile disease, characterized by an extensively-diffused bright- scarlet efflorescence of the skin, and of the mucous membrane of the fauces and tonsils, commencing about the second day of the fever, and declining about the fifth: it is often accom- panied by inflammation of the throat, and sometimes of the submaxillary glands. Like measles, it is essentially a disease of childhood, but it is more to be dreaded. The average mor- tality from it is about one in seventeen cases in adults; pro- bably one in twelve in children under fifteen years of age. In London, in 1854, the deaths from it were 3,43'J; in 1856 the number was only 1,705. SCARLATINA, OR SCARLET FEVER. 260 There are three varieties of this disease. Scarlatina sim- plex, in which the skin only is affected; scarlatina anginosa, in which both skin and throat are implicated; and scarlatina maligna, in which all the force of the disease seems to be ex- pended upon the throat. Scarlatina simplex commences—after a period of incuba- tion, which lasts from four to six days—with slight fever, rigors, lassitude, and headache. The eruption appears on the second day; first about the neck, face, and chest, in the form of numberless red points, which, in twenty-four hours from their first appearance, cover the whole body. On the limbs, but especially about the fingers, there is a diffused, continued efflorescence; but on the trunk the rash is distributed in irre- gular patches. The eruption is of a bright-scarlet color,- most distinct about the loins and the flextures of the joints. The efflorescence commonly terminates by desquamation of the cuticle, which begins about the end of the fifth day on those parts where the rash first appeared. On the face and trunk the desquamation is in the form of scurf; while on the hands and feet large flakes of cuticle are detached, so that sometimes a glove or slipper of scarf-skin comes away at once. At the same time that the efflorescence has been spreading on the surface of the body, the mucous membrane of the mouth, fauces, and nostrils has also been affected. The tongue espe- cially puts on an appearance characteristic of scarlatina. It is at first covered with a thick white fur, through which the red elongated papilla) project; but as this fur clears away, it be- comes clean and preternaturally red, and of a strawberry ap- pearance. The affection of the mucous membrane of the mouth, &c, termiuates by resolution : with the disappearance of the rash the febrile symptoms subside; and the disease ter- minates at the end of eight or nine days, leaving the patient very weak. Scarlatina anginosa is ushered in with more violent symp- toms than the preceding. There is headache with some deli- 23* 270 SCARLATINA, OR SCARLET FEVER. riuin, more pungent heat of the skin, and marked prostration. About the second day there is stiffness of the neck, uneasiness in the throat, hoarseness, and pain on swallowing. The fau- ces, palate, uvula, and tonsils arc red and swollen; and the inflamed surfaces are covered with an exudation of coagulablc lymph. As this inflammation goes on, all the febrile symp- toms increase, and the skin becomes very dry and hot. The efiiorescence does not observe the same regularity as in the simple form; it does not appear so early, is delayed to the third or fourth day, comes out in scattered patches on the chest and arms, and shows a tendency to vanish the day after its appearance, and to reappear partially at uncertain times. With the fading of the eruption about the fifth or sixth day, the fever and inflammation of the throat begin to abate although the throat often remains sore for a week or ten days after the disappearance of the rash. Occasionally this variety of scarlet fever assumes a more aggravated form; being accom- panied with an acrid discharge from the nostrils and ears, deafness, and inflammation of the parotid and cervical glands —sometimes going on to suppuration. During the progress of the disease, particular attention should be paid to the internal organs, since there is a great predisposition to inflammation of the serous and mucous membranes. Scarlatina maligna, described by Cullcn under the title of Cynanche maligna, differs but little in its symptoms, at first, from scarlatina anginosa. The fever, however, soon assumes a malignant or typhoid character; great cerebral disturbance being superadded to the affection of the fauces and skin. There is great irritability, restlessness, and delirium,—the delirium being sometimes violent, but usually of the low mut- tering kind. The tongue is dry and brown, tender and chapped; the lips, teeth, and gums are covered with sordes; and the breath is extremely foetid. The throat is not much swollen, but appears of a dusky-red hue, while the velum uvula, and tonsils are covered with dark incrustations, con- SCARLATINA, OR SCARLET FEVER. 271 sisting of exudations of lymph; in some cases there is gan- grenous inflammation of these parts, followed by sloughing. The cervical glands are often involved in the inflammation. The rash is exceedingly irregular as to the time of its appear- ance and duration; often coming out late, disappearing after a few hours, and being renewed several times during the pro- gress of the disorder. It is at first of a pale hue, but soon becomes changed to a dark livid red; petechise also often appear upon the skin. In many instances this malignant form of scarlet fever ter- minates fatally on the third or fourth day. It is always a dis- ease of such extreme danger that only patients with vigorous constitutions survive it; great hopes may be entertained, how- ever, if the seventh day be passed. Sequelm.—Children who have suffered from scarlatina are very liable to have their health permanently affected, and to become afflicted with some of the many forms of scrofula, especially strumous ulcers, ophthalmia, scrofulous enlarge- ments of the cervical glands, diseases of the scalp, &c. But the most frequent and most serious sequel is a peculiar renal affection, with general anasarca: the former being charac- terized by the secretion of scanty, smoky-looking, albuminous urine; the latter by serous infiltration. of the subcutaneous areolar tissue, often accompanied by dropsy of the larger serous cavities. It occurs about the twenty-second day from the commencement of the fever. Now it is curious that this scarlatinal dropsy is more frequent after a mild than after a severe attack; owing, probably, to the want of caution which is often observed in such cases during the period of desqua- mation. The patient gets exposed to the action of cold : the exposure arrests the functions of the skin: the scarlatinal poison which was being eliminated by the cutaneous excre- tion is thrown back into the circulation: the kidneys are, as it were, called upon to eliminate that material which the skin has been temporarily rendered incapable of doing: but the contaminated blood is sent to them in larger quantities than 272 SCARLATINA, OR SCARLET FEVEK. they can bear, or the morbid poison in the blood overwhelms them, and hence arises— Acute Desquamative Nephritis.—This renal affection also occurs from cold, the cholera-poison, and other causes besides scarlatina; but for a description of it, as well as for an account of the treatment it requires, I must refer my readers to Chapter XIX., Section 1. During the progress of scarlatinal dropsy—as indeed from dropsy produced by other causes—children are liable to suffer from— (Edema or the Lungs.—The symptoms in the commence- ment are those of bronchitis; but at the end of two or three days the breathing becomes greatly hurried, dyspnoea or even orthopncea sets in, there is violent action of the heart, and a very feeble pulse. On practising oscultation and percussion no signs will be found to account for the severity of the suffer- ings ; for there is neither bronchial respiration, nor crepitation, nor diminished resonance. Notwithstanding, however—unless relief be given by free purging, the hot-air bath, an antimonial emetic, and frequently-repeated doses of the nitric aether—the symptoms increase, the distress becomes very great, the coun- tenance gets livid, and the child dies. On cutting into the lungs after death, they are found loaded with reddish serum: an accumulation of fluid having taken place either in the pul- monary vesicles or in the areolar tissue surrounding them, and thus impeded the entrance of air. Treatment.—The treatment of scarlatina yet remains to be considered. The simple form, says Sydenham, is " fatal only through the officiousness of the doctor." It requires no treat- ment beyond confinement to the house for at least two or three weeks after all symptoms of the disease have disap- peared, warm clothing, spare diet, and attention to the bowels. In scarlatina anginosa the treatment is often much the same as that for many cases of continued fever. Cold or tepid sponging where there is great heat; perfect ventilation of the sick-room, without draughts of cold air; emetics when the SCARLATINA, OR SCARLET FEVER. 273 tongue is much coated, and nausea and irritability of the stomach exist; shaving the scalp and the application of cold lotions where there is much delirium; great caution in the use of antiphlogistic medicines—as antimony; and a strict avoidance of bleeding, even by two or three leeches. Purga- tives judiciously employed will often obviate the necessity for lowering measures of any other kind, but they must on no account be given too freely, or in too large doses. Saline medicines are grateful and cooling; or, where the pulse is feeble, effervescing draughts containing an excess of ammonia. When there are decided symptoms of depression or collapse, wine, cordial draughts of ammonia, aether, and camphor, and nourishing food, must be ordered. In malignant scarlet fever, a stimulating plan of treatment, such as that so successfully pursued by Dr. Todd, myself, and others in typhus, alone offers any chance of success. The vital powers are so prostrated by the deadly force of the poison, that unless we support them by the free administra- tion of brandy, wine, and bark, they will fail altogether. When seen early, however, the treatment may be advan- tageously commenced by a mild emetic (F. 23.) The gan- grenous ulceration of the fauces, which often complicates this form, will be also best combated by the use of stimulants and the local application of a solution of the chloride of soda: but when very severe the throat and fauces must be swabbed with a strong solution of nitrate of silver—gr. x. to §j. The chlorate of potass drink (F. 36,) will be useful. Chlorine itself—(F. 32)—is used by some practitioners, who speak highly of its good effects, in even the worst cases. Bella- donna, in very minute doses, has been recommended as a prophylactic against scarlatina. In an epidemic of this dis- ease which occurred on board Her Majesty's ships " Agamem- non" and "Odin," in 1S53, this remedy was freely tried, without the slightest benefit. 274 INFANTILE FEVER. CHAPTER XIII. INFANTILE FEVER. Simple, or infantile, or remittent, or more correctly—ty- phoid fever, occurs in children in two degrees, i. e., in a mild and in a severe form. In cases of the first, or the mild kind, the disease comes on very gradually; the earliest symptoms that attract attention being loss of appetite, great thirst, and mental depression, so that the child is no longer lively and cheerful. During the day, also, it is listless, indolent and peevish; and though drowsy towards the evening, yet its nights are restless, and there is a want of sound refreshing sleep. When these indi- cations of ill-health have persisted for a few days, it is noticed that the skin is hot, at some hours of the day dry, at others covered with perspiration; the breath is offensive; the bowels are generally loose, the evacuations being unhealthy and offen- sive ; and sometimes there is obstinate constipation. In the second week the symptoms increase; the child passes very bad nights; screams, moans, grates its teeth, and starts in its sleep; suffers much from thirst and occasionally from sick- ness and vomiting; and perhaps has slight delirium. There is exacerbation of the fever towards the evening, with remis- sion as the morning approaches; occasionally there is a second though less severe exacerbation about eleven o'clock in the morning. In mild cases there is seldom any rash; if any appear, it will be at this time in the form of the rose spots— so very characteristic of typhoid fever. The skin of the lips, face, nose, and fingers becomes dry and rough, and the child is constantly picking it; and there is a marked loss of flesh, with great debility. Towards the end of the second, or the beginning of the third week, the symptoms begin to abate, and day by day the child improves in health; although some time often elapses before convalescence is completely estab- lished. INFANTILE FEVER. 275 In the second or severe form of fever, the symptoms just enumerated commence more suddenly and are more strongly marked. There is vomiting, great drowsiness, and sometimes slight rigors; the countenance looks heavy; the mind wanders at night: the skin is very hot and dry; the pulse very fre- quent ; and from the sixth to the tenth day a very scanty eruption of rose spots makes its appearance upon the back, thorax, or abdomen. As the disease progresses, the restless- ness and delirium become aggravated; the tongue is dry, brown, and glazed; the abdomen is found tumid and tender; the respiration is accelerated, and there may be cough, with a feeling of oppression at the chest; there is generally diarrhoea; the urine is scanty and high colored ; and all the evacuations are passed unconsciously. By the end of the second week the patient is reduced to the most emaciated and helpless state; until, when apparently in the worst possible condition, slight signs of amendment show themselves. Day by day the improvement increases, and at the end of some weeks health is restored. Typhoid fever is, I believe, contagious; relapses sometimes occur; and cerebral or pulmonary complications occasionally arise and increase the danger. It must not be confounded with the simple irritative fever which is produced by dentition, improper food, &c. The cases which terminate fatally are few in number. The mortality of one in ten in France, as given by MM. Rilliet and Barthez, is too high for this country. When fatal, the prominent post-mortem appearances are slight congestion of the membranes of the brain, engorgement of the lungs, softening of the spleen, enlargement of the mesen- teric glands, and more particularly tumefaction and ulceration of the agminated glands or Peyer's patches situated in the ileum. Treatment.—All fevers—whether in the adult or the very young—seem disposed to run a certain course, and to termi- nate in the re-establishment of health. But, as in the treat- ment of all disease, there are certain general objects called the 276 INFANTILE fever. indications of cure, which must be kept in view. In fever these indications are—1, to moderate, when necessary, the violence of arterial excitement by the antiphlogistic regi- men; 2, to support the powers of the system; 3, to obviate local inflammations and congestions; and 4, to relieve the urgent symptoms. It was well observed by Pitcrain,—"I do not like fever-curers. You may guide a fever; you cannot cure it. What would you think of a pilot who attempted to quell a storm ? either position is equally absurd. In the storm you steer the ship as well as you can; and in a fever you can only employ patience and judicious measures to meet the diffi- culties of the case." At first, medicine is little needed; the diet should be low; toast-water or plain water may be allowed rather freely as a drink; the use of the tepid bath every morning, or frequent sponging of the body with lukewarm water, will be bene- ficial ; and the little patient's apartment must be kept well ventilated. The chloride of lime may be used as a disin- fectant. If the abdomen becomes tender, warm linseed-meal poultices will give ease : and the unhealthy diarrhoea will be best relieved by castor oil, followed by small doses of the hydrargyrum cum creta. and Dover's powder. WThen the vital powers need support, good beef-tea, chicken-broth, and wine will be necessary; or a stimulant draught (F. 58 or 59) may be ordered in the place of the wine, or, if necessary, to alter- nate with it. Dr. Stieglitz, of St. Petersburg, strongly recommends F. 66 where there is great depression. During convalescence the food must be nourishing, but very digestible. Change of air, especially removal to the sea-side, will prove of great advantage. INFANTILE INTERMITTENT FEVER. 277 CHAPTER XIV. INFANTILE INTERMITTENT FEVER. The intermittent fever of infants, though arising in the same way and from the same causes as that of older children and adults, has this remarkable difference—that the paroxysms are not very regular, and that it is not accompanied by rigors. It is also a rare disease in children under five years of age. There are three species of intermittent fever or ague from which adults suffer, viz., Quotidian, Tertian, and Quartan ague ; of which the tertian is the most common. Children at the breast, however, seem generally to suffer from the quoti- dian. When the paroxysm occurs at the same hour every day, it is called quotidian ague; when every other day, tertian, though secunda would be more appropriate; and when it is absent for two whole days, and then recurs, quartan. In the first species the interval is twenty-four hours, in the second forty-eight, in the third seventy-two. The time between the commencement of one paroxysm and the beginning of the next is termed the interval; that between the termination of one paroxysm and the commencement of the next, the inter- mission. In quotidians the paroxysm occurs, for the most part, in the morning ; in tertians, at noon ; in quartans, in the the afternoon. The first is most common in the spring, the second in the spring and autumn, and the third in the autumn. The predisposing causes of ague are debility, and the once having suffered from it. The exciting cause consists of certain emanations or invisible effluvia from the surface of the earth, known as malaria. It is worth remembering that malarious districts are most dangerous at night, and that this poison lies low, or, as Dr. Watson says, " loves the ground." An ague fit is composed of three stages, the cold, hot, and sweating; the first being almost always absent in infants, the second well marked, and the third only slightly manifested. 24 278 INFANTILE INTERMITTENT FEVER. The cold stage, in adults, is ushered in with feelings of languor and chilliness, though the heat of the body may not be really lessened ; sensations as of streams of cold water running down the back, and shivering; the teeth chatter, and the whole frame is shaken; there is exhaustion; often urgent thirst; the countenance appears anxious, the features shrunk and pale, and the eyes dull and hollow; the pulse is small; the respiration hurried and oppressed; and there is a peculiar mental irritability. The duration of this stage varies from half an hour to four hours, and is gradually succeeded by the hot stage, which is one of reaction. The surface of the body becomes dry and intensely hot, the temperature being raised considerably, above the natural standard; the mouth is parched, there is excessive thirst, frequent full pulse, a painful sense of fullness in the head, and great restlessness, general uneasiness, and sometimes delirium. This condition continues rarely less than three or more than twelve hours; and then follows the sweating stage, commencing with perspi- ration appearing first on the forehead and breast, and grad- ually extending over the whole body. The pulse and breath- ing become natural; the headache, heat of skin, and thirst abate; the bowels and kidneys act freely; and all the dis- tressing symptoms are relieved, so that the patient, if the case be recent, often feels in perfect health. The prominent symptoms of ague in infants are—the occur- rence of a decided attack of fever once a-day, emaciation, debility, and enlargement of the spleen. The skin also is flabby, the gums are pale, the extremities cold—except during the hot stage, there is frequently purpura, and not uncommonly other signs of anaemia. Treatment.—Alteratives and tonics, especially quinine, will cure this affection. When the attacks of fever have ceased to recur, the blood must be improved by steel, good diet, and pure air. SCROFULA. 279 CHAPTER XV. GENERAL DISEASES. SECTION J.—SCROFULA. 1. General Observations.—Scrofula, or struma, is a disease of the constitution manifested by certain external signs, of which swelling of the subcutaneous lymphatic glands, espe- cially those of the neck, is the most conclusive.* Not that engorgements of the lymphatic vessels and glands constitute scrofula, or are always due to it; such enlargements often occur from temporary causes, but they are then easily recog- nized by their histories and symptoms. It is still doubtful whether scrofula and tuberculosis are different diseases or not; many authorities regarding them as distinct, though they allow that some unknown relation subsists between them. The question is as yet subjudice; for of the two most recent writers on the subject—Mr. Phillips and Mr. Ancell— the former considers that, though these affections possess a certain general similarity, yet they have no identity; while the latterf regards the disease of the blood which leads to the deposit of tubercle, and that which gives the specific character to scrofulous affections as essentially the same. By many authorities it is stated—though the truthfulness of the statement may be questioned—that persons possessing the strumous constitution or diathesis manifest certain pecu- liarities, such as a coldness of the body; a dull-white, but very delicate skin; a rounded, graceful outline of face/ with a delicacy of feature, and rosy hue of the cheeks, strongly con- trasting with the surrounding pallor, and often giving to the countenance, especially in women, a characteristic beauty; hair which is usually blond or auburn; and eyes large, blue, * See the Treatise of Mr. Benjamin Phillips, on Scrofula, p. 26. London, 1846. f A Treatise on Tuberculosis. London, 1852. 280 SCROFULA. projecting, and humid, with the pupils habitually dilated. Moreover, it is said that such persous are remarkable for the development of the head, of the ahe nasi, and of the upper lip; for the large development of the lower jaw, and tho milk-white teeth, which early become carious ; that the breath is habitually sour and foetid, the neck long and rounded, the chest narrow and flat, the shoulders high, the abdomen large and prominent, the limbs thin, and the flesh soft and flabby. It is commonly believed that in youth all scrofulous persons manifest'great cerebral activity; that they are impatient and passionate; that their intellectual system is largely developed; and that although many have more imagination than judgment, yet some occasionally are ca- pable of sustained mental exertion. There are very few cases, however, where the actual appearances will correspond with this description; the most constant peculiarities are the paleness and coldness of tho body, and the tumidity of the abdomen. As regards the nature of the scrofulous deposit, I cannot do better than give the opinion of Ilecht, who says :—" If we take a large lymphatic gland, altered in structure and con- verted into a mass of scrofulous matter, the whole mass seems homogeneous, and of the same yellowish or dirty-white color; towards the centre the mass is softer, and of a creamy, pulpy appearance. The softened pulp turns litmus-paper green; acted upon by boiling water, or acids, it coagulates, presenting no globule either of fibrin or of pus, and is apparently only a mass of coagulated albumen, with an excess of alkaline salts. But when inflammation is excited by its presence, pus may be found mixed with the matter." He then goes on to show, that, in addition to albumen, it consists of gelatine, fibrin, and probably a little stearine. 2. Causes of Scrofula.—The causes which have been most frequently assigned are hereditary influence, syphilis, bad air, bad food, and a cold and damp atmosphere. As regards hereditary influence, it may be noticed that, if by this is SCROFULA. 281 meant that there is a certain poison or strumous virus trans- mitted from parents to children, the position is totally unten- able ; but, on the other hand, if it be only understood that the children of scrofulous parents are more liable to have the disease developed in them on the application of the exciting causes than the children of healthy parents, as was the opinion of John Hunter, the position is most probably true. That it is not contagious is certain. Many authors have imagined that a syphilitic taint in either parent will induce scrofula in their offspring; while some have even maintained that this disease is only a generated species of syphilis. There seems, however, to be no truth in either of these suppositions; scrof- ula and syphilis being very different diseases, quite indepen- dent the one of the other. Neither does the development of struma appear to be influenced by climate or temperature. But it is to diseased nutrition, however brought about, that we may refer the production of scrofula; and it is to insuffi- cient, or innutritious, or improper food, that the vast majority of cases of diseased nutrition are due, though it may also arise from breathing a vitiated atmosphere, or from want of cleanli- ness and healthy exercise * 3. Prevention.—There are four points to be attended to in the prevention of scrofula. 1. To obtain well-assorted marriages—the marriages of parties in sound health and vigor. 2. Where this disease exists in the parents, or in either of them, great care should be taken to maintain the * " In all parts of Europe," says Dr. Baly, physician to the Mill- bank Penitentiary, "the proportion of deaths has been much greater among criminals in prison, than amongst persons of a corresponding class out of prison; and the increased mortality is due to various forms of scrofula, and especially tubercular phthisis. The causes which contribute to this result are cold, poorness of diet, deficient ventilation, want of sufficient bodily exercise, and dejection of mind. In a great number of cases of phthisis in this prison, apparently hope- less, "the disease was immediately checked on the release of the pris- oners, many of whom entirely recovered." Quoted by Dr. William Addison.—On Healthy and Diseased Structure, p. 48. London, 1849. 24* 282 SCROFULA. health of the mother during the period of utero-gestation. She should wear warm clothing, should take regular exercise in the open air, avoid heated rooms and late hours, and have a plain nourishing diet. 3. On the birth of the child, every means should be taken to strengthen its general health, and to counteract the hereditary influence by attention to the food, air, clothing, ^~ AOUTI] HYDROCEPHALUS. hydrocephaloid affection there are not only prominent signs of delicate health, and extreme langour, but an absence of all active febrile symptoms. Nevertheless it must not be forgot- ten that to bleed, purge, or lower such cases, or even to with- hold from them cordials and proper nourishment, is to sentence them to death. Prognosis.—This is unfavorable, even in the early stages ; more especially when there is any hereditary tendency to tuberculosis. Recovery from advanced hydrocephalus is so rare that Dr. West has never seen one instance of it; and only one case in which the child got well after the second stage had commenced. M. Rilliet also remarks that all the instances in which recovery from hydrocephalus is said to have occurred, took place before the real nature of the disease was understood; but that since its tubercular nature has been recognized, no well-authenticated case has been published by any French physician. He, however, records one case.* The average duration of the disease, from the setting in of well-marked symptoms, is about twenty days; when the symp- toms have run their course very rapidly, death has occurred in less than five days. It is probably most common between the third and fifth years of age. Morbid Anatomy.—The post-mortem appearances usually found are, traces of inflammation of the membranes of the brain ; especially effusion of serous fluid beneath the arachnoid and in the meshes of the pia mater, as well as the presence of false membranes between- the arachnoid and pia mater. These appearances are always most marked at the base of the brain. The cerebral substance often contains scrofulous tu- bercles, while granular tubercular deposits may be seen scattered upon and between the membranes. But the charac- teristic morbid appearance consists of softening of the central parts of the brain, with effusion of thin, transparent serum in- to the ventricles. Thus, in thirty-eight out of forty cases in which death had taken place under the symptoms of acute * Archives Umorales de M<'dccine. December, 1853. ACUTE HYDROCEPHALUS. 303 hydrocephalus, Dr. West discovered an appreciable quantity of fluid in the ventricles; while in thirty-four of the cases the quantity was considerable, amounting to several ounces.* In a few instances the whole brain is found to have lost much of its natural firmness; but commonly the softening is confined to the central portions, and varies in degree from a slight diminution of consistence to such an extent that the cerebral matter resembles thick cream. In addition to the foregoing, deposits of tubercle are gene- rally found in other organs of the body: their most frequent site being the lungs and bronchial glands; and the next in frequency—the liver, spleen, aud mesenteric glands. Treatment.—Our treatment must be prophylactic; for let the disease become established, and medicine can do little or almost nothing. Hence when we find a mother having an evident tendency to tuberculosis, or when we learn that she has already lost children by this disease, we should forbid her suckling; and should take especial care that her infant be reared by a strong and healthy wet-nurse. The infant is to be warmly clothed; it should be taken into the open air daily, if the weather will permit; it should have the benefit of country or sea-air at least for some weeks in the year; and at the period of weaning it should be carefully watched, while the new diet is to be simple but nourishing. In any illness that may effect it, all lowering remedies must be abstained from if possible, or at all events used with great caution; care must be taken to shield it from the contagion of the eruptive fevers, hooping-cough, &c.; and, as it grows older, the intellectual faculties must be cultivated with gentleness and judgment. Supposing that with this care the infant does not thrive, its diet should be made more nourishing, and cod-liver oil—in drachm doses, twice daily—administered. But we may not see the patient until the disease has set in, and what is then to be done ? The treatment of acute hydro- cephalus is beset with difficulties; for, as an inflammatory ■<■ Opus citat., p. 53. 304 ACUTE HYDROCEPHALUS. affection, it is generally said to require remedies which the sufferer—a strumous child—will not bear. With regard to depletion, I doubt very much whether it ought to be had re- course to; at all events I remember no instance in which I have practised it. Some physicians recommend blisters to the vertex or nape of the neck, but the good to be derived from them is pro- blematical. An ointment composed of one part of tartar emetic to two of simple cerate has been recommended; a piece the size of a nut being rubbed over a portion of the scalp every two hours until an abundant eruption is produced. Dr. Hahn asserts that he has cured advanced cases with this remedy.* In purgatives, however, we possess a valuable class of remedies; but they must be given so as to maintain a free action of the bowels for two or three days at least:—F. 13 or 14. At the same time that these agents are employed, Dr. West advises the continued administration of calomel, in one or two-grain doses, twice or thrice daily. Green evacuations, resembling chopped spinach, follow its use : salivation is very rarely produced in young children. The local employment of cold is likewise an important remedy when used in the first stage of the disease. A rag wetted with cold water, or any simple evaporating lotion laid on the child's head and fre- quently renewed, will generally suffice : but it may be neces- sary to have recourse to the use of ice. When the child is teething, many practitioners resort, as a matter of course, to scarification of the gums; forgetting that the irritation arises from the passage of the tooth through the bony canal of the jaw, rather than from pressure on the gum. Such practice is only to be adopted when there is distinct evidence that the gum is offering resistance to the tooth, or when there is decided tenderness and swelling of the gum. Should the vital powers become much depressed, either from * De la Meningite Tubcrculeusc, itudiee aupoint devue clinique. Par II. Hahn. Paris, 1853. SIMPLE ENCEPHALITIS. 305 the course of the disease or from the use of the remedies, stimulants must be freely had recourse to. I have frequently given a child from six to twelve months old a teaspoonful of port wine and water—equal parts, or port wine and beef-tea —in the same proportions, every hour, or every second hour, with the greatest advantage. If physic is preferred, some ammonia with Hoffmann's anodyne may be ordered, accord- ing to F. 57, or 58. The diet must be light but not poor: good-veal-broth or beef-tea, the yolk of an egg beaten up in milk, and arrowroot will often be serviceable. When the sickness causes all food to be rejected, I have seen iced water exceedingly useful. SECTION VI—SIMPLE ENCEPHALITIS. Our knowledge of the effects of inflammation of the parts within the cranium is not sufficiently perfect to enable us to point out with certainty the symptoms which indicate inflam- mation of the substance of the brain—phrenitis, as distin- guished from that of the membranes—meningitis; and for- tunately the distinction is not of much practical importance, since it is doubtful whether meningitis and phrenitis ever occur as separate diseases. Simple encephalitis is a very rare disease during childhood: while acute hydrocephalus, as I have before remarked, is very common. Symptoms.—After a restless night, the disease sets in sud- denly with a violent attack of partial or general convulsions, accompanied by fever, and sometimes by hurried breathing. As the convulsions diminish, the child becomes drowsy or comatose, and continues so for a few hours until they return. When they again cease, there is often vomiting, and a return of the stupor; and there maybe complete abolition of the intelligence, subsultus tendinum, trismus, squinting, contrac- tion of the pupils, and perhaps hemiplegia. The pulse is quick and irregular; the bowels are open, and the motions passed involuntarily; the face is pale and the expression vacant; and at the end of three or four days, death takes 26* 301 SIMPLE UN CEPHALITIS. place during a fit of convulsions, or from increase of the coma. In some forms of simple inflammation of the brain the course is different and slower. At the commencement there is sickness, drowsiness, great irritability, frontal headache, and general fever—lasting perhaps for seven or ten days: convulsions then make their appearance. The convulsion is generally long and severe; it may be followed immediately by coma, which in a few days is fatal; or it may recur frequently at short intervals, and pass into coma at the end of twenty- four hours. Dr. Watson thinks that when nausea and voinit- in^ are the earliest symptoms in adults, the inflammation has had its origin in the cerebral pulp—in the substance of the brain; and that when the attack commences with a con- vulsion, the inflammation has commenced in the pia mater or arachnoid. In all the forms of this dangerous complaint there is great variety in the symptoms, and much observation is necessary to put us on our guard against the insidious characters which many of the cases assume, and the deceitful appearances of amendment which often take place. Fortunately the disease is of rare occurrence. It may terminate fatally in a few hours, or the patient may struggle on for two or three weeks : or although death is the most common termination, yet re- covery may ensue in children with good constitutional powers. The post-mortem appearances usually found are, great vascu- larity of the meninges; a loaded state of the sinuses; serous effusion beneath the pia mater and into the ventricles; the deposition of pus or false membranes between the bone and the dura mater, or the dura mater and arachnoid; thickening of the membranes; and ramollissement, or softening of the cerebral substance. Causes.—I have already spoken of the occasional occur- rence of disease of the brain from inflammation of the internal ear. Hence it will suffice here to put the practitioner on his guard against this affection of the ear; which, though it gives SIMPLE ENCEPHALITIS. 307 rise to much pain and discharge at first, yet is apt to become chronic, and in this condition to progress insidiously but very mischievously, if neglected. The other causes of simple meningitis is not very clear. In some cases it has been attributed to dentition; in some, to the suppression of an eruption on the scalp; in others, to exposure of the head to the sun; and again in others, to injuries—such as blows and falls. Treatment.—The means which are most to be relied upon are the sedulous application of cold to the head, the use of purgatives, the exhibition of mercury or of the iodide of potassium, and restriction to a low diet.* With regard to the use of cold, I believe it will be found most valuable; but it must be applied continuously for many hours, the condition of the child being watched. Pounded ice, or an artificial freezing composition, or a mixture of pounded ice and salt, placed in bladders—as I have before directed, can alone be trusted to. Active purgatives—F. 9 or 13—so as to empty the entestinal canal, and perhaps to produce a revulsive action on the mucous membrane, will be needed; their use being followed by mercurials—F. 34—or by the iodide of potassium —F. 38. From my own observations during the past few * Although Dr. J. F. Meigs, and many authors, state that the most powerful antiphlogistic treatment is necessary, yet I would counsel the practitioner not to resort to bleeding, for the reasons already men- tioned. It is, however, but fair to quote Dr. Meigs' own words. He says—" Venesection ought always to be preferred to local bleeding, even in the youngest children, unless it is impossible to find a vein, or unless this is evidently too small to bleed well. If we cannot succeed in performing the operation at the bend of the arm, we must resort to the vein running over the inner ankle, or to the external jugular. When venesection cannot, from any reason, be employed, blood should be freely drawn by means of leeches or cups. It is customary to apply the leeches to the temples, or behind the ears. I may remark that MM. Rilliett and Barthez object to the application of leeches to the head and propose that they should be placed rather about the anus, or on the inferior extremities." On the Diseases of Children, p. 360. Philadelphia, 1848. 308 CHRONIC HYDROCEPHALUS. years, I believe that this last agent is by no means employed as frequently in the acute inflammations of childhood as it deserves to be. Given in doses of one grain every four hours, dissolved in weak tea or plain barley-water, I have seen it produce relief in croup, and in some severe cases of bron- chitis ; and although I have not had an opportunity of trying it in the disease under consideration, yet I cannot help think- ing it would prove very valuable. Counter-irritants to the scalp can only be of any value when it is thought—if such a supposition can ever be entertained —that the encephalitis is. due to the suppression of some cutaneous eruption. In all stages of the disease the practitioner must watch his little patient almost hour by hour; must be careful that he is kept dry and clean; and that the bladder does not become distended. Should the disorder happily yield to these measures, great care will be requisite for some time—especially with regard to diet and the avoidance of all excitement—to prevent a relapse. SECTION VII.—CHRONIC HYDROCEPHALUS. Chronic hydrocephalus, or dropsy of the brain, is met with in children at various ages, as the result of a great variety of circumstances. When congenital, as it often is, it is generally associated with malformation of the brain—with deficiency of some of its parts. It is sometimes the result, sometimes the precursor, of acute hydrocephalus. The head attains a very great size in this disease, the unossified sutures readily yield- ing to the pressure of the liquid : the skull of James Cardinal —who lived to the age of twenty-nine years—measured rather more than thirty-two inches in diameter.* The serous fluid is usually contained in the lateral ventricles, which are often expanded into one cavity; very rarely the effusion takes place * Reports of Medical Cases, Sec, by Dr. Bright, p. 431. London, 1827-31. CHRONIC HYDROCEPHALUS. 309 only on one side : occasionally it is collected in the sac of the arachnoid. Symptoms.—The effects of dropsy of the brain are not very uniform. Frequently the bodily functions are but little im- paired, sometimes not at all, till a short time before death; it is remarkable also how little the mental powers are affected in many cases, though in some instances it produces complete idiocy. The most frequent symptom is convulsions : in some cases there is a fit daily, but it may be slight, and consist only of a twitching of the muscles of the mouth, or of a peculiar rolling of the eyes. The enlargement of the head may not become apparent until the disease has existed some short time; but in congenital cases it is usually apparent from the birth. As the affection progresses there is wasting of the flesh; the infant sucks greedily, yet gets weaker; the head seems too heavy, so that the infant cannot support it in an erect position; there is generally constipation, and the evacua- tions are unhealthy; there is drowsiness but the sleep is dis- turbed; vision is impaired, sometimes lost; and there may be spasmodic attacks of dyspnoea. Although essentially an affec- tion of childhood, yet cases are recorded in which it has affected adults; thus the celebrated Dean Swift suffered and died from it. According to Dr. West, almost every case is fatal: either directly, by the convulsions or great debility induced; or indirectly, by rendering its victims more liable than healthy children to other diseases, and less able to bear up against them. Professor Golis, of Vienna, affirms on the contrary, that of the cases which began after birth, and which were seen and treated early by him, he saved the majority. Diagnosis.—When the disease is thoroughly established, it can hardly be mistaken; the large head upon the diminutive emaciated trunk and wasted extremities, together with the disproportion in size between the cranium and face—making the visage triangular, producing a distressing but most charac- teristic appearance. In the earlier stages, however, the diag- nosis are not so easy; hypertrophy OF the brain being very 310 CHRONIC HYDROCEPHALUS. likely to be mistaken for chronic hydrocephalus, inasmuch as it sometimes produces well-marked symptoms of cerebral dis- turbance and enlargement of the head. In most of the recorded cases of cerebral hypertrophy there were epileptic fits, or paroxysms of convulsions; the intellectual faculties were dull; the head seemed too heavy to be borne; and headache was complained of. But when the skull enlarges equally with the undue development of the brain, there may be no morbid phenomena; since there will be no pressure. The general health, however, suffers; the child wastes and gets weak, and often becomes afflicted with rickets or scrofula. This condition must not be too actively treated, for the nimia cur a Medici will only be baneful. The great point is to maintain the general health, by bark or by some preparation of iron; by salt-water or tan-water sponging baths; by sea-air; and by a nourishing diet. A small horse-hair cushion,'with a piece cut out large enough to receive the occiput, should be prepared for the child's head to rest upon. On comparing this plan of treatment with that required in chronic hydrocephalus, it will at once be seen how important it is not to mistake one disease for the other. The error is not very easily avoided. But in hypertrophy of the cerebral mass the symptoms are less serious than in chronic hydrocephalus; they come on more slowly; and the head seldom attains the same size. In the latter affection, also, the fontanelles and sutures are more widely open, and the head assumes a more rounded appearance, than in the former : moreover in dropsy of the brain there is often a certain amount of transparence, which can be readily recognized if a light be held upon one side of the head. Treatment.—The plan advocated by Professor Golis, after great experience, consists in the administration of calomel in quarter or half-grain doses, twice daily; together with the inunction of one or two drachms of mild mercurial ointment into the shaven scalp once in the twenty-four hours. At the same time the head is to be kept constantly covered with a CHRONIC HYDROCEPHALUS. 311 flannel cap, to prevent all risk of the perspiration being checked. If no improvement be perceptible after a lapse of six or eight weeks, diuretics—as the acetate of potash, or squills, or both—are to be combined with the mercurial treat- ment; and an issue should be made in the neck or on each shoulder, to be kept open for months. When convalescence is once established, he thinks benefit is derived from small doses of quinine—a quarter of a grain three or four times daily. Two remedies—compression of the head, wad puncturing it— have' been strongly advocated by some writers. Compression is best effected by bandaging, or by the application of strips of adhesive plaster applied over the whole of the cranium, so as to make equal pressure on every part. In cases where there are no symptoms of active cerebral disease, pressure will probably do good. Puncture is performed with a small trocar and canula at the coronal suture, about an inch and a half from the anterior fontanelle, so as to avoid the longitudinal sinus; only a part of the fluid is to be taken at one time, and gentle pressure must be kept up both during its escape and afterwards. Moreover the trocar is to be introduced in a per- pendicular direction. This operation is only to be had recourse to when other means have failed; and when the bones of the skull have not become united together. While resorting to either proceeding, constitutional remedies are not to be neg- lected; and I would especially advise the administration of cod-liver oil, of iodide of potassium—or what is better in many cases, iodide, of iron—and-of mercury in alterative doses, such as two or three grains of the hydrargyrum cum creta every night. Dr. Watson mentions two hopeless cases—a lad whose age is not.stated, and a boy about twelve years old—successfully treated on a plan suggested by Dr. Gower, after the admini- stration of mercury in the usual form and of other remedies, had failed to give the slightest relief. Ten grains of crude mercury were rubbed down with a scruple of manna and five grains of fresh squills. This formed a dose which was taken 312 INFLAMMATION OF THE SPINAL CORD. every eight hours, for three or four weeks. It caused a profuse flow of urine, great debility, and emaciation; no ptyalism. When the symptoms of hydrocephalus had disappeared, the health was restored by steel.* SECTION VIII.—INFLAMMATION OF THE MEMBRANES AND SUBSTANCE OF THE SPINAL CORD. 1. Meningitis of the Spinal Cord is an uncommon af- fection in this country, although an epidemic of it prevailed in the Irish workhouses about ten years ago,"f" and in many parts of France between the years 1842 and 1844. In the first in- stance it was almost confined to boys about twelve years old; in the second case, it affected youths at the period of puberty. The disease usually came on suddenly with pain in the ab- domen, vomiting and purging, and collapse; succeeded in a few hours by strong reaction, heat of skin, frequency of pulse, stiffness of the muscles, retraction and fixing of the head, con- vulsions, coma, and death. In every case the spinal arach- noid was found to have been chiefly affected, and in most instances the membranes of the brain had been slightly in- volved. Layers of lymph were frequently present under the arachnoid and in its cavity, sometimes extending along the whole anterior and posterior surfaces of the cord: generally, too, the latter was apparently healthy. 2. Acute Inflammation of the Substance of the Cord is more rare than the preceding. It generally produces soften- ing of the cord with paralysis. The following is an interest- ing example of it :|—A girl aged eleven years, whose occupa- tion as a sempstress obliged her to remain for many hours daily in a sitting posture exposed to cold draughts, was seized three weeks after following this employment, with dragging and tearing pains in the back of her neck. As these .pains * Lectures on the Principles and Practice of Physic, p. 458, vol. i. 3rd. ed. London, 1848. ■j- An account of this epidemic has been given by Dr. Mayne in the Dublin Quarterly Journal of Medical Science for August, 1846. % Quoted by Dr. West. Liber cit., p. 138. INFLAMMATION OF THE SPINAL CORD. 313 grew more severe, voluntary power over the arms became impaired, and the paralysis increasing rapidly in spite of the application of leeches to the back of the neck, she was ad- mitted into the Hospital for Children at Vienna, under Dr. Mauthner's care, on 26th December. Both arms were then completely palsied, flaccid, cool, and almost insensible; the lower extremities still obeyed the will, but the girl was unable to stand firmly. The mind was clear, appetite good, deglutition easy, pulse natural; and in these respects her con- dition continued unchanged to the last, except that on the day of death the pulse became very frequent. On the 28th the legs were palsied, and the urine passed involuntarily. On the 29th, voluntary power over the hands and feet was com- pletely lost, and sensation was imperfect. On the 30th, sen- sation was quite lost in all the extremities : the child desired to pass faeces, but had not power to do so. On the 31st the sphincter ani was likewise paralyzed and open to the size of a shilling. On January 4th, the hardened faeces began to fall out of the gaping anus: the respiration was feeble, and the articulation difficult. On the 6th there was much dis- tress ; for many days there had been no sleep; the whole of the left side of the body was completely paralyzed; and only the right side of the chest moved in respiration. The ex- haustion was so extreme that the voice was scarcely audible, but the muscles of the face still retained the power of motion and sensation perfectly, and the intellect was quite clear : the child died the same night. The spinal cord presented the only morbid appearance; the membranes being perfectly healthy. The medulla oblongata was as soft as butter, of a yellow color, without a trace of its natural organization; and the same condition was presented by the whole of the spinal cord as low as the corda equina, where it once more resumed its natural appearance and character. 3. Chronic Inflammation of the Substance of the Cord sometimes results from caries of the vertebrae; and sometimes from injury to the cord by shocks, blows, strains, 27 314 INFANTILE TRISMUS. &c, without any disease of the bones. It generally occurs in strumous children. WThen produced by caries, the paralysis which results is due partly to the inflammatory action, and partly to the distortion of the spine and the mechanical com- pression of the cord. SECTION IX.—INFANTILE TRISMUS. Infantile trismus, trismus nascentium, tetanus of new-born children, or nine-day fits, is a peculiar malady which occurs in infants about the commencement of the second week after birth. This affection is very rare in this country, but was very common in the Dublin Lying-in Hospital until the late Dr. Joseph Clarke introduced improvements in its ventilation and cleanliness; and it is still very frequent in the West Indies'. Symptoms.—The onset of this disease is in general gradual. Some hours after birth it is perhaps noticed that the infant is very fretful, frequently whining and crying; its sleep is disturbed, and during sleep there appear to be curious at- tempts at smiling; it is restless when awake, and twists its limbs about without any cause; there is a livid circle round the eyes; the evacuations from the bowels are greenish and slimy; and there is generally great desire for the breast. After these indications have been more or less noticed for a few days, and sometimes without any warning whatever, the infant is seized with violent irregular contractions and relaxa- tions of the muscular frame, especially of the muscles of the extremities and face. These convulsive motions recur at uncertain intervals, and produce various effects. Sometimes the agitation is very great; the mouth foams; the thumbs are riveted into the palms of the hands; the jaws are locked from the commencement, so as to prevent the action of sucking and swallowing; any attempts to wet the mouth or fauces, or to administer the medicines, seem to aggravate the spasms; and the face becomes turgid and of a livid hue, as do most other parts of the body. From this latter circumstance nurses INFANTILE TRISMUS. 315 speak of this form as "the black fits." The conflict lasts from eight to thirty hours, and in some very rare instances to about forty hours; when the powers of nature seem to sink, exhausted and overpowered by their own exertions. There is a milder variety, termed by nurses "the white fits," in which the paroxysms are less frequent, the power of sucking is enfeebled but not lost, and the attack is prolonged from three to nine days.* Causes.—Although opinions on this subject vary, it seems impossible to doubt that a vitiated state of the atmosphere is the powerful predisposing cause. This may operate—as Pro- fessor Colles ingeniously suggested—by inducing an unhealthy or unkindly form of inflammation or ulceration at the navel; so that the disease is really a kind of traumatic tetanus imme- diately excited through the wound occasioned by the separa- tion of the umbilical cord. Morbid Anatomy.—The peritoneum covering the umbilical vein has been found in many instances very vascula, this vas- cularity sometimes extending up to the edge of the liver: the portion of membrane in the course of the umbilical arteries, is usually inflamed, the inflammation often reaching as far as the bladder. There have also been seen signs of inflammation of the coats of the umbilical arteries: and more rarely of phle- bitis in the umbilical vein. Conjoined with these appearances, the vessels of the spinal arachnoid are engorged; and some- times there is effusion of blood or serum intoSts cavity, or ex- travasation of blood external to the theca. Less frequently the membranes at the base of the brain have been found much congested. Treatment.—All that we can do is to avert this fatal malady by hygienic precautions: by having the lying-in room clean and thoroughly ventilated, by attending to the mother's diet, and by taking care that the infant is kept clean and dry. With respect to the direct treatment I can only suggest that * Abridged from an excellent paper by Dr. Joseph Clark, in vol. iii. of the Transactions of the Royal Irish Academy. 310 EPILEPSY. inhalation of the vapor of chloroform, continuously for many hours; with the application of ice to the spine. As regards other remedies Dr. Collins says—" I have never seen an in- stance where the child seemed even temporarily relieved by the measures adopted. Calomel has been tried in large quantity, also in small doses often repeated, as well as exten- sive friction with mercurial ointment. I have tried frequent leeching along the spinal column, also repeated blistering over its entire length. Opium I have exhibited in many ways, both in very large and small doses; also tartar emetic in the same manner, and at times both combined. I have tried tobacco extensively, in the form of stupes and injections of various degrees of strength, from one grain to the ounce of fluid, to five or more; besides the frequent use of the warm bath, oil of turpentine, tincture of soot assafcetida, and many of the ordinary purgatives and stimulants ; and all, as far as I could judge, without a shade of relief."* SECTION X.—EPILEPSY. Epilepsy is a disease the leading symptoms of which are sudden loss of consciousness and sensibility, with clonic spasm, usually "followed by coma; the attack recurring at in- tervals. It is as common during the early years of life as subsequently; and is as difficult to cure. After the age of seven years, female children are more subject to epilepsy than male. Symptoms.—There are sometimes, though not in the ma- jority of cases, premonitory symptoms sufficient to warn the patient of an approaching seizure. These warnings differ both in duration and character, in some cases being too short even to allow the sufferer to dismount from horseback, or to get away from the fire, or even to lie down; while in other in- stances, many minutes, or even hours, elapse before the attack. Dr. Gregory, of Edinburgh, was assured by an epileptic that when a fit was approaching, he fancied he saw a little old * Practical Treatise on Midwifery, p. 517. London, 1836. EPILEPSY. 317 woman in a red cloak advance towards him, and strike him a blow on the head, on which he at once lost all recollection and fell down. Spectral illusions, headache, giddiness, dimness of vision, confusion of thought, and especially that peculiar sensation known as the aura epileptica, constitute the most frequent premonitory symptoms. The epileptic aura is differ- ently compared by patients to a stream of cold water—or a current of cold or warm air—or the creeping of an insect— the sensation commencing at the extremity of a limb, and gradually ascending along the skin towards the head: when it stops, the paroxysm takes place. Diagnosis.—The commencement of the seizure is generally characterized by the utterance of a loud piercing shriek or scream, immediately after which the child falls to the ground senseless and violently convulsed. Hence the disease has been called by the vulgar the falling sickness, or more vaguely, fits. During the attack the convulsive movements continue violent; there is gnashing of the teeth, foaming at the mouth, the tongue is thrust forward and often severely bitten, the eyes are fixed and partly open, the breathing is laborious or almost suspended, the face flushed and turgid, and death, in fact, seems about to take place from suffocation ; when—gra- dually—these alarming phenomena subside, and shortly after- wards cease, leaving the epileptic insensible, and apparently in a sound sleep, or state of coma, from which he recovers exhausted, but without any knowledge of what he has just gone through. Prognosis, cause, &c.—The average duration of the fit is about five or eight minutes; it may last for half an hour or more. It may also be very slight or very severe, constituting the petit mal and the grand mat of the French. The periods at which the seizures recur are variable. At first there is often an interval of two or three months; but as the disease progresses the intervals become shorter, until hardly avday passes without one or more paroxysms. In recent cases espe- cially, the fits often take place in the night, either on just 27* 318 EPILEPSY. going to sleep, or on awakening. As may be imagined, va- rious accidents are likely to occur from falls, kc, during the fit: and many children have been severely burnt from thus falling upon the fire. The tendency to epilepsy is often here- ditary. Malformations of the head are frequent predisposing causes. When an epileptic dies who has only labored under the disease for a short time, no appreciable lesion of any part of the nervous system can, as a rule, be discovered. If death occur during a paroxysm, the brain is often found more or less congested. In cases of long standing, disease of the cerebral blood-vessels, with softening or induration of the brain, may be found. Occasionally the bones of the skull are thickened or otherwise diseased. Treatment.—As in adults so with children this must have reference to the measures to be adopted during a fit, and those to be employed in the interval. During the fit the patient should be laid on a large bed, air freely admitted around him, his head raised, and his neck- tie, together with any tight parts of his dress, loosened. A piece of cork or soft wood should, if possible, be intro- duced between his teeth, to prevent injury to the tongue. Cold affusion to the head will sometimes be useful, especially if the countenance is turgid and congested. In cases puc- ceded by the epileptic aura, the application of a ligature just above the part where the sensation is experienced has been said to prevent the attack. In the interval we must endeavor to improve the patient's general health, and especially to give tone and firmness to the nervous system. Dr. C. B. Badcliffe, in his excellent " Comments on Convulsive Diseases," has well shown that everything tending to depress the vital powers does harm. Mineral tonics, especially the salts of iron, zinc, and silver, are consequently to be employed. The cold shower-bath may be especially recommended, if it can be borne, otherwise the tepid sponging-bath should be substituted; the diet must be simple but nutritious; the patient's habits must be regu- ECLAMPSIA NUTANS. 319 lated by such rules as common sense will dictate—daily exercise, early hours, and quiet amusements; while mental excitement or exertion is, on the other hand, especially contraindicated. Backwardness in book-learning will prove no evil, when compared against the persistence of epilepsy. SECTION XI.—ECLAMPSIA NUTANS. Eclampsia nutans, or the " Salaam " convulsions of infancy, is an important but very rare malady—so rare that the majority of practitioners never see an example of it. It is probably a form of epilepsy; and like it may lead to impair- ment of the intellect. Thus of four cases—the history of which have been collected by Mr. Newnham*—two termi- nated in complete idiocy, and two in impairment of the intellect. The ages of the sufferers were 16 months, 4 J months, 12 months, (?) and 6 months respectively. Symptoms.—The pathognomonic symptom by which this affection is distinguished—and which induced Sir Charles Clarke to denominate it " the Salaam" convulsion, is a peculiar, involuntary, rapid bowing forward of the head, and occasionally of the body; the bowings being repeated in rapid succession, and the attacks coming on in paroxysms several times daily. The severe attacks appear usually to come on in the morning on awaking from the night's sleep. After a time cerebral symptoms and general convulsions arise, or pure epilepsy; there may be hemiplegia, or para- plegia; and the little patients pine and waste away. After several months, the symptoms remit; and at the end of two or three years the bodily health may be partially restored. The causes of this affection are involved in obscurity. Pathology.—Mr. Newnham believes that the essential character of this malady is inflammatory action of a weak or strumous, character. This probably commences in the mem- branes investing the medulla oblongata, and extends to the membranes at the base of the brain. Hence exudations of * Clay's Obstetrie Journal, vol. ii. Manchester, 1849. 320 CHOREA. lymph or serum occur, cause pressure, and, consequently, paralysis; the regular nutrition of the brain is interrupted, and its manifestations blunted; while in the more aggravated cases, the organ becomes so deteriorated, as to lose all power of carrying on the intellectual functions, it having in all probability, partaken of the same kind of inflammatory action as first appeared in its investing membranes. Treatment.—The two chief points to attend to are these:— Keep the secretions in order by calomel in small doses, or by the hydrargyrum cum creta, or by aloes; and at the same time support the powers of life by bark, or by quinine com- bined with some preparation of steel. In the cases which have been referred to, hydrocyanic acid palliated the symp- toms, while opium aggravated them; had chloroform been in use, it doubtless would have been tried. Tepid or cold bathing will be useful, and so will a nourishing diet: the body must also be warmly clad, while the head is kept cool. All quick movements, and all harsh- ness or anything which produces mental excitement should be carefully avoided. SECTION XII.—CHOREA. Chorea, or St. Vitus's dance, is characterized by incomplete subserviency of the muscles of voluntary motion to the will, giving rise to irregular, tremulous, and often ludicrous actions. It has been quaintly designated " insanity of the muscles." Symptoms.—This disease occurs most frequently in young girls between the ages of six and fifteen, and begins generally with twitchings of the muscles of the face. By degrees, all or almost all the voluntary muscles become affected; the child finds it impossible to keep quiet; there is a constant movement of the hands and arms, and even of the legs; the features are most curiously twisted and contorted, and the articulation is impeded; while these movements are, more- over, always most severe when the child is watched. If you CHOREA. 321 ask your patient to put out her tongue, she is unable to do so for some moments, but at last suddenly thrusts it out, and as suddenly withdraws it. If you tell her to walk, she advances in a jumping manner, by fits and starts, dragging her leg rather than lifting it, and alternately halting and hopping. She cannot even sit still; her shoulders writhe about, she picks her dress, and shuffles and scrapes the floor with her feet. During sleep, these irregular actions usually cease. When the disease lasts long, the countenance assumes a vacant appearance bordering on fatuity, and some imbecility of mind becomes manifest. If auscultation be practised, an anaemic bellows-murmur will frequently be heard accom- panying the first sound of the heart. The functions of the stomach and bowels are also frequently deranged; the appetite is irregular; the abdomen swollen and hard; and there is often constipation. These symptoms, however, often cease on the termination of the disease; which is scarcely ever fatal, or even dangerous, unless it merges into organic disease of the nervous centres, or into epilepsy. Chorea may last from one week to several months; the average duration is probably five or six weeks. It is often complicated with hysteria; and it has been observed to happen in conjunction with—or on the termination of— rheumatic fever, and rheumatic inflammation of the heart. Although most common in girls, yet boys not unfrequently suffer from it. Pathology.—Chorea may be merely symptomatic of some affection of the nervous centres or of the heart, or it may be purely idiopathic. In a few cases that have proved fatal, the only morbid appearances that could be discovered were peri- carditis and endorcarditis; in others, there has been conges- tion of the meninges of the spinal cord; in a third class, some organic affection of the brain; but in the majority no morbid change of any kind. Dr. Begbie maintains that chorea and rheumatism, though apparently different diseases, depend upon some identical or analogous blood-poison: but it 322 PARALYSIS. may be doubted whether this idea of their pathology is correct, since rheumatism is common in some districts where chorea is very rare, while the complication of both diseases is exceedingly unfrequent. Treatment.—The bowels are to be regulated, irritation sub- dued, and the system strengthened. For this purpose, the employment of cathartics of a stimulating nature is neces- sary ; such as aloes, calomel and jalap, or—where worms are suspected—the oil of turpentine. A combination of tonic or antispasmodic medicines with purgatives, is often found to be serviceable. As soon as the secretions are moderately healthy, a course of treatment calculated to give tone to the nervous and muscular systems is to be commenced; and our two great remedies are the cold shower or douche bath, and steel. As regards the former, it should be employed every morning on the patient's rising; with respect to the latter, different preparations have been recommended. Perhaps the best is the carbonate of iron, given in doses varying from one scruple to two drachms, mixed with treacle. The sulphate, or the ammonio-citrate, or the tincture of the sesquichloride of iron may, however, be used almost as advantageously. Where the shower or douche bath causes alarm, or seems to disagree, a warm sulphur bath, as recommended by many French physicians, will prove very efficacious. The diet must be nutritious; exercise in the fresh air freely allowed; and mental excitement guarded against. SECTION XIII.—PARALYSIS. Infantile paralysis is by no means the same alarming affec- tion as paralysis of the adult; for though often obstinate and occasionally incurable, yet it is not perilous to life. Moreover it is very rarely the result of the same serious disease of the brain or spinal cord. The terms myogenic paralysis, and the essential paralysis of infants, are applied to cases of partial muscular paralysis, arising independently of any appreciable lesion of the nervous system. The palsy often affects only a PARALYSIS. 323 single limb—as one leg, or very seldom one arm, or one side of the face, or even a single muscle—as the sterno-mastoid; or one whole side of the body may be affected—hemiplega; or the lower half of the body—paraplegia. It often dates from such an early period, that it appears most probably to be due to some defect of conformation : such cases can of course only be remedied by some mechanical means to lessen the in- convenience of the deformity. The evils which result from persistence of the paralysis are very great: for if it is never followed by death, still it pro- duces an altered condition in the nutritive functions of the affected muscles, and often leads to incurable deformity. Not only do the affected parts cease to grow in the same proportion as the healthy, but the limbs waste, for they are imperfectly nourished: and although they do not seem to want sensation, yet their power of motion is lost or diminished. Conse- quently if the child begins to walk, the leg drags; and as it fails to support the body, the child falls. Supposing one arm to be paralyzed, it will soon be noticed that it is not used equally with its fellow, and that when raised it falls by its own weight. In many instances, partial or complete loss of power over certain limbs or particular muscles of a limb, is noticed after slight and brief cerebral disturbance : in other cases, the paralysis comes on during that irritable state of nervous sys- tem which coexists with teething; sometimes it appears after either of the eruptive fevers; and frequently it super- venes suddenly, without any apparent constitutional derange- ment. The treatment must vary according to the cause. In all cases the general health to be attended to, and the functions kept as nearly normal as possible; purgatives will often be needed, followed by tonics, and nervous stimulants: The little patient is to be taught to walk while being supported in a go-cart, or in a baby-jumper; or if old enough, by means of a pair of crutches. It is of the greatest importance that the muscles of the limb be daily exercised; hence friction should 324 NIGHT TERRORS. be used, together with gentle shocks of electricity. After the age of four years, Dr. West gives the eighth of a grain of the spirituous extract of nux vomica thrice daily; increasing the dose slowly till it reaches the third of a grain. Good diet, sea-air, and tepid bathing will increase the chance of cure. Facial hemiplegia is not unfrequently seen in infants soon after birth. It is probably caused by some injury-to the branches of the seventh pair of nerves either by the forceps, or from pressure during the passage of the head through the pelvis. The distortion usually diminishes in a few hours, and quite disappears by the end of a week or two without any treatment. section xiv.—night terrors, disorders of the mind, and idiocy. 1. Night Terrors.—A young child may go to bed quite well, but two or three hours after it has been asleep, or per- haps in the middle of the night, it suddenly awakes in great alarm, and utters loud cries. Its attention seems absorbed by some frightful dream—probably about a bear or a dog, or some animal which is thought to be in the bed; and for a few ^ moments it fails to recognize its nurse or parents who have been -fl&ffefeed by the noise. After having been soothed and taken into the nurse's arms, it weeps and sobs, then gradually grows quiet and falls asleep; and probably the attack does not return until one or more nights afterwards. Seizures of this kind are generally due to some sympathetic cerebral irritation induced by disturbance in the intestinal canal: they must not be confounded with those attacks which are owing to sudden and severe pain, such as arise in the course of some chronic affections of the ear. In treating these cases the grand point is to regulate the functions of the abdominal viscera, and to relieve the constipation which generally exists. A combination of mild aperients with tonics—F. 3, 41, &c.— will often effect a cure; especially if the diet be at the same NIGHT TERRORS. 325 time rendered simple, nourishing, and digestible. The child's cot ought also to be placed by the side of the nurse's bed; the child should not be left alone; a fire or a candle should be kept burning in its room; and great kindness should be shown to it, when it awakes with this mental torture. 2. Disorders of the Mind.—The mental disorders of childhood have not had that attention bestowed upon them that their importance demands; and this is to be regretted for many reasons, but especially because upon their early recog- nition and proper management depends all hope of their suc- cessful treatment. It is not sufficient that the practitioner be acquainted with the symptoms of confirmed mental imbecility or of idiocy : he ought likewise to be prepared to advise upon those perversions of the moral faculties—as stubbornness, in- subordination, very bad disposition, fits of passion, and that indolence, vanity, or morbid craving for sympathy leading to the feigning or-exaggeration of illness—which, unless checked, often end in permanent disorder of the intellectual powers, or scarcely less miserably in some obstinate form of hysteria. The peculiarities of the mind in early life are even more numerous and important than those of the body; and they impart certain characteristic features to the mental disorders of this period. " A child's experience "—says Dr. West— " is small, his ideas are few, and those are gathered from the world around him, not from his own reflections; while one impression succeeds another with greater rapidity than his feeble memory can hold fast. Hence in disorders of the mind in early life, we do not meet with the distinct hallucinations, the fixed ideas, which characterize insanity in the adult. But though the intellectual powers are imperfectly developed, the feelings and the impulses are stronger, or, at least, less under control, than they become with advancing years; and one great object of education is to bring them into proper subor- dination. Mental disorders, then, show themselves in the ex- aggeration of those feelings, the uncontrollable character of those impulses; in the inability or the indisposition to listen 28 32G NIGHT TERRORS. to that advice or to be swayed by those motives which govern other children. The affection, in short, is of that kind to which the name of moral insanity is usually given. With this state of mind, however, the child is of course less teach- able than others—less able to apply to any form of learning; while fits of passion or of sullenness sometimes for days to- gether put a stop to every attempt at instruction. The dis- order of {he moral faculties thus reacts upon the intellect; the child learns but little, and consequently grows up ignorant, as well as ungovernable; till at. length either the evidences of insanity become with its advancing years un- mistakable, or the mind growing more obtuse from long want of culture, the case sinks down into one of mischievous idiocy."* The frequency with which children exaggerate some little ailment or feign some disease, renders it necessary that the physician should always be upon his guard: for to allow him- self to be deceived is to produce cruel mischief, and to lay the foundation for the subsequent formation of all kinds of hallu- cinations. In a case which gave me some anxiety, inasmuch as I could discover no signs of morbid action to account for the severe sufferings complained of, I incurred some disgrace by stating—after a careful review of the history and the symptoms—that I believed there was no organic disease, and that the ailment was mental rather than physical. But that this opinion was correct, though doubted by the friends, was proved by the little girl's improvement soon after she was re- moved from the influence of her parents, who spoilt her; and upon diverting her thoughts to higher objects of interest than the condition of her own body. And the treatment which was here adopted, is in fact that which is indicated in most cases; and which will very often be successful when combined with kindness but determination, gentle mental discipline, healthy amusement, a cessation of sympathy and lamentations over the ailment, and attention to the general health—by exercise * Liber citate., p. 189. idiocy. 327 in the open air, a nourishing diet, strengthening baths, and perhaps the administration of cod-liver oil. I need hardly add a caution to the effect that the mind is not to be over- tasked in combating the evils described. To rush from the extreme of too little attention to the education to too much, will only be to perpetuate the evil or to increase it: hence a tfitor or a governess of sound common sense must be chosen, and the nature of the case must be explained in all its bear- ings. Moreover the child should not be sent to a school; but rather—as Dr. West suggests—into a quiet family, where constant control and supervision will be exercised by some person competent to engage the child's affections, to enter into its pursuits, and share its pleasures. 3. Idiocy.—The observations which have been already made on the Cretin, render it unnecessary to say much in this place. Idiocy may be defined as that condition in which the intellectual faculties have never been manifested, or have been so imperfectly developed that the idiot has never been able to acquire such an amount of knowledge as children of his own age are capable of receiving. It is often congenital, and then doubtless is associated with some imperfect organization; but it may arise during infancy from causes acting after birth. Whether congenital or not, the mind remains undeveloped; there are no ideas, or they are few. The manners continue childish; the countenance is vacant, and devoid of aught ap- proaching to intelligence; the features are irregular, the fore- head low and flattened, the lips thick, and the mouth large and often gaping; there are transient gusts of passion, with timidity, obstinacy, and a want of affection; and often a keen greedy appetite. With this, the articulation is imperfect, or the power of speech may not exist; there is partial or complete deafness; the child can hardly be taught to walk till much after the usual time, and only by great patience; there is an inability to use the hands properly, or firmly to lay hold of objects; the period of dentition is later than usual; and fre- quently there is some bodily deformity—as imperfect con- formation of the cranium, rickets, goitre, dwarfed stature, &c. 328 coryza. Happily in all or nearly all cases there are the rudiments of the intellectual and moral faculties; and it is by kindly fostering and educating these rudiments and by cultivating such aptitudes and good inclinations as may be manifested however slightly, that the poor idiot can be removed from the class of mere brutes, and can be taught to control his animal appetites and propensities. Even in the congenital forms of this affliction much can be done, but only by such earnest men as Dr. Guggenbuhl; who are content to sacrifice every- thing in order zealously and unostentatiously to practise a calling, which I believe stands alone as the very highest occu- pation that any man can follow. CHAPTER XVII. DISEASES OF THE ORGANS OF RESPIRATION AND CIRCULATION. SECTION I.—CORYZA. It is scarcely possible to overrate the importance of a caro ful study of the diseases of the respiratory apparatus as they manifest themselves in the young; for not only do they give rise to very painful symptoms, but such is their fatality, that —according to the Registrar-General's Reports—nearly one- third of the deaths under five years of age, occurring in this metropolis, are due to them. It is curious, however, that during the first month or so of life the mucous membrane lining the trachea and bronchi is not as susceptible to the in- fluence of cold, as it afterwards becomes; while, on the other hand, the Schneiderian membrane lining the nostrils appears to be readily impressed by very slight causes. Hence coryza, or nasal catarrh, or vulgarly "the snuffles," is a common af- fection among infants a few weeks old. Symptoms.—Coryza is usually ushered in with slight febrile CORYZA. 32^9 disturbance, sneezing, running from the eyes, and slight dis- charge of thin mucus from the nostrils: while owing to the tumefaction of the mucous membrane of the nares, each in- spiration is accompanied by a peculiar snuffling or snoring noise, and the infant is obliged to breathe chiefly through its mouth. If the attack be severe, respiration through the nose will be altogether prevented; and the infant will then be un- able to suck, inasmuch as directly he closes his lips round the nipple, he will be compelled to quit it, to escape suffocation. Thus, the uneasiness produced by the general disturbance will be increased by the sense of hunger; so that unless the plan of feeding with the spoon be resorted to, great exhaustion and- emaciation will speedily result. Occasionally the inflammatory action is more violent and extensive, giving rise to a pseudo-membranous exudation; or to an abundant secretion of tenacious mucus from the Schnei- dcrian membrane. The symptoms are then of a much more dangerous character; and as the vital powers are much de- pressed, this form of the disease has been termed coryza maligna. Causes.—It is probably due to cold and damp: neglect in keeping the infant clean and dry may give rise to it. It is sometimes a forerunner of one or other of the eruptive fevers : and occasionally it appears to be connected with a syphilitic taint. Treatment.—The slight attacks require but little treatment beyond attention to the clothing, &c, so that the delicate patient may be kept warm: inasmuch as they subside spon- taneously in the course of a week or ten days. When there is any difficulty in sucking, the milk should be drawn off, and the infant fed with it by the aid of a spoon. In severe cases, the general health must be supported by a course of tonics— F. 57, 58 ; a few alterative doses of mercury will be some- times beneficial, especially when the disease becomes chronic; while the tendency to the formation of the false membranes is to be combated by injections of alum—gr. x. to the ounce of 28* 330 CROUP. water, or of nitrate of silver—gr. iij. to water one ounce. In all instances, care is to be taken by cleanliness and the use of a simple cerate to prevent the discharge from forming dry crusts at the orifices of the nostrils: since such crusts increase the irritation and help to obstruct the breathing. SECTION II.—CROUP. Cynanche trachealis, tracheitis, or croup, is an inflamma- tory disease of the trachea—often of the larynx and trachea; ending, in the majority of cases, in the more or less abundant exudation of false membrane upon the affected surface. It is one of the most serious and fatal diseases of childhood : it is most common perhaps during the second year of life, and comparatively rare after the fifth: it occurs more frequently in male than in female children, though why it should do so cannot be well explained : when a child has once suffered from it, there is a liability to the recurrence of the disease at any time up to puberty, but the second attack is usually less serious than the first: it occasionally appears to prevail as an epidemic : and it is often complicated with bronchitis and pneumonia. Symptoms.—In describing the symptoms of croup, we may conveniently make an artificial division of the disease into three stages; viz., the precursory, the developed, and the stage of collapse or of threatened suffocation. The precursory symptoms are those of a common cold; slight fever, thirst, cough, hoarseness, drowsiness, suffusion of the eyes, and run- ning at the nose. In some few instances, the child clutches or rubs its larynx, as if there were some uneasy sensation there; or there may be a slight hesitation in swallowing, as in simple sore-throat. If we examine the fauces, however, no traces of disease will be found; and if wo resort to ausculta- tion or percussion, the chest will be found healthy. At the end of twenty-four or thirty-six hours the second or developed stage sets in. The child is suddenly awoke—almost inva- riably at night—by a sensation of suffocation, with a peculiar CROUP. 331 acute, dry, ringing, brassy cough, and hurried breathing. He is agitated and alarmed, and wants to sit up, or leave his bed; his face becomes slightly swelled and flushed, and his eyes are suffused and bloodshot. Each inspiration now becomes prolonged; and is attended with a characteristic crowing noise, readily recognized when once it has been heard. These distinctive coughs, and the difficult and crow- ing inspirations, probably continue to recur in paroxysms, through the remainder of the night: while the little sufferer continually changes his position to find that relief which is denied to him. As the morning dawns, however, there is a slight remission of the symptoms, and a short slumber may be obtained. But the improvement is transitory; the disease advances, the fever increases, the voice becomes more hoarse, the paroxysms of cough more frequent, and the breathing more difficult and hurried; there is also great thirst, the tongue is coated with a thick fur, the pulse gets quicker and harder, and the child is very irritable and restless. It is now very commonly noticed, that the hand seizes the larynx as if to remove some obstruction; then the arms are thrown wildly about, and all covering tossed aside; the countenance becomes flushed, and at times almost livid; and as each paroxysm of cough comes on, and as the dyspnoea becomes urgent, the head is thrown back as far as possible, in order to increase the capacity of the windpipe. Through the whole progress of the disease exacerbations are observed to take place at night, with remissions in the morning: the cough is unat- tended by expectoration, and each fit of coughing is usually followed by a paroxysm of dyspnoea: the act of speaking seems to increase the suffering, for the child only whispers or often refuses to utter a word: the bowels are constipated: and although the appetite for food is quite lost, there is a con- stant desire for drink, notwithstanding that deglutition some- times appears to cause pain. As the disease advances towards the third stage or that of collapse—or of threatened suffoca- tion, the intermissions between the paroxysms grow shorter, oo2 CROUP. so that there is scarcely any remission; the cough gets more difficult, less audible, suppressed, and strangulating; the voice is nearly or quite abolished; the croupal respiration is perma- nent; and every now and then suffocation seems imminent. Moreover, there is drowsiness, which soon becomes extreme, though the sleep is uneasy; and the child starts and wakes in terror and grasps convulsively at any object near him. If no relief be given by the expectoration of the muco-purulcnt matter or of the membranous exudation obstructing the larynx and trachea, the skin becomes cold and covered with clammy sweats; the pulse gets very quick, feeble, and inter- mitting; the respiration grows more difficult and accompanied with a hissing noise; the movements of the larynx are forci- ble and incessant; the head is thrown back, the alae nasi arc rapidly dilated and contracted, they eyes are dull and sunken, and the complexion livid; the countenance is expressive of the greatest agony; until at the end of about twelve or eighteen hours the child dies with signs of convulsive suffocation, or it sinks exhausted into a state of coma from which death ulti- mately relieves it. The practice of auscultation in the second and third stages, yields information as to the amount of air entering the lungs, and the extension or not of the inflammation to the bronchial tubes and lungs. When the obstruction to the entrance of the air is great, the inspiratory murmur may be quite imper- ceptible in the smaller bronchi, except during an unusually deep inspiration after a fit of coughing: at the same time there is healthy resonance on percussion. According to Barth and Roger,* a kind of vibrating murmur or tremblotement can be heard over the larynx or trachea, when the false membrane has become partially detached and is floating: but this mur- mur is seldom to be detected. Should bronchitis supervene, we shall find the sonorous rhonchus indicative of it, masked in some degree by the croupy noise in the trachea; and such will be the case with regard to the small crepitation of pneu- ;-- Trite pratique oVAuscultation, p. 261. 2d ed. Paris, 1844. CROUP. 333 monia. But in the latter case there will be impaired reso- nance on percussion over the inflamed portions of lung. The duration of the disease varies according to the violence of the inflammation and the strength of the patient: the aver- age time is from two to six days, a fatal issue being most common on the fourth day. Occasionally, however, it runs a very rapid course. Thus, Professor Golis, of Vienna, relates the case of a healthy little boy, aged four years; who—going into the open air on an extremely cold day—was attacked with croup, which proved fatal in fourteen hours.f Morbid Anatomy.—The mucous membrane of the larynx, trachea, and bronchial tubes is generally found inflamed, red or livid, congested, and swollen: sometimes there are abra- sions or ulcerations: and very frequently there is a layer of viscid muco-purulent matter, or more commonly an exudation of false membrane. This membrane is found more frequently in the larynx than in the trachea, and in both more often than in the bronchial tubes: while on the Continent frequently, but very rarely in this country, the exudation is also found on the velum palati, and in the fauces and pharynx. It gene- rally presents the appearance of a thin but rather firm layer; it is unorganized; and consists of either coagulated albumen or of fibrine, but most probably of the former. Signs of pneumonia are not unusual: but care must be taken not to confound the appearances due to pulmonic congestion arising from the suffocative influence of croup, with the results of inflammatory action. Pathology.—From the foregoing it seems evident that this disease consists of inflammation of the mucous mem- brane, exciting spasmodic action in the larynx and trachea, and giving rise to a peculiar product—a psuedo-membranous secretion. The result is imperfect aeration of the blood, for the access of air to the minute vessels is impeded by the spasm as well as by the accumulation of the croupal productions. + Tractatus de rile cognoscenda et sanandd Angina membranaceu. Obs. iv., p. 141. Vienna?, 1813. 334 CROUP. The question as to whether the inflammation is of a simple kind, or dependent upon some specific poison in the system— as is the case with the eruptive fevers, &c.—has been enter- tained but not satisfactorily answered. My own views arc certainly in favor of the latter opinion, and for these reasons: —the second attacks of croup are—as a rule—much less severe than the first, because the susceptibility of the system to the action of the poison is partly exhausted, just as is seen in the practice of syphilisation : the occasional prevalence of the disease in an epidemic form, seems to indicate a specific agent as its cause : when larygnitis is excited in children by some poisonous irritant, or by drinking boiling water fro'm the spout of a tea-kettle, the results are very different and false membranes are not exuded, even though the inflammation extend to the trachea. Cases of croup though rare in the adult sometimes occur, but the symptoms are different from those of simple laryngitis, and they do not yield to the same treatment —i. e., to making an artificial opening into the windpipe— which sometimes cures the latter : while if laryngitis be artifi- cially produced in the lower animals, false membranes are not exuded; though croup—identical in its phenomena and or- ganic changes with the disease in the human subject—does spontaneously occur in them, as is seen in lambs, calves, puppies, cats, and in chickens—constituting the " pip." The latter especially often prevails epidemically in a farm-yard and produces a large mortality. Complications of Croup.—One of the most dangerous, is with cynanche maligna, as is sometimes seen when croup oc- curs during the course of scarlitina anginosa. The exudation thrown out from the inflamed surface, forms a pellicle which covers the fauces and extends down the pharynx as well as down the air-passages : occasionally the pellicular exudation is only formed in patches, giving rise to an appearance of thin sloughs. Most authorities agree that the inflammation may originate in tonsillitis, thence extending over the fauces, and down the pharynx and larynx. Occasionally croup is com- CROUP. 335 plicated with aphthous ulcerations about the mouth and palate : this is seen when the disease occurs in feeble subjects, who have been previously suffering from disordered states of the alimentary canal. When croup supervenes upon measles, small-pox, or erysipelas, the inflammatory fever assumes a low type, convulsions are frequent, the difficulty of respiration is excessive, and the paroxysms of suffocation are extreme. Lastly, the croupal inflammation of the larynx and trachea, may extend to the bronchial tubes, and thence to the substance of the lungs—pneumonia ; a complication which in almost all cases terminates fatally. Diagnosis.—The history of the attack, the hoarseness or loss of voice, the dry ringing cough, the early severity of the symptoms, the exacerbations and remissions, the croupal inspirations, the inflammatory fever, the heaving of the thorax, and the motions of the larynx and trachea, distinguish this disease from every other. It can indeed only be confounded with true laryngitis ; but this affection occurs in adults, very rarely in children, except as associated with croup; it causes a fixed burning pain in the larnyx, increased by any examina- tion ; it does not give rise to the exudation of false mem- branes ; and—if prolonged—it ends in suppuration, or ulcera. tion. The diagnosis between croup and spasm of the glottis is very simple: for in the latter there is an absence of fever and of the peculiar cough, the intermissions between the fits of suffocation are complete, and there are general convulsions, with spasmodic contractions of the toes and thumbs during the seizure. Prognosis.—Croup may terminate in—1. Recovery. This result may be expected in mild forms, when the respiration is comparatively quiet during the intervals between the paroxysms of cough; when the cough is loose, and followed by the expectoration of muco-purulent matter, or of fragments of the membranous exudation; when there is a gentle per- spiration over the skin; when the disease is uncomplicated; and when it is not attended with great prostration of the vital 330 CROUP. powers. 2. The disease may pass into some other malady, or excite additional disease,—thus materially increasing the danger. In addition to the obstruction of the respiration produced by the exudation of croup, this affection tends to give rise to spasmodic clossure of the glottis; thus inducing —through the fits of suffocation which result—great pul- monary congestion, and a marked disposition to consecutive disturbance. The extension of the inflammation to the bron- chi and to the substance of the lungs is a very unfavorable event; producing lividity of the face, great drowsiness, cold clammy sweats, great frequency of pulse, and suffocating paroxysms of cough with very short intermissions. What is called laryngeal or tracheal consumption may result from croup; characterized by pain in the larynx, suffocating cough, spasmodic attacks of dyspnoea, muco-purulent expectoration, and hectic fever,—coming on after the subsidence of the acute symptoms, and perhaps just as a successful termination is about to be prognosticated. Or,'the active signs of this affec- tion may be subsiding, but a relapse may take place, owing to the aggravation of the slight inflammatory action which re- mained unsubdued : this tendency to a relapse, must make our prognosis guarded for the two or three weeks during which it exists, in all instances; but particularly in weakly irritable children. Lastly congestion of the brain, giving rise to the effusion of serum into the ventricles, convulsions, &c, may be an indirect consequence of croup. Dr. Copeland and others have met with cases of hydrocephalus following the disease, but they are not common. 3. In the greater number of cases it is to be feared this disease ends fatally. Great danger is to be apprehended when the symptoms progress to the third stage; when the fever from the first is intense; when the attacks of dyspnoea are very severe; when the cough is not followed by expectoration ; when the pulse is very frequent, small, and irregular; and when the counte- nance becomes livid, the eyes sunken, the features contracted, CROUP. 337 the tongue dark, and the lips covered with sordes,—all symp- toms indicative of great exhaustion. Causes.—Croup is more frequent in'cold, damp, changeable climates than in warm regions : hence it is common in the north-west countries of Europe, but almost unknown in the south. It is also most prevalent in low moist localities; in the winter months and in the early spring; and especially perhaps after the long continuance of heavy rains with east or north-east winds.—Children of a nervous and sanguine temperament seem more disposed to the disease, than others; so, when it occurs during the first twelve months of life it is seen most frequently in weakly infants brought up by hand; and boys arc more liable to it than girls, perhaps—though this is very doubtful—because they are more exposed to its exciting causes. Some authors imagine that a hereditary tendency to croup often exists; others that the disease is infectious; but the only support to these opinions is derived from the circumstance that two or more children in the same family are often seized with it, forgetting that they have been placed under the same circumstances as regards the exciting causes. There is but little doubt, that though croup usually occurs as a sporadic disease,.yet it sometimes prevails as an epidemic ; and perhaps it did so more in former times than in the present day. As regards the immediate or exciting causes of croup—the foregoing must be regarded more as predisposing causes— very little is positively known : but it is probable that habi- tual exposure of the neck and throat to cold, insufficient clothing and such circumstances as induce common catarrh and bronchitis, will under certain conditions give rise to it. Treatment.—In no disease, probably, is it more necessary to be prompt, cautious, and unwearying in our attendance. Even where an attack of croup is merely apprehended in a child having a catarrh and slight rough or ringing cough, we should carefully watch the patient, place it in a warm bath for ten or fifteen minutes, confine it to bed, keep the air of the apartment 29 338 CROUP. moist by the evaporation of boiling water, allow only a spare diet, and administer an emetic—F. 22, 23 ; repeating the bath at the end of four hours, and ordering frequently-repeated draughts of a saline mixture containing small doses of an- timony or of ipecacuanha—F. 31, unless the symptoms are relieved. When the inflammatory action is established, there are three remedies on which all authorities teach us to rely,—viz., blood-letting, tartar emetic, and mercury. Perhaps there is no infantile disorder which is so surely and early recognized by practitioners, and so zealously and perseveringly treated on this plan, as croup; for mistakes in diagnosis are very rare, and errors in treatment are seldom committed,—sup- posing that the authorities are correct. The question may well be asked then,—How is it that this disease is so fatal'( I believe, from my own experience, because one of the chief agents is not only inappropriate but mischievous. Every physician knows that when he is summoned to a consultation on a case of croup, he is sure to find that the sufferer has been freely bled, either generally or locally; and he probably is informed that in spite of the loss of blood the inflammation increased. It never strikes the practitioner that he should say—"in consequence of;" yet it would probably be nearer the truth. I would strongly urge then, that this plan of indiscriminate bleeding be discontinued; that the case be fairly looked at, in all its bearings; that the sufferer's constitution and the condition of his vital powers be fully taken into con- sideration ; and that we hesitate to deprive the flesh of that which we are told is its life, simply because there is inflam- mation of the air-tube, and books tell us to treat this dangerous affection by bleeding. Moreover we are taught to bleed very freely when the child is plethoric and robust, full of blood, full of life, healthy and vigorous, with all its powers active. But are such, the children who—generally speaking—suffer from this disease? Certainly not in town practice. And again, will bleeding render impure blood pure, or will it CROUP. 339 check inflammation? Is conjunctivitis controlled by the application of leeches round the orbit ? does the vascularity decrease as the blood flows ? I have never seen it do so. In rheumatic fever, which are the cases that are most liable to be affected with pericarditis or endocarditis ? Is it not those that have been bled? Do women who have had natural labors suffer most frequently from puerperal metritis, or such as have had severe floodings? According to my own experience undoubtedly the latter. In short, I would counsel every practitioner to think and reason for himself: to scan every case of inflammation narrowly, and ask himself—Is there an excess of healthy blood here ? and even if there be, will it not be required by-and-by to support the system under the pros- trating effects of the disease? and finally—to consider well the result which has followed the employment of depletion when he has resorted to it or has actually witnessed its employment, and if he find that the good derived from the use of the lancet has been more than problematical, then I would advise him to throw the instrument away, let authorities say what they may. But if we are not to bleed in a severe case of croup, what are we to do ? When the patient is seen at the onset of the disease, the inflammatory action may sometimes be arrested by hot fomentations alone—as recommended by Dr. Lehman and successfully practised by Dr. Graves. A sponge, the size of a large fist, dipped in water as hot as the hand can bear, must be gently squeezed half dry, and instantly ap- plied beneath the little sufferer's chin, over the larynx; the temperature being maintained by resoaking it every two or three minutes. A steady perseverance in this plan for twenty or thirty minutes, produces vivid redness of the skin over thevwhole surface of the throat; while under the influ- ence of this topical treatment, a gentle perspiration breaks out—to be encouraged by warm diluents. A notable diminu- tion also takes place in the cough, hoarseness, tone of voice, dyspnoea, restlessness, &c; and generally a sound sleep is 3-10 CROUP. enjoyed, from which the patient awakes nearly well. Suppos- ing that this amelioration does not take place, very little time has been lost, and we must resort to emetics—a most valuable class of remedies. The ipecacuanha wine—in doses varying from one drachm to two drachms, according to the age— should be given every fifteen minutes until free vomiting has been induced; and unless the breathing is relieved, a dose sufficient to keep up the nausea should be repeated every three or four hours until decided ease is afforded. When this is obtained, great benefit will result from the administration of a draught containing a little antimony, ipecacuanha, , an animal—occasionally found inhabiting the intestinal canal of which three possess an alimentary tube, and are therefore called hollow worms, or Cck/mintha —xoaoss hollow, and 'frpivg, a worm; and two which have no abdominal cavity, and are hence termed solid worms, or Stcrel- mintha—crepibf, solid, and 'frpivg. In the first class we have,— a. The Tricocephalus Dispar, or long thread-worm, usually found in the coccum and large intestines, measuring about two inches in length, and having a very slender body. It is often found in considerable numbers, even in the intestines of healthy persons: during life they give rise to no symptoms. b. The Ascaris Lumbrieoides, or large round-worm, is found in the small intestines, especially of ill-fed children. It some- what resembles in size the common earth-worm, varies in length from six to nine inches, and is a light-yellow color. The symptoms which it may possibly give rise to, arc—thirst, disturbed sleep with grinding of the teeth, pallid countenance, dilated pupils, bluish rings beneath the eyelids, foetid breath, swelled belly, emaciated extremities, depraved appetite, slimy stools, itching of the nose, tenesmus, and itching of the anus. c. The Ascaris Vermicidaris, or small thread-worm, is found in the rectum, and is the smallest of the intestinal worms, averaging usually about a quarter of an inch in length. It gives rise to intolerable itching and irritation about the anus, tenesmus, depraved appetite, picking of the nose, offensive bre.ath, and disturbed sleep. In the second class we find,— a. The Tccnia Solium, or common tape-worm of this coun- try, which exists in the small intestines, varying in length from five to ten feet, and in breadth from one line—at its narrowest part—to four or five at its central or broadest por- tion. The head of this parasite is small and flattened, having in its centre a projecting papilla armed with a double circle of hooks, around which are four suckers or mouth.s, by which nourishment is imbibed; the generative apparatus consists of DISEASES OF THE INTESTINES. 403 a ramified canal or ovarium containing the ova, and occupying the centre of each joint. The symptoms of its presence are not very striking, its existence being generally unsuspected until single joints are passed in the stools; in many cases, however, there is a continual craving for food, debility, pain in the stomach, emaciation, and itching about the nose and anus. b. The Bothriocephalus Latus, or broad tape-worm, is almost peculiar to the inhabitants of Switzerland, Russia, and Poland. It differs from the common tape-worm in having its segments of a greater breadth than length. " The extreme fertility of the Bothriocephalus latus may be understood by considering that each foot of the well-developed worm contains 150 seg- ments or joints, each joint possessing its own ovary and male organs. Hence each joint is fertile; and as each ovary would produce 8,000 ova, it may be calculated that ten feet of such a worm would produce the enormous number of 12,000,000. They are very rarely met with in this country, but they are so occasionally. Professor Owen, examining the collection of a worm doctor in Long Acre, found three specimens; two had come from persons who had been in Switzerland, but of the third nothing was known. If, for the sake of convenience, we tabulate these entozoa according to the parts they inhabit, we shall have,— Small intestines . . Ascaris lumbricoides, or round-worm. Taenia solium, or common tape-worm. Bothriocephalus latus, or broad tape- worm. Large intestines . . Tricocephalus dispar, or long thread- worm. Ascaris vermicularis, or common thread-worm. Treatment—We have several remedies for the round and tape worms; such as—the oil of turpentine, scammony and jalap, compound jalap-powder with calomel, the bark of the pomegranate root, the kousso, and the oil of male fern. I am 404 DISEASES OE THE INTESTINES. in the habit of trusting to the latter, which I thus administer. On the first morning I commence with a dose of castor oil or a Seidlitz powder, and during the day keep the patient on very low diet, only allowing a little good beef-tea. At night the purgative is repeated; and thus the worm or worms get thoroughly uncovered by the removal of the contents of the alimentary canal, and therefore receive the full benefit of the —to them poisonous—dose of oil of male fern, which is taken the first thing on the following morning, according to—F. 19. By this means, perhaps twice repeated, I seldom fail to re- move the whole worm, including the head. To prevent its re-formation, tonics should be given; especially the mineral acids in infusion of quassia, or the tincture of the sesqui- chloride of iron with tincture of aloes, &c.—F. 17. The patients should also be directed to take plenty of salt with their food; and to avoid pork and all imperfectly-cooked meats. The ascarides may generally be killed by enemata of in- fusion of quassia, or of common salt, or of lime-water, or of the tincture of the sesquichloride of iron—in the proportion of half an ounce to half a pint of water. It need hardly be mentioned that none of these remedies ought to be resorted to, unless we are quite certain that the child is affected with some verminous affection. The general symptoms are in all cases untrustworthy, since none of them are peculiar to helminthiasis; moreover, when worms are present in the intestinal canal> distinct evidence can almost always be obtained by examining the evacuations, inasmuch as portions of them are most likely to pass away. Lastly, it may be added, that I have never met with a verminous affec- tion in an infant confined to the breast: although it is said that worms have been found even in the intestines of the foetus. 6. Prolapsus Ani—not unfrequently occurs as a conse- quence of the tenesmus in inflammatory diarrhoea, or from the abuse of purgative drugs, or it may follow from the strain- PERITONITIS. 405 ing requisite to pass hardened faeces after prolonged constipa- tion. Generally, as the cause of the protrusion is removed, so the affection ceases; but such is not always the case. Hence the practitioner should be prepared to recommend appropriate remedies for its cure. Perhaps the best plan is to insist that the little patients shall pass their evacuations while lying on the back, in which position the bowel rarely descends, as it is impossible for much straining to be exerted. Or the nurse may be directed to support the margin of the anus with her fingers, during defalcation; provided the child is not old enough to do so for itself. Then if the rectum or its mucous membrane still prolapse, the nurse is to be taught to gently return it; and if necessary a bandage and compress must be applied to keep the parts in their normal position. Tone should in all instances be imparted to the relaxed tissues by the use of astringent injections; such as, infusions of oak bark or of rhatany, or solutions of alum or of sulphate of iron —gr. ij.—vj. in water ^j. In one obstinate instance under my care, a cure was affected by the free application of the solid nitrate of silver, but this is seldom necessary. Ferruginous tonics, quinine, or the mineral acids, may also be administered internally; and the regular action of the bowels ought to be insured by the frequent use of mild, unirritating laxatives, or by the occasional exhibition of a good dose of calomel and rhubarb, as advised by Sir Benjamin Brodie. SECTION IV.—PERITONITIS. 1. Acute Peritonitis.—Acute inflammation of the peri- toneum is not a very common idiopathic affection at any period of life, but fortunately it is still more rare during childhood. There seems to be abundant evidence, however, that it is occasionally a disease of intra-uterine life; in which case it is possibly due to some syphilitic taint. It may cause the death of the foetus; or the infant may be born suffering from the morbid action. Symptoms.—When idiopathic peritoneal inflammation is 406 L'EIUTON 1TTS. set up in a child, the symptoms are much the same as those which are developed in the adult; but when the peritonitis is the secondary disease, then the diagnosis is more difficult, inasmuch as the symptoms are often obscure in tho commence- ment and are generally masked by the primary affection. The earliest and most prominent indication of peritonitis in both instances, is the severe suffering which is produced; the pain being at first confined to a part but afterwards extending over the whole abdomen, and being accompanied by great fever and constitutional disturbance. Moreover the pain is aggravated by any movement which calls the abdominal muscles into action, or by pressure—even the weight of the bedclothes being insupportable : the little patient consequently lies quiet on his back, with his knees bent, and legs drawn up. The abdomen is also tense, hot, and frequently tympani- tic ; the bowels are constipated; there is often nausea and vomiting; the skin is hot and dry; the pulse, small, rapid, and weak; the respirations hurried, short, incomplete, and jerking; the tongue furred; and the countenance is expressive of suffering, and great anxiety. After a time the belly ceases to be tympanitic, but remains somewhat enlarged from the effusion of serum. When a fatal termination is approaching, the abdomen often becomes much distended, the pulse Very quick and weak, the countenance ghastly, and death occurs from exhaustion. Treatment.—Hot anodyne fomentations, mercury, and espe- cially opium—in as large doses as the child will bear—are the remedies on which I would advise the practitioner to rely. Of course general and local bleedirfg is usually recommended; but the true physician will think for himself, and take all the circumstances of the case into consideration, before resorting to depletion. The best mode of getting the system under the influence of mercury will be through the cutaneous absorb- ents : two or three drachms of mercurial ointment are to be spread on muslin, and then laid upon the abdomen underneath the fomentation flannels. Where the sufferings are not re- PERITONITIS. 407 lieved by opium I should not hesitate to keep the patient for some hours under the influence of chloroform. In all cases, purgatives do the greatest mischief. The diet must consist at first, of barley-water, or iced water only; should the patient become very low, great good may be effected by the judicious use of wine and strong beef-tea. In curing the inflammation, care must be taken not to let the suf- ferer die from exhaustion. 2. Chronic Peritonitis.—Chronic inflammation of the peritoneum is sometimes the sequel of acute, but more fre- quently an independent affection. M. Louis is of opinion that this disease, when not following acute inflammation, is always' complicated with strumous tubercles. In many cases, certainly, the lungs-and bronchial glands contain a greater or less amount of tubercle; the intestines are matted together by lymph and tubercular de- posits: and the peritoneum is beset with small granulations or patches consisting of the same material. But these appear- ances are not universal. Dr. Hodgkin says—" My own inspections would lead me also to the conclusion that chronic peritonitis is very frequently conjoined with tubercles; yet this concurrence has not been so uniformly supported by cases observed in this country, as has been by Louis's cases. That form of peritonitis which is accompanied by copious effusion, and which might easily be regarded as ascites, occurs without any appearance of tubercles. The same may be said of other cases in which the concrete product of inflammation had been more considerable."* The symptoms are somewhat obscure, the abdominal pain being slight, and the constitutional symptoms variable. Usually, the health gradually fails, the appetite becomes capricious, occasional attacks of abdominal pain take place, the bowels are alternately relaxed and constipated, the sleep is disturbed, and the skin is found hot and dry at night. * Lectures on Morbid Anatomy of Serous and Mucous Membranes, vol. i., p. 149. London, 1836. 408 TARES MESENTER10A. After a time effusion of fluid takes place, the abdomen en- larges, and perhaps fluctuation is felt; while the superficial veins of the abdominal parietes are seen full and prominent. Then the patient rapidly loses strength, becomes much emaciated, and has constant diarrhoea; and death either occurs from exhaustion, or from some intercurrent tubercular affection. The treatment must consist in attention to the bowels, in allowing a mild but nutritious diet, and in employing fugitive blisters or stimulating liniments to the abdomen; iodine paint and the iodine ointment may be recommended. I think I have seen benefit also, from the internal use of iodine, from different preparations of steel, and from cod-liver oil. These cases are, however, most unpromising. SECTION V.—TABES MESENTERICA. Tabes mesenterica is the name given to a tubercular or strumous degeneration of the mesenteric glands : it might be termed abdominal phthisis, were it not for the tubercular nature of some forms of chronic peritonitis, which could also claim this title. The mesenteric glands are so small at birth that they can scarcely be distinguished. But about the period of dentition they gradually become more developed, in common with many of the other glands of the body: and it is at this period that they often take on diseased action—forming the seat of tuber- cular deposits, especially in strumous, badly-tended, and im- perfectly-nourished children. The liability to tabes mesente- rica may be said to continue chiefly from the eighth month to the eighth or tenth year. Symptoms.—The symptoms bear a strong analogy to those which have just been described as significant of chronic peri- tonitis. They principally consist of pain in the bowels, more or less constant, sometimes severe, causing the child to keep his legs drawn up towards his belly. The lips are of a deep red and the angles of the mouth are covered with small ulcers, DISEASES OF THE LIVER. 409 or the whole lip is fissured. The bowels are variable, though generally relaxed; the motions are often unhealthy, of a light clay color, and extremely foetid. The abdomen is swollen and tense, while the other parts of the body waste away, until an extreme degree of emaciation exists—hence the name tabes; there is great pallor, and general debility which increases rapidly. The enlarged glands in the mesentery can sometimes even be felt through the attenuated abdominal parietes, when the disease has become thoroughly established. Obstinate diarrhoea often sets in with hectic fever, &c. Symptoms of pulmonary consumption may supervene, or the irritation of the enlarged glands may produce acute and fatal abdominal inflammation, or the child may die worn out by the disease, unless remission takes place. When recovery does for- tunately occur, the period of convalescence is protracted ; and great caution will be required during its progress, to shield the patient from relapses as also from all contagious and other infantile disorders. Treatment.—This must consist in the use of mild nourish- ing food adapted to the child's age and strength; asses' milk and farinaceous preparations being very useful. Cod-liver oil will be of much use in all cases, especially when given with vegetable tonics; the syrup of iodide of iron is also often valuable. In some instances benefit seems to have been derived from minute doses of the bichloride of mercury, dissolved in the decoction of sarsaparilla or in infusion of bark; or from alterative doses of the hydrargyrum cum creta. with Dover's powder; or from the gentle inunction of small quantities of mercurial ointment. Change of air—espe- cially to the sea-side, warm or tepid salt water baths, and good animal food—provided it can be digested, will often work wonders. SECTION VI.—DISEASES OF THE LIVER. 1. Jaundice.—Icterus or jaundice is rather a symptom of some affection of the liver, than a separate disease. It is a 410 DISEASES OF THE LIVER. condition at once recognized by the yellow hue of the skin and conjunctiva, by the dark-saffron tint of the urine, and by the white or light clay color of the intestinal evacuations. Infantile jaundice—icterus neonatorum—is generally a common trivial disorder, occurring a few days after birth, and usually disappearing gradually and spontaneously in about a week. It is most common in immature and feeble children, and is most intense in infants affected with sclerema and pul- monary atelectasis: it is probably unconnected with any pri- mary affection of the liver, but is a secondary hepatic disorder due to defective respiration, to breathing a cold or vitiated air, or to imperfect performance of the functions of the skin. Besides these simple cases, jaundice does sometimes depend on more serious causes; as on congenital absence of the hepatic or cystic biliary ducts, or on obstruction of these ducts by inspissated bile. In these fatal cases there is a strong ten- dency to haemorrhage which often occurs from the umbilicus just about the period of the separation of the funis. If the bleeding be controlled and life prolonged, general atrophy usually comes on; followed by exhausting diarrhoea, and death at the end of two or three weeks. During childhood, jaundice may oocur and have its origin from the same conditions as give rise to it in the adult. Thus it may be produced in two ways :—1st, By some temporary impediment to the flow of bile into the duodenum, and the consequent absorption of the retained bile; and, 2nd, by defective secretion on the part of the liver, so that the prin- ciples of the bile are not separated from the blood. The most common impediment to the flow of bile into the duodenum, is the impaction of one or more gall-stones in the ductus communis choledochus. These concretions consist of inspissated bile, and chiefly perhaps of cholesterine—a pecu- liar substance, which exists in a state of solution in healthy bile, but which, under certain circumstances, becomes released from its solvent, and assumes its natural crystalline form. In all cases the nucleus of the concretion consists of a small piece DISEASES OF THE LIVER. 411 of solid biliary matter, or of inspissated bile cemented by mucus. When the obstructing stone or stones have passed into the duodenum, they are voided with the faeces; and the cause of the jaundice being removed, the skin gradually assumes its natural color. The other causes of jaundice from obstructed gall-ducts are, cancer of the liver or pancreas, closure of the ducts from adhesive inflammation of the liver, from spasm of the ducts, and from constipation, the loaded intestine pressing upon the duct, and so impeding the flow of bile. The secretion of bile may be suppressed or rendered defective by congestion and inflammation of the liver; by mental shocks, or grief, or fits of anger; by certain poisons in the blood; and by certain disorders of the stomach. Treatment.—In the simple cases nothing will be needed beyond attention to the clothing of the infant, keeping the air of its apartment pure and warm, and perhaps the admini- stration of a dose or two of some mild laxative. If the mother be unable from any cause to suckle her offspring, a strong healthy wet-nurse must be procured. The other varieties of jaundice will have to be treated on principles varying with the nature of the cause. Where there is congenital absence of the hepatic or cystic biliary ducts, all attempts to materially prolong life will be unavailing; hence we must be content with alleviating as far as possible any distressing symptoms that may arise. In jaundice from the obstruction of gall-stones, hot baths, warm fomentations, hot alkaline drinks, saline purgatives, and sedatives are the remedies on which to rely: while when the diagnosis points to defective secretion as the cause of the disturbance, we may perhaps cautiously try mercury, or taraxacum, or the nitro- muriatic acid in small doses; but in most instances, as we shall be merely working in the dark, it will be better to rest contented with saline purgatives, diaphoretics, baths, rest, and regulated diet. 2. Strumous Enlargement of the Liver.—Inflamma- tory affections of the liver are so very rare in the young, that 412 DISEASES OF THE LIVER. it is unnecessary to describe them in these pages. A peculiar enlargement of this gland, however, not unfrequently occurs in feeble, delicate children. The abdomen gradually enlarges, so that the little patient is said to be "pot-bellied;" and on examination one or more well-defined tumors are discovered. These tumors are formed by the enlarged liver, with perhaps an enlarged spleen; the increase in size in both cases being due to the interstitial deposit of albuminous matter. As this foreign matter is soft, and has no tendency to contract like the lymph poured out in ordinary inflammation, it does not much impede the passage of the blood through the liver, or the escape of the bile through the ducts; and hence it very seldom gives rise to serious disturbance. Should the same material, however, become deposited in the structure of the kidneys, then the functions of these glands become so com- pletely interfered with, that the cases cease to be amenable to treatment; and albuminuria, ascites, and anasarca ensue, and death ultimately results. The peculiar condition just described is probably the conse- quence of a scrofulous or syphilitic cachexia. In its highest degree, in the liver, it is most frequently found—according to Dr. Budd—in young persons who have long suffered from scrofulous caries. Occasionally, however, there is no disease of the bones, but the patient is much wasted by scrofulous disease. The following case,—related by Portal*—may be quoted as a characteristic example:—A boy, eight years of age, gradually became extremely emaciated. The submaxillary glands were enlarged, and on each side of the neck was a string of enlarged cervical glands; the liver extended low in the belly. The child was in a slow fever, had a great distaste for all kinds of food, and died a fortnight after he was first seen by Portal. On dissection, the maxillary glands, the glands on each side of the neck, and the bronchial and mesenteric glands were found enlarged, and filled with a substance like plaster. The liver was of a prodigious size : when stripped of its cap- :; Observations sur le Maladies du Foie, p. 94. Paris, 1813. DISEASES OF THE LIVER. 413 sule, the substance appeared whitish; in the interior it was still whiter than on the surface. On the surface, as well as in the interior, were lymphatic vessels containing a substance so thick that they formed small hard cylinders. The matter with which the liver was gorged had the same whiteness. A slice of the liver, exposed to heat, to the action of boiling water, or to alcohol, was hardened like albumen. When only the liver and spleen—either separately or to- gether—are affected, proper remedial measures do great good; and it is probable that under their use the hypertrophy will diminish, of perhaps disappear. As, in all cases, there are obvious indications of a scrofulous habit, our treatment must be directed to the improvement of the general nutrition. A digestible nourishing diet, sea air, and tepid salt-water baths, will be of the greatest benefit; especially if, at the same time, the iodide of potassium be administered in combination with steel—F. 40. If there be any signs of a depraved appetite— of pica, as it is called—the little child must be prevented from indulging in morbid fancies; while attempts are made to restore the healthy functions of the stomach by giving small doses of pepsine with those meals at which animal food is taken. 3. Hydatid Tumors of the Liver.—Hydatid tumors are found in the liver more frequently than in any other organ. They are most common between the ages of twenty and forty; but they may occur at any age from six years to fifty. Dr. George Budd states that he has found no instance recorded in which such a tumor occurred under the age of five or six, or above that of fifty-two.* An hydatid tumor consists of a sac, lined by a thin bladder or cyst, and filled with a limpid, colorless fluid; floating in which, numerous small cysts, similar to the cyst lining the sac, and varying in size from a pea to a pigeon's egg, are usually found. To these cysts or bladders Laennec gave the name acephalocyst—a bladder without a head. The acephalocyst * On Diseases of the Liver. 2nd ed., p. 438. London, 1852. 35* 414 DISEASES OF THE LIVER. lining the-sac is composed of finely-laminated, friable coats, about the firmness of coagulated albumen. Sometimes it con- tains no floating hydatids, or very few; in other cases it is literally crammed with them; and these again, it is said, may contain another generation. To distinguish these different kinds, as well as to mark the mode of their increase, naturalists have divided these productions into two species : 1st, the acephalocystis endogena, of Kuhn, likewise called socialis, vel proliferd by Cruveilhier, the pill-box hydatid of Hunter, which is the kind most commonly developed in the human subject, and in which the fissiparous process of generation takes place usually from the internal surface of the parent cyst, the pro- geny being sometimes successively included; and, 2nd, the acephalocystis exogena of Kuhn, eremita, vel sterilis of Cru- veilhier, which developes its progeny generally from the ex- ternal surface, and is found in the ox and other domestic ani- mals. The true nature of these acephalocysts has long been a subject of investigation. M. Livois seems, however, to have settled the question by his discovery that they are the dwell- ing-place of those minute animalcules, to which Rudolphi gave the name echinococcus, from the cylinder of hooks surrounding the head. M. Livois states that echinocci exist in all acepha- locysts, and this observation has been confirmed by Dr. Budd and other observers. Symptoms.—When an hydatid tumor forms in the liver, its growth is generally slow. It gives rise to little inconvenience beyond a sensation of weight, so that its presence is often not suspected until found after death. When the tumor is of large size, it may then be easily felt; sometimes it compresses the portal vein of vena cava, producing ascites and oedema of the legs. It may burst into the peritoneum—causing fatal peritonitis, or into the lung, or into the intestines, or through the abdominal wall; in the two latter cases, the contents will often be entirely discharged, and the sac ultimately closing up, will leave the patient well. When the tumor opens into the lung, the patient becomes so worn out with the constant ACUTE DESQUAMATIVE NEPHRITIS. 415 expectoration of hydatids and puriform matter, and the con- stitutional disturbance is so severe, that he generally sinks under it. Sometimes an hydatid tumor gets well without opening, namely, by the secretion of a thick putty-like matter within its sac, owing either to the destruction, or at all events causing the destruction, of the hydatids. Treatment.—Two agents, iodide of potassium and common salt, are supposed to possess the power of stopping the growth of these tumors. Confirmatory evidence is still required, however, to prove conclusively the value of these remedies. CHAPTER XIX. DISEASES OF THE URINARY AND GENITAL ORGANS. SECTION I.—ACUTE DESQUAMATIVE NEPHRITIS. Acute desquamative inflammation of the kidney is very rarely seen in early life as an idiopathic affection; but it is far from uncommon as a consequence of scarlatina.—Chapter XII., section 6. Symptoms.—This renal affection, whether produced by the poison of scarlatina, or of cholera, or simply from cold, is attended by the same symptoms. It commences usually with rigors or chilliness, followed by feverish reaction, headache, restlessness, «pain and tenderness in the loins, and often vomiting. In most "cases, but by no means in all, there is dropsy; and usually this is an early symptom. The face first becomes puffy, followed by general swelling of the areolar tissue throughout the body, and by effusion of fluid into one or more of the serous cavities. At the same time there is frequent desire to pass urine, which is scanty, 416 ACUTE DESQUAMATIVE NEPHRITIS. of a dark smoky color, and on being tested by heat and nitric acid, is found to be highly albuminous. Examined microscopically, it is seen to contain masses of coagulated fibrin, blood-corpuscles, epithelial casts and cells, and occa- sionally crystals of lithic acid. When the progress of the case is favorable, the earliest signs of improvement are the disappearance of the dropsy and an increase in the quautity of urine. It is not uncommon for a patient, during con- valescence from acute desquamative nephritis, to pass from four to six pints of urine in the twenty-four hours; the natural quantity averaging only—in the adult—from a pint and a half to two pints. Treatment.—In seeking to cure acute inflammation of the kidney, we have to remember, as Dr. George Johnson re- marks,—" that there has been, first, a morbid condition of the blood, which has excited disease in the kidney, and that, as a secondary consequence of the renal disease, the blood has become contaminated by the retention in it of urea and other excrementitious matters."* Our object of treatment must, therefore, be to rest the kidney, and to purify the blood by means of the other excretory organs. To carry this object into practice, the patient must rest in bed, in a moderately warm room; low diet; plenty of simple drink—water or bar- ley-water; and, in order to get the skin and bowels to act freely, the hot-air bath, or hot-water bath must be used, dia- phoretic medicines—F. 33, 35—administered, together with saline purgatives—F. 3, 8, or 15. When the urine is highly albuminous and scanty, the pain in the back severe, and the —•' head seems affected, Dr. Johnson thinks the most valuable remedy is cupping on the loins; two or three ounces of blood being as much as should be taken from a child four years of age. Having treated several cases of this disease, however, without resorting to cupping, and having cured myself of this form of nephritis succeeding to scarlatina without losing an ounce of blood—indeed I had a strong conviction that in * On Diseases of the Kidneys, p. 126. London, 1852. CANCER OF THE KIDNEY. 417 my own case loss of blood would have been loss of life—I can- not recommend this practice. It is only necessary to say that diuretics should, under no circumstances, be had recourse to in this disease. As recovery advances, great care must be taken to avoid exposure to cold; and all errors in diet should be rigidly guarded against. SECTION II.--CANCER OF THE KIDNEY. Cancer is probably the rarest form of renal diseases. Dr. Walshe has collected forty cases of cancer of the kidney from different sources. In thirty-one of these, pure encephaloid— or one of its varieties—was the species of cancer observed, while there were only five cases of scirrhus. The disease affected both organs sixteen times, the right alone - thirteen times, the left alone six. Out of thirty-one of the cases, two occurred in children under two years of age. The Transac- tions of the Pathological Society of London contains the re- port of a case of cancer of the kidneys ending fatally at the age of thirteen months; in which, after death, the weight of the two kidneys was found to amount to five pounds.* Can- cerous degeneration, like many other forms of renal disease, commences usually in the cortical substance, and thence ex- tends to the medullary cones and to the walls of the pelvis and ureters. The symptoms are often insignificant: the chief are—pain, increase in size of kidney—as may be felt through the abdominal walls, haematuria, and possibly the passage of urine containing pus and encephaloid pulp. The treatment must consist in palliating the effects of the disease, in reliev- ing pain by fomentations and sedatives, and in supporting the strength. SECTION III.—INFANTILE DIURESIS. An increased flow of urine in young children—as in adults— is a symptom of very various diseases. Thus, the disturbance of the functions of the kidneys may be merely a secondary * Vol. i. p. 119. London, 1847. 418 INFANTILE DIURESIS. affection, arising from gastric and intestinal disorder; or it may be associated with the tuberculous cachexia; or it may be due to true diabetes,—though so uncommon is this disease in the young, that Dr. Prout, out of nearly seven hundred cases only saw one in a child under five years of age, while Dr. West has never seen a single instance at the same period of life. There is, however, a remarkable form of diuresis, which has been described by Dr. Prout* as not uncommonly occurring soon after the period of weaning. The symptoms are as fol- lows:—From having been to that time healthy, the child begins to get dull and inactive, and to daily lose flesh; the skin feels harsh, dry, and hot; the bowels become irregular; the motions assume an unnatural greenish appearance; and the abdomen becomes prominent, so as to lead to the sus- picion of mesenteric disease. At this period the urine is generally scanty and high colored; becomes turbid imme- diately on cooling; and lets fall a pale, clay-colored deposit of lithate of ammonia, sometimes intermixed with the oxalate of lime, or an excess of phosphates. As the disease proceeds, the quantity of urine rapidly increases, and the thirst being commensurate, large quantities of fluid are consequently taken; so that an infant about twelve months old will be often found to pass from two to four or five pints of urine in the twenty-four hours. The urine in this, and indeed in all the subsequent stages of the affection, is commonly trans- parent and of a pale-yellow or greenish tint. Its specific gravity varies from 1-010 to 1-025; and on examination it will be found to contain a great excess of urea, and occa- sionally even traces of albumen or sugar. This form of diuresis must be considered as rather formid- able; since, if it be neglected or mal-treated, it most com- monly ends in organic lesions of the kidneys, or in diabetes. It most frequently occurs in the children of strumous indi- * On the Nature and Treatment of Stomach and. Renal Diseases. 5th ed., p. 58. London, 1848. INCONTINENCE OF URINE. 419 viduals, who are at the same time dyspeptic or gouty; espe- cially if- they have been improperly nourished, or brought up in confined^ imperfectly-ventilated apartments. The general principles of treatment are,—removal to a pure country atmosphere, or to the sea-side, where a bracing dry air can be breathed; the employment of tepid or warm sea- water baths; attention to diet—animal and farinaceous matters being most suitable, with plenty of milk; a gradual but steady diminution in the quantity of fluids allowed; and the adminis- tration of small doses of Dover's powder to increase the func- tions of the skin, as well as to relieve the general irritability. Gentle aperients will be needed to regulate the state of the bowels; pepsine should be tried, if any indications of dys- pepsia present themselves; and lastly, tonics of bark, quinine, or steel, will prove highly useful. SECTION IV.--INCONTINENCE OF URINE. Incontinence of urine may occur in early life from many causes. It may be associated with a tendency to renal dis- ease, or with a disposition to gravel, or it may depend upon constitutional weakness and irritability, or it may be due to an increase of uric acid in the urine. The troublesome involuntary flow of urine during sleep, which is so common in young children, may result from any of the causes of incontinence: hence in all cases of the kind the renal secretion should be examined. But usually this affection is the consequence of bad habits; being favored by the free use of fluids during the after part of the day, by exposure to cold in the night, and by lying on the back,—a posture which seems to be very unfavorable to the retention of the urine, especially when the natural sensibility of the mucous membrane of the neck of the bladder is at all in- creased. It may usually be cured by making the little patient almost abstain from fluids for three or four hours before going to bed: by waking him to empty his bladder twice or thrice during the night: by tying a cotton reel over his spinal 420 DISEASES OF THE MALE GENITAL OROANS. column, so that when he turns round upon his back he may at once be awoke : and by giving strength and tone to his system, by the administration of the tincture of the sesqui- chloride of iron. In some inveterate cases, the application of a succession of small blisters over the sacrum has affected a cure : but such agents should be avoided, if possible. Where the bladder is very irritable a belladonna plaster over the loins and sacrum will often be very useful: or four or five grains of the extract of this drug may be rubbed into the same region every night. SECTION V.—DISEASES OF THE MALE GENITAL ORGANS. 1. Discharge from the Urethra.—Boys occasionally suffer from a discharge from the urethra; though this is more rare than the leucorrhoea of female children, probably because the mucous membrane of the genitals is less extensive and more protected from the irritating influence of external agents than in girls. An instructive case is recorded by Mr. Moss,* of a little boy six years old, affected with swelling and inflam- mation of the prepuce and glans penis, accompanied by a pro- fuse discharge and pain in passing urine. His three sisters also suffered from leucorrhoea, and his grandmother had a severe attack of purulent ophthalmia: there was " no reason to believe that these children had been infected from any vene- real source." The treatment of these cases consists in the use of the warm hip-bath, the application of bread-and-water poul- tices when the morbid action runs high, saline purgatives, and great cleanliness. The parents should be cautioned as to the infectious nature of the discharge, and the risk of ophthalmia from its contact with the eye. 2. Phymosis—signifies a preternatural constriction of the orifice of the prepuce, so that the glans penis cannot be un- covered. Most children are born with the opening of the prepuce too small to allow of the complete retraction of the foreskin; but - Lancet, 10 December, 1835. DISEASES OF THE MALE GENITAL ORGANS. 421 as the orifice becomes naturally dilated about the time of puberty, nothing need be done unless the opening is too small to allow the urine to pass freely. Should this prove to be the case the preputial orifice must be cautiously slit up, or circumcision may be performed; the latter being the most ad- visable proceeding. 3. Paraphymosis—consists of a retraction of a tight pre- puce over the glans penis, with swelling preventing its return. This swelling is quickly followed by inflammation, which may run on to gangrene of the constricted glans as well as of the constricting ring of foreskin. The everted prepuce should be replaced as quickly as possible. Ice or cold water is to be applied for a few minutes to reduce the swelling, and then gentle but persevering attempts must be made to draw the prepuce forwards whilst the glans is pressed back. If these attempts fail, the constricting ring of foreskin must be divided with a bistoury. 4. Hydrocele.—Having already spoken of congenital hy- drocele—Chapter VI., paragraph 14—it is only necessary to mention that simple hydrocele sometimes occurs in infants only one or two months old, giving rise to feelings of alarm on the part of the parents. It is however generally to be cured by the application of a cold or slightly-stimulating lotion ; or by simply painting the scrotum three or four times with the tincture of iodine. Should these means fail to p'rocure absorp- tion, the hydrocele may be punctured with a cataract needle, and the fluid allowed to drain away. 5. Acute Testitis.—Inflammation of the testicle—orchitis —is rare in young children, but it does sometimes occur. The symptoms are generally acute, and the swelling consider- able ; but the disease soon subsides, and is confined to one gland. Mr. Curling relates the following example:—A Jew child, only five months old, was brought to me at the London Hospital on account of a swelling in the left groin and scrotum. The mother first observed it the day before on washing the child; he afterwaads cried the greater part of the 36 422 DISEASES OF THE FEMALE GENITAL ORGANS. night. The tumor extended from the external ring to the bottom of the scrotum, was full six times the size of the right testicle, felt firm and hard, and received no impulse wheu the child cried or struggled. The scrotum was distended and very red and hot. I ordered the application of a leech and cold lotion, and two drachms of castor oil to be given. In two days I found the swelling reduced about one-third, and much less tender; and the infant appeared to be free from suffering. I directed four grains of the hydrargyrum cum creta to be given every night. Under this treatment the swelling and induration soon subsided, and in a week the gland was nearly reduced to the size of the right testis, but the cord still remained thickened and hard. Three weeks after the attack first commenced, I found the parts perfectly natural.* SECTION VI.—DISEASES OF THE FEMALE GENITAL ORGANS. 1. Infantile Leucorrhoea.—Children of all ages are liable to suffer from a discharge from the mucous glands of the vulva. Occasionally the disease spreads up the vaginal canal; giving rise to profuse purulent or muco-purulent foetid dis- charge, with heat and pain during micturition, and excoriation of the surrounding parts. Care must be taken not to mistake this disease for gonorrhoea produced by infection, though I am unable to point out any diagnostic signs by which the error may be avoided; for I have seen instances where the inflammation has been so intense that the appearance has very much resembled that caused by violence, and yet it has been impossible for anything of the kind to have taken place. The history must be therefore thoroughly inquired into, and the cause surmised. The nature of the child's constitution will sometimes throw light on the nature of the discharge, in- asmuch as strumous subjects are especially apt to be affected with leucorrhoea; particularly during the period of dentition, * A Practical Treatise on the Diseases of the Testis, SfC, p. 227. London, 184:;. DISEASES OF THE FEMALE GENITAL ORGANS. 423 or if they suffer from neglect of cleanliness, or from the irri- tation of ascarides in the rectum, or from constitutional debility. Occasionally the discharge seems to prevail as an epidemic. The virus is highly contagious, and its application to the eye gives rise to violent ophthalmia. It has been doubted whether the discharge is communicable from the child to the adult male or female; for unfortunately cases of infantile leucorrhoea have led to false accusations, and much misery. Since the occurrence of some important trials in the Dublin law courts four years ago, Mr. Wilde has examined this question with great skill; and from his inves- tigations there can be now no dispute, that the answer must be in the affirmative. Amongst other remarkable cases, this gen- tleman relates the following :—During the summer weather of 1855, " a lady and a gentleman both became affected with a discharge from the genitals; in the female, however, the disease was most virulent, and presented all the symptoms of vaginitis, with the usual excoriations and incrustations consequent thereon. The lady accused the gentleman, and the gentleman the lady. Mutual recrimination ensued, and both parties, strong in their own innocence, felt aggrieved and insulted. Fortunately the police authorities were not con- sulted in this dilemma, otherwise we might have had it brought before the gentlemen of the long robe, to eventuate, perhaps, in an appeal to the House of Lords. Each party appealed to the surgeon, who on examining into the state of the case, expressed a desire to see the children, when he found that a girl, eight or nine years of age, labored under .well- marked symptoms of infantile leucorrhoea ; that she had slept with her mother, had evidently infected her, and that the mother had given the disease to the husband."* The treatment of infantile leucorrhoea mnst be perserver- ingly carried out, or the disease will last for months. Atten- tion to cleanliness, frequent sponging with an astringent lotion the use of cold hip baths containing a little alum, * Medical Times and Gazette, January 17, 1857. 424 FOREIGN BODIES IN THE AIR-PASSAGES. and mild alteratives or laxatives will be needed. The diet should be plain but nourishing; and tonics—especially of quinine and steel—will always be useful. If the discharge prove obstinate, a short residence at the sea-side with sea- bathing will generally cure it. 2. Cohesion of the Labia.—After inflammation of tho vaginal labia, the contiguous surfaces have been found adhe- rent ; the adhesions perhaps being due to the organization of the lymph which has been effused. The only treatment re- quired, will be the separation of the labia by a probe, or if necessary by a bistoury; taking care to keep the edges of the wound apart by lint, until cicatrization has taken place. __________fe CHAPTER XX. ACCIDENTS, BURNS, &c. SECTION I.—FOREIGN BODIES IN THE AIR-PASSAGES. General Observations.—The number and variety of articles that may enter the air-tubes, and give rise to severe or fatal mischief is very remarkable. The most frequent substances which do so in children, are—seeds of all kinds, beans, peas, cherry-stones, pieces of hard wood, buttons, pins, small coins, marbles, pebbles, bits of slate pencil, beads, and small nails. The size of these articles is often such that it seems impossible they could have passed through the chink of the glottis: yet they do so. Thus Dr. Mott has recorded an instance in which a child only eleven months old, inhaled a black shawl-pin two inches long, with a head nearly as large as a small marble :* at Koenigsburg in Germany, the larynx of a goose became impacted in the windpipe of a boy twelve years old :f M. * New Hampshire Journal of Medicine, p. 197. April, 1852. f London Medical Gazette, vol. xi., p. 559. 1850. FOREIGN BODIES IN THE AIR-PASSAGES. 425 Berard had to perform tracheotomy on a boy not quite seven years old, to remove a marble eight lines in diameter :* and Mr. Fergusson has had to resort to the same operation to extract a plum-stone from the trachea of a girl seven years of age.f When the extraneous substance is of an animal or vegetable nature, it is apt to swell, owing to its imbibing moisture; so that a small bean or pea has been known to increase to thrice its size in a few days. In a few fortunate cases it has become softened and broken up, so as to permit of its expulsion piece- meal ; when retained—as it is usually—the foreign body becomes incrustated with mucus, or with lymph, or even with a few grains of carbonate or phosphate of lime. The substance may get lodged in one of the ventricles of the larynx, or it may become fixed between the chordae vocales, or it may be arrested in the trachea, or it may descend into one of the bronchial tubes—especially into the right. Symptoms.—The entrance of a foreign body usually occurs during a strong and sudden inspiration; it immediately gives rise to a violent spasmodic cough, dyspnoea, and a sense of impending suffocation; and sometimes even to sudden death, by arresting the respiration. After a few minutes, the vio- lence of the first symptoms usually abates for a time; the cough and dyspnoea returning at variable intervals. Some- times the calm lasts for many hours; usually it is short—of twenty or thirty minutes' duration. The subsequent symp- toms will depend upon the situation in which the foreign body is retained. Thus, if it remain in the larynx, there will usually be violent, harassing, and suffocating cough; perhaps loss of voice, or inability to speak above a whisper; probably pain in swallowing; tenderness over the part; and noisy hissing respiration, with more orjess dyspnoea. When the substance descends below the larynx, it is seldom retained in * Archives G^nirales de Midecine. 2nd series, torn, ii., p. 125. Paris, 1833. f Opus cit., p. 648. 426 FOREIGN CODIES IN THE AIR-PASSAGES. the trachea, but passes on into one of the bronchial tubes—in the great majority of instances into the right, being directed to this by the bronchial septum. If, under these circum- stances, auscultation and percussion be practised, it will be found that air does not enter the obstructed lung at all, or where the obstruction is only partial—that it fills the lung in- completely. Hence there will be a complete loss or a dimi- nution or absence of the respiratory murmur on auscultation. The foreign body not unfrequently plays up and down the trachea, under the influence of fits of coughing. This change in position gives rise to severe spasmodic attacks of dyspnoea; a peculiar sensation of movement appreciable by the patient; and a sound of motion detected by auscultation, as well as —perhaps—to a flapping or valve-like sound produced by the foreign body being forced against the rima glotidis in expiration. Supposing that the substance is not expelled or removed, the patient will be liable to be suffocated at any moment from the foreign body pressing up into the larynx under the in- fluence of a fit of coughing; or if he escape this risk, there is the fear of inflammation with all its dangers. After the sub- sidence of the immediate symptoms, the foreign body some- times gives rise to no appreciable inconvenience for many weeks or months: Louis relates such an instance, where the patient did* not—after the first few minutes—experience a bad symptom for twelve months, at the end of which time he coughed up a cherry-stone followed by such copious expec- toration, that he died from exhaustion in three days.* Dr. Condie attended a child who continued free from all symptoms of disease for a week, after the first symptoms had subsided; pneumonia then set in, which ended fatally on the fifth day, when a large bead was founrl obstructing the right bronchus.f Occasionally death occurs during the act of vomiting, owing * Memoir on Bronchotomy, in Memoirs of the Royal Paris Academy of Surgery. Translated by Ottley, p. 277. London, 1848. f Diseases of Children. 3rd ed., p. 366. Philadelphia, 1850. . FOREIGN BODIES IN THE AIR-PASSAGES. 427 to some of the ejected matters lodging against the rima glot- tidis, or even passing down the windpipe. Thus, Corvisart being desirous of exercising a close supervision of the clinical wards at La Charite, visited them one evening unexpectedly. The steward, who had been indulging in a hearty meal, was taken by surprise, and became sick; but making a violent effort to repress the vomiting, he fell to the ground and ex- pired. On examining the body, the larynx, trachea, and bronchial tubes were found filled with half-digested food.* Diagnosis.—The symptoms of extraneous bodies in the re- spiratory organs may be imitated by different diseases. They may be distinguished from those of croup, by the state of the pulse and skin, which are rarely excited until the foreign sub- stance has had time to give rise to inflammation,—by the difi ficulty of breathing existing during expiration and not most severely during inspiration as in croup,—by the absence of the croupy character of voice,—and by the complete inter- missions : from hooping-cough, by the history,—the absence of the peculiar hoop,—and by the absence of great dyspnoea during inspiration ; from spasm of the glottis, by the history and by the absence of any auscultatory signs : and lastly, from the impaction of extraneous substances in the pharynx and wsophagus, by examining these passages with the finger and probang. The want of this latter precaution has proved fatal:—a man while eating, was seized with symptoms of suf- focation and difficult deglutition; the trachea was opened; but as nothing was found it was concluded that the substance had descended into one of the bronchial tubes, until after death the surgeon was surprised at discovering it fixed in the oeso- phagus. There will, however, be but little difficulty in forming a correct diagnosis in the majority of cases, if the history be carefully attended to. Thus, suppose a child " has been play- ing with a grain of corn, bean, pebble, or similar body, and * Laennec on Diseases of the Chest. Translated by Forbes. 4th ed., p. 131. London, 1834. 428 FOREIGN BODIES IN THE AIR-PASSAGES. has been suddenly seized with symptoms of suffocation, vio- lent spasmodic cough, lividity of the face, pain in the upper part of the windpipe, and partial insensibility, the presump- tion will be strong, that the substance whatever it may have been, has slipped into the air-passages, and is tho immediate and only cause of the suffering which the surgeon has been sent for to relieve. The presumption will be converted almost into positive certainty if the person was just previous- ly in the enjoyment of good health; if he was romping, jump- ing, or laughing at the moment of the accident, with the sub- stance, perhaps, in his mouth, or while attempting to throw it into that cavity; and especially, if the symptoms, after having been interrupted for a few minutes, continue to recur, with their former, or even with increased intensity, at longer or shorter intervals." * Pathological Effects.—The most common is inflammation of the mucous membrane, perhaps going on to ulceration : the latter effect is generally confined to the tissues in contact with the extraneous substance. The normal secretion of mucus is always increased; frequently it becomes muco-purulent, and in some instances the bronchi have been found loaded with the latter. When the foreign matter is retained in one of the bronchial tubes, it may produce pulmonary collapse if it com- pletely obstruct the tube, or inflammation of the corresponding lung may be set up, giving rise to all the ordinary symptoms of pneumonia. Abscesses also form at the seat of obstruction. In a few instances pulmonary emphysema has been induced : in others, pleurisy leading to effusion : and in a very small number, inflammation of the heart and its investing serous membrane. Mr. Herbert Mayo has recorded a case in which a boy twelve years old died in consequence of the inhalation of an ear of rye : pulmonary irritation with the most foetid ex- pectoration followed, and hectic fever set in which proved fatal." On dissection the extraneous body was found in an * A Practical Treatise on Foreign Bodies in the Air-Passages. By S. D. Gross, M. D., &c, p. 90. Philadelphia, 1854. FOREIGN BODIES IN THE AIR-PASSAGES. 429 abscess common to the lung and liver; the latter having be- come involved by the extension of the inflammation through the diaphragm.* Treatment.—The foreign substance is sometimes sponta- neously expelled, especially during a paroxysm of cough and dyspnoea. It has occurred when the patient has been laid upon a bed with his head hanging over the edge; and in a few instances when he has been in the erect posture. The period of this fortunate occurrence is variable : it may happen a few minutes after the accident, or months subsequently. Dr. Webster has recorded an instance where a cherry-stone was expelled sixty-eight days after its introduction, and the patient recovered after having suffered from pneumonia, abscess, and hectic fever ;f while Dr. Watson refers to an instance where an ear of barley was spontaneously ejected seven years after the accident, and the patient got well.J In a few instances the substance has been got rid of by inverting the body, and smartly striking the back of the chest to dislodge the obstruct- ing agent; but the latter, on touching the glottis, gives rise to such severe spasm, that it very rarely passes out. These facts have led practitioners to attempt to expel these extraneous substances by the use of medicines, especially by sternutatories and emetics : but the anticipated result has so very rarely ensued, that the practice ought to be abolished, especially as it is not without danger, and it causes the loss of valuable time. Since then, no patient can be safe who has a foreign body in the windpipe, how is it to be got rid of? When the body is in the larynx, laryngotomy should be per- formed as early as possible : but when it has descended lower, and perhaps in all cases in young children, then the trachea should be opened. The substance may be ejected through the glottis, or through an artificial opening, directly the latter is made : but should this not take place, then the patient's body * Outlines of Pathology, p. 506. London, 1836. + Lancet, vol. i., p. 802. London, 1830. % Practice of Physic, vol. ii., p. 225. 3rd ed. London, 1848. 430 BURNS AND SCALDS. should be inverted, and a few smart taps made to dislodge the substance. The inversion is not likely to be followed by any bad consequences, because the patient will breathe through the artificial opening; and hence the coin, or bean, or whatever it may be, will not give rise to that severe spasm of the glottis which it would otherwise do. The question may be enter- tained whether this spasm of the glottis cannot be overcome by the inhalation of chloroform, without opening the trachea; but I am not aware of any instance where such a plan has been tried. If, however, a surgeon determine to resort to it, he should be prepared to perform tracheotomy immediately, in case of the necessity arising. When the extraneous body resists all efforts to remove it, the wound in the trachea should be kept open to favor its extrusion subsequently. When the operation, however, is successful, the incision should be immediately closed by strips of plaster, or by sutures. SECTION II.—BURNS AND SCALDS. Amongst the most frequent accidents that bcfiill children, burns and scalds deserve prominent notice. Thes% casualties vary as regards their local and constitutional effects, according to the degree and duration of the heat, the extent of surface involved, the seat of the burn, 'and the strength of the vital powers at the time of the accident. The great depression which follows immediately after the occurrence of an extensive burn, will of course be felt more severely by a weak strumous child than by one whose constitutional powers have been pre- viously kept up to the standard of health. Burns may be classified into four groups, according as they give rise to simple inflammation of the skin, inflammation with separation of the cuticle and the production of blisters, destruction of the papillary layer of the derma or cutis, and disorganization of the entire skin down to the subcutaneous areolar tissue. 1. The burn which produces simple inflammation of the BURNS AND SCALDS. 431 skin is characterized by redness of the affected parts, slight swelling, and severe smarting pains which last for some hours. It may be caused by the momentary application of hot water, or of steam, or of the rays of a strong fire, or even—in tropical climates—by exposure to the sun's rays. The constitutional disturbance is slight; and the local effects cease in a few days with desquamation of the cuticle. 2. Inflammation of the skin with the production of blisters filled with serum results from a more severe burn. The skin is intensely red and swollen, the vesicles are often large, and • the pain is hot and smarting: if the vesicles get broken or rubbed off, the excoriated derma becomes exquisitely sensi- tive. In favorable cases the epidermis exfoliates, and the part is restored to health without leaving any mark; but not un- frequently suppuration or superficial ulceration takes place, and a cicatrix is left to show the extent of the mischief. The constitutional symptoms are often severe, the shock to the ner- vous system being especially felt by delicate children. 3. Destruction of the papillary or superficial layer of the derma is distinguished " by the presence of one or more patches of a greyish-white, yellowish, or brownish color, representing the dead portions of the papillary layer of the skin; the vesicles covering these patches are filled with a brownish, lactescent, or sanguineous serum, while those on the erythematous part of the burn are transparent. If the discolored patches be lightly touched, they are found to be insensible; but if they be pressed with any force, so as to act upon the parts below, the pain is considerable. The pain attending this form of burn is always more severe than that of any other kind, in consequence of the seat of mischief being the most sensitive part of that organ of acute sensation, the skin; and it lasts for one or two days. In three or four days after the burn, the pain, which had ceased, is suddenly renewed, suppuration becomes active, and the process of .separation, by which the dead is to be removed from the living tissue, is established. When the ulceration finally heals, it leaves behind it a cicatrix, which is white from 432 BURNS AND SCALDS. the loss of the vascular layer of the skin, and more or less fibrous and areolated, according to the depth in the corium, to which the burn had extended.* 4. Disorganization of the entire skin down to the subcutane- ous areolar tissue takes place when the heat is prolonged. The. pain is excessive during the application of the burning body, but ceases soon afterwards owing to the destruction of the vitality of the part. A black, hard, dry, eschar forms—or a soft eschar in scalds—which at the end of three or four days begins to be detached by suppuration; when perfectly separated, a deep ulcer is left behind. This ulcer gradually heals by granula- tion ; but an indelible cicatrix is formed, which has a great tendency subsequently to contract. When the contraction is excessive, considerable deformity is likely to result: thus in burns of the neck, the chin may be drawn down to the ster- num by the tightening of the cicatrix. The constitutional symptoms of the last two classes of burns are very important, and of two distinct kinds—viz., primary and secondary. The primary symptoms are due to the pain, as well as to congestion and irritation of the cranial, thoracic, and abdominal viscera. The shock to the nervous system from the agonizing sufferings may even destroy life almost at the onset; but where the patient survives this, the pain may —by exciting the heart, brain, and spinal cord—give rise to dangerous congestion of some of the vital organs. In the one case there will be extreme prostration, stupor, and coldness of the extremities; in the other, restlessness, excessive excite- ment, and a high degree of fever. The secondary symptoms accompany the inflammation and suppuration which is set up for the removal of the destroyed tissues. The inflammation when severe produces general fever with symptoms of cerebral or pulmonary congestion : but it is soon followed by exhaus- tion which increases the longer the suppurative stage con- tinues. A curious observation has been made by Mr. Curling * On Diseases of the Skin, by Erasmus Wilson. 4th ed., p. 282. London, 1857. HERNS AND SCALDS. 433 to the effect that a sloughing ulcer sometimes forms in the upper part of the duodenum within a few days after a severe burn, and doubtless in consequence of it.* Further observa- tions are required, however, to confirm the correctness of Mr. Curling's views; since in twelve fatal cases which occurred in Guy's Hospital during the year 1855 and part of 1856 no disease of any kind was discoverable in the duodenum after death. | Treatment.—In the treatment of burns and scalds, the first object of the practitioner should be to relieve the pain and depression; and for young children nothing can be better employed than small doses of opium in port wine or in sweetened port wine negus. When the suffering is severe, the inhalation of chloroform will be very beneficial; but the opium should be first administered, so that the sleep or ease induced by the anaesthetic may be prolonged by the narcotic. I have only had an opportunity of putting this plan into prac- tice in one case; but the effects were so excellent, that I am bound to recommend it. The best local application in my opinion is the common carron oil—F. 85; which should be freely applied, and the parts then covered with a sufficient layer of cotton wool to exclude the atmospheric air. Some physicians speak highly of the use of flour, thickly dusted over the burnt or scalded skin; and where there are no vesi- cations it is useful. But when the cuticle is raised into blisters, these are apt to burst; and the serum mixing with the flour forms a dirty, irritating paste, which is with difficulty removed. When the vesicles are large, it is better to punc- ture them with a fine needle to prevent their rupturing; but care must be taken not to remove the elevated cuticle. The importance of not disturbing the first dressing unnecessarily, can hardly be too strongly enforced; for independently of the * Medico-Chirurgical Transactions, vol. xxv.,p. 260. London, 1842. f Report of Post-Mortem Examinations of Cases of Burn, by Dr. S. Wilks. Guy's Hospital Reports. Third Series, vol. ii., p. 133. Lon- don, 185*. 37 434 BURNS AND SCALDS. suffering which such meddlesome surgery will always give rise to, the admission of the air to the inflamed surface will only in- crease the mischief. When suppuration is setting in, warm light poultices or plain water dressings often give great relief; but if the inflammatory action is severe, cold goulard water lotions are to be perferred. At the end of twenty-four or forty-eight hours, reaction will be established; and occurrence of internal congestions must be guarded against. Simple effervescing salines and mild laxatives are then valuable, and often suffice to remove all danger. But when the reaction is excessive, great good will arise from inducing copious sweating; and in no way can this be better produced—:when the child is irritable, restless, parched and thirsty, and with a hot dry skin—than by taking it out of bed, gently plunging it into a tub of water at 70° Fah., and then enveloping it immediately in several warm blankets. A copious perspiration will soon break out over the whole body; and this is to be encouraged for several hours by freely giving sweetened water or barley-water. The subsequent management should depend very much upon the condition of the patient. The numerous symptoms must be combated as they arise; but great caution will have to be exercised in the employment of lowering measures. I generally try to support the strength during the whole progress of the case by stimulants and nourishing food; strong beef- tea thickened with arrowroot, plenty of good milk, and two or three raw eggs daily being favorite remedies. At the same time we must take care that the patient does not pass restless nights, but by the use of sedatives give ease and sleep. Al- though young children are very susceptible to the influence of opium, yet this drug is very beneficial; and when the injury produces great suffering they bear larger doses than in natural disease.* * The most extensive burn ending in complete recovery that I have read of, is described by Mr. Grantham. A youth sixteen years of age, was burnt to the following extent by the explosion of some fire- BURNS AND SCALDS. 435 A rather extensive observation of nurses and their habits has shown me a favorite practice of these matrons which has not unfrequently led to most disastrous consequences. At the conclusion of the meal known as " tea," the bonne fre- quently fills the teapot with water; so that when the children complain of thirst in the course of the evening there may be something for them to drink. In allowing the child to quench its thirst, it is not deemed necessary to pour the infusion into a cup; but the spout is offered to the lips, and a draught is given. This popular habit leads young children to prefer drinking through the spout as often as the opportunity presents itself; but unfortunately they sometimes avail them- selves of the nurse's absence to do so when the teapot contains boiling water, or they even experimentalize with the kettle. Most severe scalds of the fauces, glottis, and pharynx have been thus produced-, the spasmodic contraction of the con- strictor muscles of pharynx preventing the passage of the fluid further downwards, and so saving the stomach. In works. From the upper and fore part of the neck, extending laterally down the left arm to the insertion of the deltoid; occupying both axilla;; passing backwards to within three inches of the spines of the vertebrae; over the chest, body, and genitals, to the verge of the anus; extending along the upper part of the right thigh, and down the left thigh to the knee ; destroying the cuticle, rete mucosum, and corium. The whole measured above six hundred superficial inches ; and averaged a quarter of an inch in depth. The subcutaneous structure was completely lost, so that the arteries and veins were seen, as if neatly dissected, lying on the surface of the muscles and the fascia. The treatment consisted in freely giving opium, in well sup- porting the strength, in properly protecting the wound, and in the ex- ternal and internal use of antiseptics. Three months after the acci- dent, the patient had a sphacelated wound over the sacrum; four months after this, an attack of bronchitis ; and two years subsequently —when he had improved so as to be able to walk a short distance—a severe attack of erysipelas. Five years elapsed from the time of the burn until the wound healed: during the whole of which time there was a greater or less tendency to congestion of the brain—Facts and Observations in Medicine and Surgery, p. 90. London, 1849. 436 FROSTBIT!] AND CHILBLAINS. the treatment of these cases we must be guided by the princi- ples already laid down; opium and soothing diluents—such as treacle and water, or mucilage with liquorice—being espe- cially required, followed if necessary by the bath. When oedema of the glottis arises, relief may perhaps be given by making rather free scarifications; but if suffocation seems to be imminent, laryngotomy or tracheotomy must be quickly performed. Unfortunately the operation does not often suc- ceed, owing to the prostrating effects of the scald- upon the system generally. SECTION III.--FROSTBITE AND CHILBLAINS. 1. Gelatio, or Frostbite.—Severe cold when long con- tinued, produces insensibility, arrest of the circulation, and death of the part to which it is applied. Examples of gelatio are very rarely seen in this country; but the unfortunate children of drunken parents have suffered from frostbite, after exposure to the keen night air of winter. The management of such cases consists in gradually restoring the circulation to the affected part; friction with snow or cold water, followed by the cautious use of stimulants, being the best means of effecting this. 2. Pernio, or Chilblain—is the result of a suspension of vitality in a limited portion of the skin, from the action of cold. The effect of the cold is not felt at first; but as warmth returns to the affected part, there is itching and tingling, and the toe or finger is found on examination to be red and swollen. This condition lasts for several hours or even days, and the part then resumes its healthy condition; or if the morbid action continue, vesication and ulceration take place, and what is called a broken chilblain results. It is essentially a disease of childhood. The treatment must consist in general attempts to restore normal circulation and the tone of the chilled member, by frictions with powdered starch or stimulating liniments. For this purpose the compound iodine ointment, or the compound CARBUNCLES AND BOILS. 437 camphor liniment, or the turpentine liniment of the Pharma- copoea may be prescribed: or the skin may'be painted twice or thrice daily with compound tincture of iodine. When the chilblain is ulcerated it must be at first soothed with water dressing or bread poultices mixed with goulard water; but subsequently—unless it heals kindly—it is often advisable to apply stimulating ointments, such as the ceratum resinas mixed with a little turpentine. The constitutional powers will generally be found to be below the normal standard: hence tonic medicines will often be required, and attention will have to be paid to the digestive organs. SECTION IV.—CARBUNCLES AND BOILS. 1. Anthrax, or Carbuncle—maybe defined as an acute inflammation of a circumscribed portion of the skin, extending deeply into the cutaneous tissue, and forming a more or less prominent swelling on the surface. The tumor is at first red, but soon becomes livid; it is excessively painful, the pain being of a throbbing, burning kind; and as it attains its full size, numerous little points on the surface suppurate, and form perforations through which the. core issues in the form of sloughs. A large carbuncle is very dangerous; for in the first place, it is due to a vitiated state of the blood and enfeebled consti- tutional power; and secondly, the pain and irritative fever which it directly produces, gives rise to great disturbance of the system generally. The nape of the neck is a common situation of carbuncle: there is generally only one tumor: and it is a disease of the latter half of life, children very rarely —if ever—suffering. Treatment—-Mild aperients; quickly followed by good, nourishing food, and tonics—especially ammonia and cin- chona, quinine and steel, or the mineral acids. Locally, water-dressing, or linseed poultices, or poultices made with linseed and yeast, should be applied. When the pain is very 37* 4R8 CARBUNCLES AND'BOILS. severe, and the carbuncle threatens to be large, or the inflam- mation to be extending, it may be necessary to make a free incision into it; or when the tension is very great, relief will be given by using the knife, before suppuration has occurred; but there are many cases which do best left alone. Moreover it must not be forgotten that incisions are apt to be followed by erysipelas. 2. Furunculus, OR Boil.—A boil may be described as a miniature carbuncle; commencing as a small red and painful point, slowly forming a little prominent tumor which con- tains a central core or slough, and ultimately ulcerating to discharge this core. Boils may occur singly or in crops. There is often only one; but as it heals, it is followed by another, which appears in a different region; and so one is succeeded by another for perhaps many weeks. The pain and general irritability is out of all proportion to the size of the tumor: and I have seen patients quite worn out at the end of two or three days with the suffering they have en- dured. Weakly and strumous children often suffer from boils; and many seem especially prone to them even from early infancy. The treatment is the -same as that recommended in the previous paragraph; with this proviso, that incisions are much more rarely necessary. One of the most frightful cases of erysipelas that I ever attended, and which endangered life for some weeks, was caused by the use of the knife to a trifling boil, that would have suppurated and got well in a day or two had it been simply poulticed. In ordering a poultice, care must be taken to have it small, so as to cover the inflamed surface only; as otherwise it merely soddens the surrounding tissues, and perhaps predisposes to a cop of boils. When the pain has been very severe I fancy that I have seen relief given by mixing the linseed-meal with hot laudanum or with a strong solution of morphia, iastead of with plain water. Lastly, I must mention that I have in BLOWS AND BRUISES. 439 some six or eight instances tried the application of the acid nitrate of mercury and of the potassa fusa; but my expe- rience of these agents does not induce me to recommend their employment. SECTION V.—BLOWS AND BRUISES. 1. Blows, &C.—The blows and bruises which children receive from the rough treatment of their playmates, from falls, and similar accidents, seldom give rise to any thing worse than a greater or less amount of pain and perhaps temporary disfigurement. It may perhaps be convenient, however, for the practitioner to remember, that in bruise- marks, "black-eye," ecchymosis of the conjunctiva, &c, the best application—and the one used by professed pugilists, according to Mr. Tyrrell*—is a poultice of black bryony-root [Bryonia nigra.) The root is to be deprived of its external bark, finely scraped, mixed to a proper consistence with bread crumbs or flour, and then placed—in a thin muslin bag, —over the discolored part: a fresh poultice should be applied every six hours. The ecchymosis disappears in about forty- eight hours, even in severe cases. When the" bryony-root cannot be procured, a linseed-meal poultice, mixed with a solution of hydrochlorate of ammonia, is the best substitute. 2. Epistaxis—or bleeding from the mucous membrane of the nose, may be produced by a slight blow, or by over-exer- cise, or it not uncommonly arises spontaneously—particularly during early childhood. When primary, it never continues to such an excess as to endanger life: when secondary—as when it occurs in the course of hooping-cough, fever, purpura, &c. —its effects are often very serious. Quiet, cold to the nose and forehead, cold to the back or neck—so as to produce con- striction of the superficial blood-vessels by reflex action, mild laxatives, and astringent injections—as the decoction of ma- * On Diseases of the Eye, p. 436, vol. i. London, 1840. 440 blows and bruises. tico, will generally suffice to stop it. When the bleeding continues obstinate, or ceases merely to return repeatedly, no remedy will prove so beneficial as mercury given to the ex- tent of producing very slight salivation. At the same time the bleeding nostril should be plugged with cotton wool soaked in a solution of alum; or it may even be necessary, as a last resource, to plug the posterior nares. APPENDIX OF FORMULAE. The following Formulae are intended for children about two years of age, unless the contrary is stated. Formida 1. Aperient and Alterative. R,. Pulveris rhei, sodse sesquicarbonatis, aa 9j.; infusi calumbae, §iij. Misce. Capiat §ss. omni mane. For strumous children between three and six years of age. 2. Mild Aperient. ty. Infusi rhei, §iss.; tinctures cinnamomi, 51; potassae sulphatis, 5ss.; syrupi sennae, §ss. Misce. Capiat 5U- nocte maneque. In faidly digestion with torpidity of the bowels. 3. Aperient and Stimulant. fy. Potassae bitartratis, 5ij-l spiritus ammoniae aromatici, nixx.; tincturae cardamomi compositae, 5j.; extracti glycyrrhizse, 9j.; decocti aloes compositi, ad §ij. Misce. Sumat 3ij. ad 5iv. pro re nata. In laryngismus stridulus and other spasmodic diseases. 4. Simple Aperient. R,. Pulveris rhei, 9j.; magnesiae carbonatis, 3ij.; pulveris cinna- momi, gr. x. Misce. Six grains may be given to an infant less than twelve months old. Afterwards from gr. x.—3j. The cinnamon disguises the taste of the rhubarb. 5. Laxatives for Infants at the Breast. fy. Magnesia) carbonatis, 3j.; syrupi rosae, §j. Misce. 3j.— 5ij. pro re nata. In constipation with acidity. 6. Mild Laxatives for Young Infants. fy. Potassae bitartratis, 3j.; mannae optima?, §j.; aquae destillatac, 5iiss. Misce. This forms a rather palatable paste, which infants readily suck. Gr. x.—xv. may be given every morning. 442 appendix of formulae. 7. Infantile Purgatives. R,. Mannae optimae, 3ij-; aquie anethi, §j. Misec. When the me- conium is retained, 3j- ma!/ oe given every hour until the bowels arc opened. 8. A Common Purgative Mixture. ^. Infusi sennae compositi, §j.; aqua; menthoe piperita1, 5SS. ; mannae optima;, 5U-J bene commisce, cola, et adde magnesias car- bonatis, 3j.; tinctura; rhei composita;, 3j-; syrupi rosae, 3'j- Misce. 5J-—5U- horil quaoue tertia ad effectum catharticum. [Mnun sell and Evanson.) 9. Alterative, Purgative, and Diaphoretic. R> Pulveris jalapse, 5SS- 5 pulveris ipecacuanha;, gr. v. Hydrargyri chloridi, gr. v.—gr. x.; sacchari albi, gr. x. Misce. Gr. ij.—gr. vj. tertia quaque hora. In inflammatory affections, ic/icre it is desired to jrromntc excretion. Vel. ty. Sulphuris sublimati, §j.; theriacae, §ij. Misce. Capiat coch- leare parvum omni mane. This nursery remedy is useful as a gentle stimulant to the intestinal mucous membrane, especially to that of the rectum. It also acts as a mild stimulant to the skin and secreting organs generally. 10. Mild Mercurial Purgative for Infants. R,. Hydrargyri cum creta, gr. x.; pulveris rhei, 3j. ; pulveris ciu- namomi compositi, gr. v. Misce. Sumat gr. iij.—gr. v. tertiis horis, donee alvus bene responderit. 11. An Effectual Purgative. R:. Pulveris rhei, pulveris scammonii compositi, potassae sulphatis, aa gr. x.; optime tere simul et adde, pulveris cinnamomi compositi, gr. v. Misce. Gr. iij.—gr. vj. quarta quaque hortl ad effectum cathar- ticum. In croup, §c. 12. Purgative Oil. Pp. Pulveris scammonii, 3j ; olei amygdalae, §j.; solve caloris mitioris ope, et adde Confectionis amygdala?, §j. Misce Dosis, 3J — 3ij. pro re nata. 13. Calomel and Scammony. R> Hydrargyri chloridi, gr. ij.—gr. iij.; pulveris scammonii com- positi, gr. iv.; pulveris zingiberis, gr. j. Misce fiat pulvis. A very valuable purgative in the head affections of children; also useful as an anthelmintic. appendix of formulae. 440 14. A Drastic Purgative. Pp. Pulveris scammonii compositi, gr. iij.—gr. viij.; pulveris cin- namomi compositi, gr. v. Misce. Useful when there is torpidity of the abdominal viscera. 15. Another Drastic Purge. Pp. Pulveris jalapae compositi, gr. x.—3SS- In habitual costiveness, and in the dropsy which sometimes follows scarlatina. 16. Purgative Biscuits. Jalap powder, 3j.; flour, giv.; moist sugar, §vj.; ginger, 3ss.: eggs, iv. Mix, and divide into twelve biscuits. One should be eaten once or twice a-day, according to the effect desired. 17. Tonic, Purgative, and Anthelmintic Pp. Tincturae ferri sesquichloridi, 5ss.; extracti glycyrrhizae, 3ij.; decocti aloes compositi, §iss. Misce. 3j.—3ij. bis terve indies. 18. Purgative Liniment. Pp. Tincturae aloes, §ss. linimenti saponis, §j. Misce. (Dr. Mer- riman.) Effectual in keeping the bowels regular, if rubbed over the abdo- men for five minutes daily. 19. An Excellent Anthelmintic. R. Olei filicis maris, 3ss.— 3iss.; syrupi zingiberis, 3j. ; misturae acaciae, 3jj. Misce. fiat haustus primo mane sumendus. Especially valuable for destroying tape-worms. 20. Purgative Enemata. Pp. Sodii chloridi, 5iij.; olei olivae, §ss.; decocti hordei, §iij. Misce. To destroy and cause the expulsion of thread-worms. Vel. R. Sodii chloridi, 3J.; tincturae aloes, 3j.; decocti avenae, giiiss. Misce. fiat enema. Vel. Ip. Olei ricini, olei terebinthinae, aa 3ij. ; tincturae assafoetidae, 3ss. ; decocti avenae, §iv. Misce. In obstinate constipation. Vel. r. Olei ricini, 3iss.; confectionis rutse, gr. x.; decocti hordei, ad ?iv Misce. Very useful when the intestines are distended with flatus. 414 APPENDIX OF F01OIUL.E. 21. Stimulating Emetic. Pp. Cupri sulphatus, gr. ij. ; aquae, §ss. Misce. Signetur.—"One- fourth part to be taken every quarter of an hour, in barley-water, until free vomiting takes place." For an infant one year old. The advantage of this emetic over sulphate of zinc is its tastelessness; it is valuable in the third stage of croup to aid the removal of the false membrane. 22. Alum Emetic. R. Aluminis, 5hj-; syrupi, §j- Misce. Signetur.—" Half to be taken immediately, and the remainder in fifteen minutes unless vomit- ing be induced." • Recommended by Dr. Meigs as one of the most certain emetics in croup. It does not produce prostration like antimony, nor does it act injuriously upon the gastro-inteslinal mucous membrane. 23. Mild Emetics. Pp. Pulveris ipecacuanha;, gr. ss.—gr. j.; sacchari albi, quantum placeat. Misce. This is a certain and mild emetic which may be exhibited to the youngest infant, and repeated every twenty minutes until vomiting takes place. After one year of age the dose may be doubled. Vel. Pp. Vini ipecacuanhae, syrupi, aa, ^ss. Misce. Capiat 3SS-—5U- saepe ad eniesem. 24. Antimonial Emetics. R. Antimonii potassio-tartratis, gr. ss.; syrupi, aquae, aa gss. Misce. Sumat 3j.—3iij. saepe ad emesem. Vel. R. Antimonii potassio-tartratis, gr. iij.; oxymellis scillae, §j.; aquae fonta-nae, §ij. Misce. A tablespoonful every quarter of an hour for a child three years of age, suffering from croup. (Sachse.) Vel. R. Vini antimonii potassio-tartratis, oxymellis scillae, aa f.^ss. Misce. 3J- saepe ad emesem. Vel. R. Vini ipecacuanhae, §ss.; vini antimonii potassio-tartratis, 3u-i oxymellis scillae, 3ij.; aquae destillatae, §j. Misce. 31—3'j- saEPe a(* emesem. More certain and less violent than the preceding. 'Maunsell and Evanson.) APPENDIX OF FORMUL/E. 445 25. Coxe's Hive Syrup. R. SciHae, radicis senega;, aa §j.: mellis, Ib.ss.; aquae, lb.j. Misce. Fiat syrupus, cuique unciae cujus addatur antimonii potassio- tartratis, gr. j. Dose from ten drops to a teaspoonful every fifteen minutes, as an emetic; or every two or three hours as an expectorant. This compound is highly esteemed in America in the advanced stages of infantile bronchitis, croup, pertussis, #c. 26. Depressing Expectorant Mixture. R. Vini ipecacuanhae, 3U- ; vini amtimonii potassio-tartratis, 3j- J oxymellis scillae, 3iss- > liquoris ammonia; citratis, §ss.; misturae cam- phors ad §ij. Capiat 3j-—3'j- quarta quaque hora. In the early stage of acute bronchitis. 27. Stimulant and Expectorant. R. Ammoniac sesquicarbonatis, gr. ij.,; tincturae scillae, ~n\x. ; sacchari faecis, 5SS- i decocti senegae, §ss. Misce, fiat haustus secunda quaque hora sumendus. Very useful during the convalescence from croup. 28. Stiimdant and Expectorant. R. Viui antimonii potassio-tartratis, 31 j spiritus ammonia; aro- matici, 3'ss-j syrupi tolutani, 3J-! tincturae camphorae compositae, 3ij.; misturae camphorae, giss. Misce. Capiat 3J-—5ij- tertia vel quarta quaque hora. In those pulmonary affections of infants and children where we wish to administer tartar emetic without producing depression. 29. Senega and Squills. R. Oxymellis scillae, 3ij.; syrupi papaveris, 3iij.; viniipecacu anha;, 3j.; liquoris ammoniae acetatis, §ss.; decocti senegae, §j. Misce. 3j.—3ij. secunda quaque hora. In pneumonia occurring during fever, or in a depressed constitution. 30. Expectorant and Sedative. R. Vini ipecacuanhae, 3iss.; tincturae scillae, 3j.; syrupi papaveris, 3iij.; misturae acacia;, ad §ij. Misce. Capiat 3j.—3ij. tertia quaque hora. In irritable cough with deficient expectoration. Vel. R. Pulveris ipecacuanhae compositi, gr. ij.; pulveris ipecacuanhae, gr. 1. Misce, fiat pulvis hora somni sumendus. For a child between four and six years. 38 4-16 APPENDIX OF FORMl'L/E. 31. Saline Expectorant and Diaphoretic. R. Vini ipecacuanhae, n\xl., liquoris ammonia? citrntia, 5'ij-; aquae menthae viridis, ad §j. Misce. Sumat 3j-—3'j- quarta quaque hora. In catarrh with mild fever. Vel. R. Potassae nitratis, gr. xii.; spiritus a;theris nitrici, uixx.; vini antimonii potassio-tartratis, 3SS- > tincturae camphorae compositae, 3j., aquae anethi, 3 V). Misce. Signetur.—" One drachm to be given every four hours in sugared water." For a child between one and two years of age, suffering from bronchitis. 32. Chlorine for Internal Administration. Put eight grains of chlorate of potass in a strong pint bottle, and pour upon them one drachm of strong hydrochloric acid. Close the mouth of the bottle until the violent action ceases, when add one ounce of water, and agitate well; add another ounce, again shake, and continue this process until the bottle is full. §ss. or §j. may be taken frequently according to the ago. An adult may use the whole pint in one day. 33. Sedative and Diaphoretic Mixtures. R. Vini ipecacuanhae, 3SS- i Yini antimonii potassio-tartratis, uixvj.; tincturae camphorae compositae, lrixx.; mistura; amygdalae, 5vij. Misce. Capiat, 5ij> quarta quaque hora. For infants one year old suffering from febrile disturbance, catarrh, Sec. Vel. R. Vini ipecacuanhae, u^xx.; oxymellis scillae, 5J-! spiritus aetheris nitrici, 3ss->° syrupi papaveris, 3U-J aquae anisi, 3VUJ- Misce. Su- mat, 3ij-J tertia vel quarta quaque hora. For an infant one year old, afected with catarrh. Vel. R. Potassae bicarbonatis, 3ij.; acidi citrici, 3j.; vini antimonii po- tassio-tartratis, vini ipecacuanhae, aa, 3J-i syrupi papaveris, 3''J-> misturae camphorae, giiss. Misce. Capiat 3i'j- tertia, quaque hora. For a child two years old. 34. Alterative and Diaphoretic. R. Antimonii-potassio-tartratis, gr. ss.; hydrargyri chloridi, gr. ij.; potassae nitratis, 3ij. Misce. Fiant pulveres, xij. Sumat unum quarta quaque hora. In some cases of pericarditis, meningitis, $c. For an infant six months old. APPENDIX OF FORMULAE. 447 Alterative and Diaphoretic Mixtures—continued. R. Hydrargyri chloridi, gr. vj.; pulveris ipecacuanhae compositi, gr. ij. Misce, et divide in pulveris sex. Sumat unum omnibus sex- tis horis. For a child between eighteen and twenty-four months old. Vel. R. Antimonii-potassio-tartratis, gr. j.; hydrargyri chloridi, gr. iij.; sacchari albi, 3j. Misce, et divide in pulveres xij. Sumat j. quarta quaque hora. In acute inflammations of the serous membranes, Sec. For an infant twelve months old. Vel. R. Hydrargyri cum creta, gr. xij.; pulveris ipecacuanhae compositi, gr. ij. Misce, et divide in pulveres sex. Capiat unum nocte maneque. 35. Mild Fever. R. Potassae nitratis, 3ss-j viQi ipecacuanhae, 51; syrupi papaveris, 5ij.; misturae camphorae, 3x. Misce. 3j—3ij. tertia quaque hora. Vel. R. Spiritus aetheris nitrici, 3ss.; liquoris ammonise citratis, 3jss-i misturae camphorae, ad giij.; Misce, Capiat §ss. quarta quaque hora. 36. Fever Drinks. R. Potassae chloratis, 5ss.—5J-> decocti hordei, Oj. Misce fiat po- tus. A child under three years of age should be allowed only from one- quarter to one-half of the pint. Vel. R. Potassae nitratis, gr. x.—3j.; decocti hordei, Oj. Misce. This may be taken during the twenty-four hours when feverish symptoms pre- dominate without any apparent cause. 37. Chlorate of Potash Mixtures. R. Potassae chloratis, gr. xv.; aquae, §iij. Misce. Sumat §ss. quarta qutlque hora. For a child one year old affected with stomatitis or with odontitis. It may be given in barley-water. Vel. R. Potassae chloratis, gr. v.; tincturae cinchonae compositae, 3ss.; tincturae camphorae compositae, uiy.; aquae anethi, ad 3iv. Misce. Fiat haustus quarta quaque hora sumendus. For a child two years old, suffering from gangrenous stomatitis. 448 APPENDIX OF FORMULAE. 3S. Iodine Mixtures. R. Iodinii, gr. x.; potassii iodidi, 3j.; aquae distillatae, §j. Misce. Four or six drops three times a day in sweetened water; in bronchocele, enlargement of mesenteric glands, Sfc. Vel. R. Potassii iodidi, gr. ij.; syrupi papaveris, 3J->' aquae pulegii, 3vij. Misce. Sumat 5j- ter die. For an infant six months old. Vel. R. Potassii iodidi, gr. viij.; syrupi sarsa^, syrupi, aa 3'v- Misce. Capiat 3J- ter die. Very usefnl in pleurisy, Sec, when we fear that effu- sion is taking place. For a child three years old. Vel. R. Potassii iodidi, gr. vj.—gr. xij.; aquae, 3xrJ- Misce. Signetur. —" One drachm—by measure—every four hours, in a small cup of weak tea, or of plain barley-water." Very valuable in some of the acute inflammatory affections of childhood:—in certain cases of croup, it may be given as above, to an infant one year old. 39. Alterative and Antispasmodic. R. Potassii iodidi, gr. viij.; tincturae hyoscyami, Ulxij.; tincturae assafcetidae, 3J-—S'^j-i decocti senegse, ad §iss. Misce. Capiat coch- leare parvum quarta quaque hora. In the third stage of croup, in some cases of acute bronchitis, and in some forms of pneumonia the author has seen great benefit from this mixture. The dose is for a child between one and two years of age. 40. Tonic and Alterative. R. Syrupi ferri iodidi, 5J-i syrupi, 3xj- Misce. Capiat 5j- ter die. In tabes' mesenterica, scrofulous diseases, early stages of phthisis, Sec. Vel. R. Ferri ammonio-citratis, gr. xij.; potassii iodidi, gr. iv.; tincturae hyosciami, uixvj.; aquae distillatae, ad §iss. Misce. One-eighth part to be taken three times a- day, with the meals, in sweetened water. Vel. R. Potassii iodidi, gr. iv.; ferri ammonio-citratis, 3j.; syrupi papa veris, 5i'J-> infusi quassiae, giij. Misce. Sumat ^ss. ter die. For a child two years old, affected with scrofula, tabes mesenterica, Sec. APPENDIX OF FORMULiE. 449 Tonic and Alterative—continued. R. Vini ferri, syrupi tolutani, aa gss.: liquoris potassae arsenitis, n\xxxij.; aquae anethi, § j. Misce. Fiat mistura. (Erasmus Wilson.) The dose for an infant about one year old, is one drachm thrice daily, di- rectly after the meals. Almost a specific in eczema infantile. Vel. R. Olei jecoris aselli, §ij.; vitelli ovi, j.; liquoris potassae arsenitis, Ttplxiv.; syrupi simplicis, 5ij-j aquae fontanae, q. s. ad 3-iv. Misce. Fiat mistura. (Erasmus Wilson.) The dose is a drachm three times a-day, with or directly after meals. 41. Alterative, Tonic, and Aperient. R. Tincturae jalapae, 3ss-> tincturae rhei compositae, 3J-j decocti taraxaci. 3viss- Misce. Capiat 3ij- omni mane. For an infant one year old, with constipation dependent on feeble peristaltic action of intes- tines. 42. Alterative and Diaphoretic. R. Hydrargyri chloridi, gr. iv.; pulveris ipecacuanhae, gr. ij.; sac- chari albi, 3j. Misce, et divide in pulveres viij. One of these powders may be given to a child twelve months old, every four hours, in acute bron- chitis, pneumonia, Sec. If the calomel irritates the boivels, gr. ss. of Do- ver's powder should be added to every third or fourth powder. 43. Astringent and Alterative. t: R. Mucilaginis acaciae, §ss.; sodae sesquicarbonatis, gr. v.; olei terebinthinae, TUiv.—x.; misturae amygdalae, §ss. Misce. Fiat haus- tus ter die sumendus. In severe forms of purpura. 44. Alterative and Tonic. R. Quinae disulphatis, gr. ij.; hydrargyri chloridi, gr. j. Misce, et divide in pulveres quatuor. One powder to be mixed with sugar and given twice a-day, in severe cases of ophthalmia neonatorum. 45. Aromatic Astringent. R. Confectionis aromatici, 3j.; tincturae hyoscyami, Tn.v.; infusi krameriae, giss. Misce. Capiat 3j-—3U- ter quaterve in die. In the simple diarrhcea of an infant about one year of age. 46. Alterative and Astringent. r Olei ricini, 3j.; pulveris acaciae, sacchari albi, aa 3ss. tincturae opii, Tn.iv.; aquae cinnamomi, 3vij. Misce. 3j. quarta quaque hora. 38* 450 APPENDIX OF 10KMUL/K. For a child one year old, suffering from dysentery. A similar mixture was found by Dr. Baly to be very valuable in the treatment of dysentery among the prisoners in Millbank Penitentiary. 47. Astringent and Sedative. R. Pulveris cretae compositi cum opio, 3j.; infusi catechu compo- siti, 3x'j- Misce. Sumat 3j- ter die. For a child one year old, with chronic diarrhwa. Vel R. Tincturae catechu composita*, 3'j-; confectionis aromatici, 3 decocti haema- toxyli, §j. Misce. Capiat 3J- omnibus sextis horis. For an infant one year old. Valuable in simple diarrhoea, or as a tonic during conva- lescence from any gastro-intcstinal disorder. The only disadvantage of logwood is, that the pink evacuations ivhich it produces permanently stain the infants napkins. Vel. R. Acidi gallici, gr. x.; tincturae cinnamomi compositi, 3J-i tinc- turae opii, ui vj.; syrupi, 5nJ-i aquae cinnamomi, 5xlbi Misce. Ca- piat 3'j- quarta quaque hora. In chronic diarrhoea. For a child one year old. Vel. R. Ferri sulphatis, gr. iv.; tincturae opii, nivj.; syrupi, 3'j-J infusi calumbae, 3X- Misce. Sumat 5U-) sextis horis. In chronic diarr- hoea. 40. Simple Astringent. \ R. Aluminis, gr. xxiv.; extracti conii, gr. xij.; syrupi rhoeado3, 3'j-i aquae anethi, §iij. Misce. Capiat cochleare medium scxta quaque hora. For a child tivo or three years of age, suffering from pertutsis, when all inflammatory symptoms have ceased. 50. Astringent Enemata. R. Argenti nitratis, gr. j.; aquae distillatae, §iij. Solve. For a child one year old, with inflammatory diarrh&a. APPENDIX OF FORMULAS. 451 Astringent Enemata—continued. R. Extracti krameriae, gr. xv.; aquae distillatae, § iij. Solve. For a child one year old. In inflammatory diarrhoea. Vel. R. Olei terebinthinae, 3j-i tinturae catechu compositae, 5ss-j tinc- turae opii, niv.; decocti amyli, §iss. Misce, fiat enema. May be em- ployed twice daily, in children between three and eight years of aye, to check the purging in typhoid fever. 51. Stomachic and Tonic. R. Acidi sulphurici diluti, ui xv.; tincturae aurantii, syrupi aurantii, aa 3ij.; infusi aurantii compositi, giss. Misce. Capiat, 3ij. ter die. For a child with weak digestive powers. 52. Stimulant and Expectorant. R. Ammoniae sesquicarbonatis, gr. ij.; tincturae scillae, v\v.) sacchari faecis, 3ss.; decocti senegae, §ss; Misce, fiat haustus, secunda quaque hora, sumendus. An excellent stimulant expectorant for young children recovering from croup. Vel. R. Ammoniae sesquicarbonatis, gr. viij.; tincturae scillae, TTlxvj.; syrupi tolutani, 3iv.; decocti senegae, §ij. Misce. Capiat 3ij.—3iv. quarta quaque hora. For a child from one to four years of age, suffering from chronic bronchitis. The taste will be best disguised by administering it in water well sweetened icith brown sugar. Vel. R. Ammoniae sesquicarbonatis, gr. vj.; tincturae scillae, 3ss.; syrupi papaveris, 3ij.; decocti senega*, misturae camphorae, aa f.3yj. Misce. 3j.__3ij- tertia quaque hora. In chronic catarrh, the later stages of pneumonia, croup, Sec. 53. Stimulant, Expectorant, and Sedative. R. Tincturae assafoetidae, 3iss.; aetheris chlorici, TTtxxv.; tincturae camphorae compositae, 315 decocti senegae, misturae camphorae, aa I). Misce. 3j.—3iij- tertia quaque hora. Very useful in bronchitis and pneumonia, ivhen the acute symptoms have been subdued. 54. Antispasmodic and Carminative. R. Spiritus ammoniae aromatici, niyiij.; aetheris chlorici, -uiiv.; tincturae opii, ntfj. ; misturae amygdalae, aquae carui, aa §ss. Misce. Capiat 3J. ter quaterve in die. In flatulence with gastro-intestinal dis- turbance^ For an infant between eight and twelve months of age. 452 APPENDIX OF FORMULA1.. 55. Stimidant and Antispasmodic. R. Spiritus ammoniae aromatici, spirtus aetheris compositi, aa Til xx.; syrupi papaveris, 3u- i aquae anethi, 5X- Misce. Capiat 3.j: —3i'j- tertia, quaque hora. Avaluablc stimulant in certain low forms of fever, in convalescence from pulmonary affections, and in some spasmodic diseases. The smallest dose may be given to an infant three months old. 56. Stimidant, Expectorant, and Antispasmodic. R. Spiritus ammoniae aromatici, 3ss-> aetheris chlorici, n\xij. ; tincturae assafcetidae, 3J-! misturae camphorae. §iij. Misce. Dosis, §ss. omnibus sextis horis. In diseases of the lungs and air passages after the subsidence of the acute symptoms, when a stimulant, expectorant, and antispasmodic is required. 57. Antispasmodic and Stimulant. R. Spiritus ammoniae aromatici, 5SS- j aetheris chlorici, ni xx.; tincturae assafcetidae, 3j-—3'j-i tincturae camphorae compositae, 3ss.; aquae pulegii, 3xrJ- Misce. 3J-—5'j- quarta quaque hora. In some cases of hooping cough, laryngismus stridulus, and other convulsive affections. Vel. R. Spiritus ammoniae aromatici, spiritus aetheris compositi, aa, 3ss.; acidi hydrocyanici diluti, Tiiyj.; tincturae opii, niiv. misturae camphorae, §iij. Misce. Capiat §ss. quarta quaque hora. In passive cerebral congestion, Sec. 58. Stimulant and Tonic. R. Ammoniae sesquicarbonatis, gr. viij.; aetheris chlorici, rrpyj.; tincturae cinchonae compositae, 3J-i aquae menthae viridis, ad §ij. Misce. Sumat 3ij- omnibus sextis horis. 59. Alkaline Tonic. R. Ammoniae sesquicarbonatis, gr. j.—gr. v.; potassae chloratis, gr. v.—gr. x.; decocti cinchonae, §ss. Misce. Fiat haustus ter die sumendus. For a child between two and twelve years of age, suffering from scurvy, gangrene of the mouth, §c. 60. Simple Tonic. R. Extracti cinchonae, 3J- j tincturae cinchonae compositae, 3'j-i aquae carui, 3X- Misce. 31 ter quotidie e lacte. For an infant one year old. Dr. West states that the taste of this mixture is best concealed by mixing it with twice the quantity of sweetened milk. APPENDIX OF FORMULA]. 433 61. Stimulant and Antispasmodic. R. Aquae anisi §j.; mucilaginis gnmmi acaciae, §ss.; olei terebin- thinoc rectificati, 5~s-> syrupi, 5iy- Misce. 31—5'j- hora quaque tertia. (Maunsell and Evanson.) 62. Expectorant and Tonic. R. Tincturae Scillae, Ttixyj.; tincturae conii, Ttixl.; tincturae calumbae, 3iij.; infusi carcarillae, misturae ferri compositae, aa §j. Misce. Capiat 3ij. ter die. For a child about two years old, suffering from honping-codgh with anaemia. Also in convalescence from bron- chitis, &LC. 63. Quinine and Acid Mixture. R. Quinae disulphatis, gr. iij.; syrupi, 3iij.; infusi rosae compositi, 5xij. Misce. Capiat 3ij. ter die. Vel. R. Tincturae quinae compositae, 3iij.; infusi aurantii compositi, ad §iij. Misce. Signetur..—" A small tablespoonful to be taken twice a-day with one teaspoonful of cod-liver oil." In scrofulous diseases. Vel. R. Quinae disulphatis, gr. j.; acidi sulphurici diluti, Ttl j.; syrupi aurantii, 3ss.; aquae, 3iiiss. Misce. Ter die sumendus. Very use- ful in strumous ophthalmia, some forms of urticaria, and in almost all cases of debility. 64. Quinine and Iron. R. Quinae disulphatis, ferri sulphatis, aa gr. ij. ; acidi sulphurici diluti, tn_v.; infusi calumbae, gij. Misce. Capiat 3ij—3iv. ter die. Vel. R. Quinae et ferri citratis, gr. j.; tincturae calumbae, Ttl *•; infusi ejusdem, ad §ss. Misce, fiat haustus ter die sumendus. An excellent tonic during convalescence from acute disease. 65. Citrate of Iron. r. Ferri citratis, gr. xij.; aquae destillatae, giij- Misce. Dosis, §ss. ter die. 66. An Acid Stimidant. R Vcidi hydrochloric! diluti, Ttiiv. ; spiritus aetheris compositi, iHviij.;' misturae camphors, 5iij. Misce, fiat haustus omnibus sextis 454 APPENDIX OF FORM PL.E. horis sumendus. Recommended by Dr. Stiegliiz, of St. Petersburgh as a stimulant for a child, aged about five, suffering from typhoid fever. 67. Stimulant and Antispasmodic. R. Acidi nitrici diluti, 3xij.; tinctura; cardamomi compositie, 3iij,; syrupi simplicis, giiiss.; aquae, §j. Misce. Sumat 3J-—3'j- secunda quaque hora. Dr. Gibb states that nitric acid is a specific in the treatment of hooping-cough, curing the disease in from two to fifteen days. He recommends this formula. 68. Alkaline Laxative and Tonic. R. Sodae bicarbonatis, 3j.; tincturae rhei, 3ij.; infusi calumbae, decocti taraxaci, aa 3vij. Misce. Capiat 3ij. nocte maneque. For a child one year old, suffering from dyspepsia, with offensive breath, acid eructations, sour evacuations, and constipation. 69. Muriatic Acid and Cascarilla. R. Acidi hydrochlorici diluti, Ttixvj.; tincturae aurantii, syrupi ejusdem, aa 3iss.; infusi cascarillae, §j. Misce. Sumat cochleare paryum ter die. For a child one year of age, with indigestion pro- duced by insufficient secretion of the gastric juice. 70. Soluble Combination of Phosphate and Carbonate of Lime. R. Calcis phosphatis, 3ij.; calcis carbonatis, 3j.; sacchari lactis, 3iij. Misce. Capiat 3ss. bis die. Lactate of iron may be substituted for the sugar of milk in weak rickety children. In case of softening of the bones this remedy will probably be found very valuable. 71. Enema of Assafcetida for a child. R. Tincturae assafcetidae, irixxx.; decocti hordei, fiss. Misce. This may be administered night and morning, in cases where the stomach will not tolerate assafatida. 72. Nutritious Enemata. Cod-liver oil, 3j.; potassio-tartrate of iron, 3j.; cow's milk, §j. Mix, and administer night and morning. Vel. Strong beef-tea, §iv.; melted butter, §ss.; port-wine, 3ij.; flour, 3ij. Mix. APPENDIX OF FORMULAE. 455 73. Sedative Mixture. R. Tincturae opii, guttam; syrupi misturae acaciae, aa §ss. Misce. Dosis, 3j. omni hora donee supervenerit somnus. To an infant under two months not more than three successive doses should be administered; and when the desired effect has been produced, five or six hours should elapse before repeating its use. Vel. R. Tincturae camphorae compositae, Ttixvj. ; mucilaginis acaciae, syrupi rhoeados, aa 3ij.; misturae camphorae, 3iv. Misce. Capiat 3j. bis terve indies. A safe narcotic for the youngest infant, when the use of opium is indicated. 74. Sedative Enema. R. Tincturae opii, Ttluj.; decocti amyli, §ss. Misce. For an infant one year old, suffering from urgent tenesmus, dysentery, §c. 75. Sedative and Expectorant. R. Vini ipecacuanhae, 3iss.; sodae bicarbonatis, gr. xij.; tinc- turae opii, TTliij.; syrupi rhoeados, 3iij.; misturae camphorae, Sjiss. Misce. 3j.—3ij. tertia vel secunda quaque hora. In pneumonia or bronchitis with great irritability of the bowels. 76. Sedative and Depressant. R? Tincturae digitalis, tincturae lobelia;, aa Ttlxij-i syrupi croci, 3J.; aquae cinnamomi, ad §j. Misce. Sumat 3j. tertia vel quarta quaque hora. As a substitute for antimony in some forms of pneu- monia, bronchitis, Sec. TJ. Sedative and Antispasmodic. R. Syrupi rhoeados, §j.; acidi hydrocyanici diluti (Ph. Lond.) guttam. Misce. 3J. bis terve indies. For an infant six months old. If it disagrees or produces head symptoms it must be discontinued. 78. Sedative and Tonic. R Acidi hydrocyanici diluti (Ph. Lond.) gnttae, iv.; syrupi papa- veris, 3ij.; infusi aurantii compositi, 3vj. Misce. 3J- ter die. For an infant one year old. 79. Simple Antispasmodic. r Tincturae assafcetidae, 3ss.; syrupi rhoeados, g. Misce. In flaZlent colic one teaspoonful may be given every hour until relief is ob- tained. 45G APPENDIX OF FORMUL.E. 80. Infantile Sedative and Diuretic. R. Potas^e nitratis, gr. xvj.; tinctura* digitalis, uiviij.; liquoris ammoniae acetatis, 3'j-l aquae anethi, 3vj- Misce. 51—3'J- qi>arta quaque hora. In anasarca dependent on cardiac disease, and in some inflammatory affections. SI. Simple Diuretic. R. Infusi digitalis, 31S3.; syrupi mori, 5vj- Misce. 51 quarta quaque hora. 82. Sedative and Antispasmodic. R. Acidi hydrocyanici diluti, Tnjv.; sodae bicarbonatis, gr. x.; spiritus u;theris compositi, Tt|xij.; syrupi papaveris, 3'j'i aquae destil- latae, 5vj- Misce. Capiat 5J-omnibus sextis horis. For a child nine months old suffering from pertussis. Vel. R. Acidi hydrocyanici diluti, TTpviij.; spiritus ammoniac foetidoe, 5ss.; tincturae hyoscyami, Ttlx.; syrupi aurantii, §ss.; spiritus anisi, 5j.; aquae §j. Misce. Capiat cochleare parvum ter die. Recom- mended by Dr. James Reid in laryngismus stridulus or spasm of the glottis. For a child one year old. Vel. R. Tincturae assafcetidae, 5KS-5 oxymellis scillae, 3J-! tincturae opii, rnjj.; syrupi rhoeados, ad §j. Misce. One teaspoonful may be given every two or three hours for three doses. 83. Belladonna for Children. R. Extracti belladonnas, gr. j.; syrupi, 3>U-j aquae, ad giss. Misce. Capiat 3j-—5'j- ter die. Valuable in incontinence of urine, in children between three and seven years of age, where there is nervous irritability. A small belladonna plaster may also be applied over the sacrum.. 84. Benzoated Oxide of Zinc Ointment. R. Adipis preparatae, §vj.; gummi benzoini, pulveris, 31 Lique- fac, cum leni calore, per horas viginti quatuor, in vaso clauso; dein cola per linteum, et adde Oxydi zinci, purificati, §j. Misce bene, et per linteum exprime. For use, one ounce of this ointment is to be rubbed down with one drachm of spirits of wiDe, or spirits of camphor, or distilled glycerine, or liquor plumbi diacetatis, &c. It is highly recommended by Erasmus Wilson, to alleviate the local distress, in eczema infantile, impetigo, S,c. APPENDIX OF FORMULAE. 457 85. Carron Oil. R. Olei lini, liquoris calcis, aa giij. Misce, fiat lotio. For irritable ulcers, burns, and as a soothing application to the pustules in small- pox. Vel. R. Liquoris calcis, olei amygdalae, aa §j. Bene admisce et adde adipis preparatae, §j. Misce. This ointment is more soothing than the carron oil, and is invaluable in irritable ulcers and sores from blisters, 4-c, in children. 86. Stimulating Liniment. R. Linimenti camphorae compositi, giss.; tincturae lyttae, tincturae opii, aa 3U- Misce. Fiat linimentum. To be gently rubbed over the back of the chest in hooping-cough, infantile bronchitis, Sec. Vel. R. Linimenti camphorae compositae, linimenti saponis, ail §ss. Misce. To be rubbed over the thorax and spine, in cases of Atelectasis. 87. Embrocations for Chilblains. One ounce of bruised oak-galls should be boiled for an hour in two pints of water; the fluid, employed two or three times a day, forms a most efiicacious application. The same result is obtainable by meaus of a docoction of oak-bark, or by a solution of half au ounce of tannic acid in gvj. of water. If no ulcerations are present, we may also employ tincture of galls. Tannin as a haemostatic and styp- tic, inducing no irritation or pain, is of the greatest service. 88. lied Precipitate Ointment. R. Hydrargyri praecipitati rubri, gr. x.—5ss.; axungiae, §j. Misce bene, et fiat unguentum. Recommended by Dr. Mackenzie, in catarr- hal ophthalmia, ophthalmia tarsi, opacity of the cornea, Sec, applied along the edges of the eyelids. 89. Iodine Paint. R. Iodinii, 5j.; potassii iodidi, 5ss.; spiritus vini rectificati, §j. Misce. To be applied gently with a camel's-hair pencil. For young children this paint should be further diluted. 90. Iodine Ointment. R. Unguenti iodinii compositi, 5j.; adipis, 3ij. Tere simul. Use- ful ivhen rubbed over the thyroid gland in bronchocele, or over enlarged 458 APPENDIX OF formula:. scrofulous glands, ortipon the tumid bellies of children suffering from mesenteric disease. Vel. R. Potassii iodidi, 3ss.—3ss.; adipis, §j. Misce, fiat unguentum. Useful as an application to strumous ulcers. 91. Iodurclted Baths for Children. Age. Water. Iodine. Iodide of Pot 4 to 7 1 to 11 11 to 14 Quarts. 36 75 125 Grs. Troy. 30 to 36 48—60—72 72—96 Org. Tro 60 to 96—120-144—1 Baths of this nature are recommended by Lugol in the treatment of scrofula. They should be employed in wooden vessels. 92. Tan Bath. Three handfuls of brusied oak-bark are to be boiled in three quarts of water for about half an hour. The decoction is to be strained, and then added to the tepid water of the child's bath. Recommended by Dr. Elsiisser to be used daily for several weeks in most of the diseases of childhood where debility is the prominent symptom. It is a very valuable remedy from which I have seen marked benefit. 93. Sulphurous Acid Lotion. The solution of sulphurous acid, recommended by Dr. Jenner in cases of tinea, is made by passing a stream of the gas through water to saturation. Two ounces of this saturated solution are then added to six ounces of water to make the lotion. 94. To remove Bruise Marks, " Black Eye," JwM be produced in from fifteen zZei:::"::^^—«■*■" *—°r *» days. 100. Alterative Collyrium. ■ whloridi srr. i.; ammoniae hydrochloratis, gr. viij.; r. Hydrargyn ^™dl^;./on Jmes, ,IacJ;mzic, <,c.) In oph. Z^r'f^ applied 'frequently by means of a piece of sponge. INDEX. Absence of Spinal Cord............. J of) Accidents occurring at Birth........ 13S Aceplialus......................... L3-3 Acidurn Hydrocyanicum Dilutum .. 9G Acne.............................. 2.32 A crania........................... L">j Active Cerebral Congestion......... 293 Acute Hydrocephalus.............. 299 JEthex............................. 10J Ague.............................. 277 Air, Change of,.................... 71 Air-passages, Foreign Bodies in..... 421 Albinismus........................ '^'^ Albinos.,........................ 211 Algide (Edema.................... 146 Aloes............................. 8o Alteratives and Kesolvents......... 98 Amaurosis........................212 Ammonia......................... l^ Amputation of the Limbs in Utero... 17o Amyelia.......................... 159 Amylene.......................... ''' Anterior Curvature of the Spine..... 179 Anthrax........................... 4'>7 Anus, Prolapsus of the.............. 404 Apueumatosis...................... 3.jo Aphthous Optlialmia............... -'1 -----Stomatitis................... 3S1 133 139 207 411 Apncea Neonatorum........... Apoplectic Apncea............ A poplexy.................... Appendix of Formula......... Application of Cold to the Head--- 29-3 Actificial Anus..................... 1[^ Asphyxia Neonatorum............. B>^ Assafcetida........................ 9' Atelectasis........................ 1*1 Atresia Ani........................ 1°° -----Lingua;..................... 15' ------Oris......................... 1«6 -----Palpebrarum............... 156 -----Vulva:...................... 168 Attitude, Examination of........... 57 Auscultation in Children........... 64 Average Duration of Life........... 30 Baths............................. 72 Birth, Injuries received during...... 141 Black-fits.......................... :!15 Bladder, Extrovert-ion of........... 1<|7 ------, Inversion of................ l"s Blear-eyes......................... 1^6 BleedingXrom the Nose...........'. 439 Blisters............................ °0 ------, Dress'ng of................ S2 Blood-letting...".................... 77 B!ov.-s and Brni-e"-................. 439 Blue Disease.....................U>3 B.-.i=.......................... «7 Brain, Dropsy of tho............... 308 -----, Hypertrophy of I ho........ 309 ------, Inflammation of the........ 30.3 ------, Congestion of tho........... 294 Breasts, Swelling of................ 1.32 Breath and Mouth of Infants....... 01 Bronchocele, or Goitre............288 BionchialTul.es Inflammation of... 358 ------Phthisis.................... 371 Bronchitis......................... 3.38 Bulla............................. 210 Burns and Scalds..................430 Button Scurvy..................... 241 Cancer of the Ey eba i I.............. 214 ------of the Kidney .............. 417 Caucroide......................... -o.'i Cancrum Oris...................... 3S2 Capillary Bronchitis............... 360 Carbonate of Magnesia............. S4 Carbuncles........................ 137 Carditis and Endocarditis........... 379 Castor Oi!........................ 83 Cataract, Congenital............... 211 Catarrhal ophthalmi.a............. 2oo Catarrho-i hcumatic Ophthalmia.... '.07 Cathariics......................... s2 Causes of Death................... 19 ------of Disease................. ID ------of Health................... 29 Cephalsematoma................... 143 Cerebral Apoplexy,................ 297 ------Congestion.................. 293 ------Hyportropliv..............309 Change of Air..................... 71 Cheloidea.........................2.33 Chemical Constitution of the Bones.. 173 Chicken-pox....................... ~'M Chilblains........................436 Child-crowitig.................... 313 Chloasma....................... 246 Chloroform vie.......... .'....... 97 Chorea...."....................... .".20 Chronic Hydrocephalus............ 308 ------Inflammation of Spinal Cord, 312 Cinchona.......................... 'f>5 Circulation in Infants.............. 6.3 Classification of Skin Diseases...... 22y Cleanliness and Clothing........... 119 ------during Pregnancy........... 36 Cleft Palate....................... 15S ------Urethra and Scrotum........ 16.3 Cloacal Formation.................. 160 Clothing and Cleanliness........... 119 ------of Pregnant Worn i ■........ 36 Club-foot, or Talipes............1 nJ Cohesion of the Labia..... . 421 Cold, application of to !le..r ... 29.3 ------Bath...................... 70 INDEX. 461 Compound Tincture of Camphor.... 94 Conduct of Women during Pregnancy, 34 Congenital Cataract................ 211 ------Hydrocele.................. 164 ------Imperfections of the Iris..... 210 ------Inguinal Hernia... .-......... 164 ------Malformations.............. 152 ------Umbilical Hernia........... 163 Congestion of the Brain............ 294 Conjunctiva. Diseases of........... 199 ------, Foreign bodies adherent to.. 199 ------, Inflammation of............ 200 Conjunctivitis Aphthosa............ 204 ------Phlyctenulosa.............. 204 Constipation....................... 399 Contracted Fingers................ 183 Convulsions....................... 291 Cornea, Diseases of the............ 206 Coryza............................. 32S ------Maligna.................... 329 Countenance, Examination of...... 5.) Cow-pox.......................... 202 Cretinism......................... 28S Croup.............................. 330 Crusta Lactea...................... 236 Cry of Infants..................... 1'0 Cryptorchism...................... 165 Curvature of the Spine............. 179 Cyanosis.......................... 163 Cynanche Maligna................. 270 ------Parotidea................... 386 ------Tonsillaris.................. 384 ------Trachealis................... 330 Deaf and Dumb................... 223 Death, Causes of................... 49 Deformities, Congenital............ lo2 ------, Non-congenital............. 172 Dentition.......................... Is6 I) agnosis of Infantile Diseases..... 53 Disorders of the Mind.............. 32.3 Doses of Medicine.................. 70 Double Cephalsematoma............ 143 Dover's Powders................... 94 Dropsy of the Spinal Medulla....... 159 ------after Scarlatina.............. 271 ------of the Brain................ 308 Dry Tetter......................... 249 Dysentery......................... 393 Dyspepsia......................... 387 Earache........................... 218 Ear, Diseases of the................ 218 ----, Foreign Bodies in............. 21S ----, Inflammation of the.......... 219 ----, Purulent Discbarge from the.. 221 Eclampsia Nutans................". 319 Ecphyma Globulus................. 241 Ecthyma,.......................... 212 Ectopia Cordis..................'... 161 Eczema............................ '-36 -, Infantile . Diapho Diarrhce; Diet of C 1 91 "_.'/...................... 391 ildren................... 117 — j'regnant Women........... 35 stion of Walls of Stomach......389 Effects of Deformities on the Mind.. 174 Elephantiasis Arabicum............ 231 Grascorum.................. 231 Di Digitalis........................... »o Diphtherias........................ d« Disease in Infancy, Peculiarities of.. 4o ------, Causes of................... J® Diseases, General.................. 2/9 ------occurring at Birth........... l3o _____of the Conj unctiva.......... 199 Emetics........................... *6 Empyema.......................... 354 Encephalii is....................... 30.5 Encephalocele..................... 155 Encephaloid Fungus of the Eyeball, 214 Endocarditis and Carditis........... 379 Enemata.......................... 86 Ephelides.......................... 254 Epilepsy........................... 316 Epiphora.......................... I9S Epispadias........................ 1°5 Epistaxis.......................... 439 Eqmuia........................... -j^° Eruption of Permanent Teeth....... 1SS ------of Temporary Teeth......... 187 Eruptive Fevers....................25.3 Erysipelas......................... 229 Erythema......................... 2-S Circinatum.................. 229 Fugax.....'................. 229 Intertrigo.................. 22!) Nodosum .................• 223 ■ of the Digestive Organs . of tho Ear........ ■ of tho Eye........ • of the Eyelids..... ■ of the Genital Oiga of the Heart. Essential Paralysis of Infants.. Examination of the Countenance .-----of the Attitude........... ------of the Eye in Infants... of the Gestures. . of the Iris . of the Liver. 3S0 218 195 195 415 374 ■ of the Intestines............. 391 409 ______of the Mouth and Fauces---3S0 ______of the Nervous System......290 ______0f the Organs of Circulation, 328 _____of the Organs of Respiration. 32S _____of the Sclerotic and Cornea.. 206 ------of the Ski n.................. 22o _____of the Stomach.............. *°° ______of the Urinary Organs.......41a Disorders of the First Dentition.....190 ______of the Second Dentition...... 1*3 201 57 Exanthemata...................... 22S Exercise and Sleep................. 1^- ------during Pro<:uai,:............ 37 Expectation of Life................ 32 Expectorants---:................. °» External Otitis.....................219 Extroversion of the Bladder........ 167 Eye, Diseases of................... I9'' Eyeball, Encephaloid Fungus of the 214 Eyelid, Diseases of the............. 195 Facial Hemiplegia ................ 324 Fasces, appearance of............... 66 False Measles...................... 232 Farcinoma......................... '" ;3 Fauces, Scalds of................... 435 Ferrum......................... 106 Fever, Infantile................. '74 ------, Intermittei:..............277 i.\i)i;x. Fingers, Contraction of...... First Dentition, Disorders of. ------Vision of Mirza...... Fissured Palate.................... Fissure of Spinal Column.......... Flat-foot........................... Foetal Limbs, Amputation of in I'lero, Follicular Stomatitis............... Food of infants.................... Foramen Ovale, Patency of......... Foreign Substances oa Conjectiva... ------Bodies in the E:i 1S3 170 381 111 162 199 218 424 441 141 2.33 251 430 438 Gangrene of the Lungs............ 367 Gangrenous Stomatitis............. 3S2 Gastritis.......................... 3SS Gelatio............................ 436 General Diseases................... 27:' ------ Surface of Infants........... 62 Genital Organs, Diseases of the..... 420 Gestures, Examination of........... 57 Glanders.......................... 243 Goitre, or Bronchocele............. 28S Gutta Rosacea..................... 2.32 Hzemorrhage, Intestinal............ 149 Hasmorrhagia...................... 233 Hare-lip........................... 157 ------with Fissured Palate........ 157 Heart, Diseases of the.............. 374 Hermaphroditism ................. 166 Hernia Cerebri.................... 153 ------, Strangulation of............ 400 Herpes................... ......... 236 Herpes Z.ister....................., 236 Hiccup............................ 292 Hooping-cough.................... 347 Hordeolum, or Stye................ 196 Humid Tetter...................... 236 Hydatid Tumors of the Liver....... 413 Hydrargyri Bichloridium........... 101 ------Ohloridum..........~....... 100 Hydrargyrum cum cret'•............ 100 Hydrocele........................ 421 ------, Congenital................. 164 Hydrocephaloid Disease............ 301 Hydrocephalus, Acute............. 299 ------Chronic..................... 309 Hydro-encephaloccle............... 155 Hydrophthalmia................... 2 7 Hydrorachis....................... 159 Hydrothorax...................... 354 Hyoscyamns...................... 96 Hypertrophy of the Brain.......... 309 ------of the Tonsils............... 384 Hypospadias....................... 165 Icterus Neonatorum............... 410 Icthyosis.......................... 230 Idiocy............................. 327 Impediments of Speech............ I si Impetigo......................••■ 242 ------Figurata................... 212 ------Sparsa...................... 212 Incontinence of 1'rine.............. Indigestion........................ Infancy, Mortality in............... Infant at Birth. Management or..... ------Structure and Constitution. .. Infantile Diuresis.................. ------Erysipelas.................. ------ Fever....................... ------Leucorrhoea................ ------Intermittent Fever.......... ------Trismus..................... Inflammation of Spinal Cord....... ------ of the Ear .................. ------ of the Pleuia ............... ------of t'mbilicus............... Inflammatory Diarrhoea............ ------Sore Throat................. Inguinal Hernia. Congenital........ Injuries received during Bin'i .... Invagination of Intestine........... Inversion of the Bladder.......... Intellectual and Moral 'lra.h.iiir..... Intermittent Fever................. Internal Otitis...................... Intestinal Haemorrhage............. ------Worms...................... Intestines, Diseases of the.......... ------, Malformotions of............ Intus-usception.................... Inward Fits...................... Iodide of Potassium................ Iodine and its Combination)......... Ipecacuanha, as an Kinetic......... ------, as an Expectorant.......... Irideremia......................... Iris, Congenital imperfections of tho, ------, liiseases of the............. Iritis.............................. Itch, the........................... Itching............................ Jalap... Jaundic. 10S 40 ■117 2U 274 422 311 312 219 333 lis 393 3.st lot 141 400 16S 127 277 219 149 401 391 168 4011 291 102 100 88 90 211 210 LOS L'OS 240 218 ■S.3 409 Keloid............................ 253 Keratitis Scrofulos.i................ 207 Kidney, Cancer of the.............. 417 Laryngismus (stridulus............. 345 Lateral Curvature of the Spine..... 179 Lentigo............................ 2.34 Lepra...........................249 Leucorrhoea Lico.............................. Lichen Strophulus................. 2 ------- Agrius..................... -------Simple x.................... Life, Average Duration......_....... 3' -------, Expectation of.......*....... — Table for England.......... 3. Liver-Spot. -------, Diseases of the..... Lungs, Inflammation of the -, Tubercular Disease 23 Lupus. Macules........................... -■>'• Malformations, Congenital.......... 15" -------, Laws regarding............. 35: -------of the Intestines............. 16. Management of Infant at Birth...... ------- and Education of Children... IXDEX. jcs Manna............................ 84 Marshall Hall's Ready Method..... 140 Measles........................... 266 .Mechanical Constipation........... 399 Meconium......................... 66 Medical Examination of Children... 50 Medicated Baths................... 74 Membranes of Spinal Cord, inflamma- tion of........................... 312 Meningeal Apoplexy............... 297 Meningitis......................... 305 ------of tho Spinal Cord........... 312 Mentagra.......................... 245 Mercurials........................ 9S Miliaria........................... 235 Milk, Composition oi............... 112 Mind, Disorders of the............. 325 Mirza, the First Vision of.......•. - -. ^ 30 Molluscum........................ 2)1 Moral and Intellectual Training..... i27 ------Discipline during Pregnancy. 37 Morbilli........................... 266 Morbus Casruleus.................. 163 Morphia........................... 94 Mortality in Infancy............... 26 Mother-marks..................... 141 Mouth and Breath of Infants....... 61 ------and Fauces, Diseases of tho.. 380 Mumps............................ 386 Myogenic Paralysis................ 322 Myringitis......................... 219 Nas vi Materni...................... 144 Narcotics and Sedatives---........ 92 Nasal Catarrh..................... 328 Nephritis.......................... 41o Nervous System, Diseases of the---290 Nettle-rash........................ 232 Night Terrors...................... 324 Nigrities........................... 2J3 Niue-day Fits...................... 314 Nitrate of Potash.................. 92 Noma............................. 382 Non-congenital Deformities......... 17.4 Nursery, Management of........... 126 Odontitis Infantum................. 191 OSdcma of the Lungs............... 272 Oleum Morrhuas................... 1°' ------Terebinthinas................ If.' 201 196 93 Pediculi Ciliorum.................. 196 Pemphigus........................ 240 Pericarditis....................... 374 Peritonitis......................... *' Permanent Teeth, Eruption of...... 188 Pertussis................'.......... 347 Phlyctenular Ophthalmia.......... 204 Photophobia...................... 200 Phrenitis.......................... 305 Phthisis........................... 370 Phymosis........,................ 420 Pityriasis......................... 250 ------Versicolor.................. 246 Pleura, Inflammation of the........3-33 Pleurisy.......................... 353 Plica Polo aic...................... 216 Pneumonia........................ 364 Pneumothorax.................... 35j ------with Elfusio....... ...... 355 Polish Ringworm......... Pompholix........................ 240 Porrigo Decalvans................. 215 -----Favosa..................... 244 ------Scutulata................... 244 Posterior Curvature of the Spine.... 179 Prognosis of Infantile Diseases..... 53 Prolapsus Ani.................... 404 Prurigo............................ 248 Psora................. Psoriasis.............. Pterygium.. .."........ Ptosis................. Pulmonary Collapse... ------Consumption . .. Pulse in Infants....... Purgatives'............ Purpura Hasmorrhagic: euilli 246 249 206 196 359 370 64 82 234 234 ------Simplex.'..................- "34 ■ Urticans Ophthalmia Neonatorum. . _____of New-born Childrc Opium............................ " Orchitis........................... **\ Otalgia............................ 2 8 Otitis.............................. ^IM Otorrhoca................... Rachitis, or Rickets.......... Ready Method of Marshall Hi Red-gum. 234 '174 140 247 Remittent Fever................... 274 Respiration in Infants.............. 63 Retro-pharyngeal Abscess.......... 38d Rheumatic'Ophtholmia............ 2o7 Rhubarb................... ...... °4 Rickets, or Rachitis................ l<* Ringworm......................... 24 , Roseola............................ ~i: ------Infantilis................... 232 Rubeola........................... 266 ------sine Gatarrho............... *ob Rules for prescribing.............. 69 Palate, Fisure o!............... Papulas........................ Paralysis...........-•••>::..... ______of the Upper Eyelid..... Paraphymosis................. Parasitici..................... Parotitis....................... Passive Cebral Congestion...... I'-itency of the Foramen Ovale lVenliarties of Disease'" Pediculi............. in Infancy.. 221 158 247 322 196 421 , 244 386 , 296 , 162 , 45 24S Running Tetter. Rupia. Saint Vitus's Dance. Salaam Convulsions Saline Aperients--- Scabies............. Scalds and Burns... Scammony......... Scarlatina.......... ------ Aiiiiinosa ... . .------ Maligna..... ------ Morbillo-i:.. ------Simplex..... Scarlet Fever....... 320 319 84 246 430 85 268 269 270 256 464 1NDKX. Sclerema.......................... 146 Sclerotic, Diseases of the..........207 Sclerotitis Idiopathica.............. 206 Scorbutus......................... 234 Scrofula........................... 279 Scrofulous Corneitis................ 207 Ophthalmia................. 204 Scurvy........................... 234 Secondary Fever in Small-pox ..... 259 Second Dentition, Disorders of...... 193 Sedatives and Narcotics............ 92 Senega............................ 90 Sex of Children.................... 31 Simple Diarrhoea.................. 391 ------Encephalitis................ 30.3 Skin, Diseases of the............... 22.3 Sleep and Exorcise................. 122 ------of Infants................... 59 Small-pox......................... 257 Softening of the Stomacli........... 389 Spasm of the Glottis............... 345 Speech, Impediments of............ 181 Spina Bifida....................... 159 Spinal Cord, Inflammation of....... 312 ------, Absence of.........,....... 159 Spine, Curvature of the............ 179 Spurious Hermaphroditism......... 166 Squamae.......................... 249 Squill, as an Emetic................ 88 ------, as an Expectorant.......... 90 Squint............................ 210 Stammering....................... 181 Still-born Children................. 138 Stiliicidium Lachrymarum......... 198 Stimulents and Tonics.............. 103 Stomach, Diseases of the............. 386 Stomatitis........................ 381 Strabismus........................ 21;> Struma............................ 279 Stannous Enlargement of the Liver. 411 ------Ophthalmia................. 204 Stuttering......................... 1S4 Stye, or Hordeolum................ 196 Suckling, Directions for............ 116 Sudamina......................... 235 Sulphate of Zinc---'............... SS Sunburn.......................... 234 Swelling of the Breasts............. 152 Sycosis........................... 245 Syphilis........................... 2S6 Syphilitic Eruptions affecting the Eyelids.......................... 195 ---_ Lepra...................... 249 Syrup of Poppies................... 94 Tabes Mesenterica................. 408 Tache Meningitique................ 62 Talipes, or Club-foot............... 182 Tartarized Antimony, as an Emetic. 88 ------, as an Expectorant.......... 89 Teeth, Cutting the.................. 187 Temperature of Infants............. 62 Temporarv Teeth, Eruption of...... 181 Testitis...'......................... 121 Tetanus of New-born Children...... 314 Tetter............................. 235 Therapeutics (Infantile,)........... 67 Thrush............................ 380 Tincture of Opium................. 91 Tinea Decalvans................... 21.3 ------ Favosa..................... 211 ------Tonsurans.................. 214 Tongue-tied........................ '.'7 Tonics and Stimulants.............. 103 Tonsillitis......................... 384 Tonsils, Hypertrophy of the........ 384 Tooth-rash........................ 2 17 Torticollis,or Wrv-neck............ 181 Tracheitis......................... 330 Tracheotomy in Croup............. 341 Trismus Nascentium............... 314 True Hermaphroditism............ 166 Tubercle, Analysis of............... 28.3 Tubercular Encephalitis........... 299 Tuberculosis....................... 283 Tuberculous matter................ 283 Typhoid Fever..................... 274 Ulcerative Stomattis................ 382 Umbilical Hernia,' Congenital....... 163 ---- Cord, Length of............. 172 Umbillicus, In 11 animation of........ 148 Unguentum Hydrargyri............ 100 Urethra, Discharge from............420 Urinary Organs, Diseases of the..... 415 Urine in Infants.................... 66 -----, Incontinence of............. 419 Urticaria.......................... 232 ------ Evanida.................... 233 Vaccination....................... 262 Vaccinia, or Cow-pox.............. 262 Vapor Bath........................ 74 Varicella.......................... 260 Variola........................... 2.37 ------ Confluens..................2.39 ------Discreta.................... 258 Vesicul.v...................,...... 235 Vitiligo........... Vomiting in Infants .. 253 ,. 65 Warts on the Eyelids.............. 196 Weaning........................117 White-fits......................... 315 Women, Conduct of, during Preg- nancy. 34 Worms in the intestines............ 396 Wounds occurring before Birth..... 142 Wry-neck, or Torticollis............ 18i Yaws............................. 2>3 236 THE END. t i ^MO.iM'vvvA-.yO-ji