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rC.GORDON MJ)
THE
2%d^*^
PRINCIPLES
OF
21WI1"
INCLUDING THE
DISEASES OF WOMEN AND CHILDREN.
         BY JOHN BURNS. CM.
  REGIUS PROFESSOR OF SURGERY IN THE UNIVERSITY OF GLASGOW,
              &c. &c.     .   — .:':"" --yvy- -£
             ====    J.j l JL> iulK x $
             ——  SUKGh'ON GtNERAL'S OFFJC


FROM THE FIFTH LONDON EDITION, ENLARGE^, WITH IN-
PROVEMENTS AND NOTES,

          T. C. JAMES, M. D.
  PIIOFESSOR OF MIDWIFERY IN THE UNIVERSITY OF PENNSYLVANIA.

         IN TWO VOLUMES.

             VOL. II.

       LIBRARY.

  MEDICAL AND CHifiURGiCAL FACULTY
    „PF THE HUlW3Pffii(PHI^ARYLA
PURLISHED,^SlC^|^2E©E^|V £$»IgU^T-STREET
         J. H. Cunningly, printer.

              1823.
*'■' 31
   2
 
v                           .wo.


                                  v.  «2
Eastern District of Pennsylvania, to wit:
■      —<   BE IT REMEMBERED. That on the fourth day  of February,
|fSEAL.j|  in the fortv-seventh year of the Independence of the United States
■L— —J*  of America, A. D. 1823, EDWARD PARKER, of the said district,
hath deposited in this office the title of a book,  the right whereof he claims as
proprietor,  in the words following, to wit:

" The Principles of Midwifery ; by  John Burns, C. M. Regius Professor of Sur-
  gery in the University of Glasgow, &c. Uc.  From the fifth London Edition, en-
  larged, -with impi ovements and notes, by T.  C. James, M. D. Professor of Mid-
  vdfery, in the University of Pennsylvania."

  In conformity to the act of the Congress of the United States, entitled " An
Act for the encouragement of learning, by securing the copies of maps, charts,
and books,  to the authors  and  proprietors of such copies, during the times
therein mentioned"—And also to the Act, entitled '«An Act supplementary to
An  A.et, entitled " An Act for the  encouragement of learnings by securing the
copies "t .naps,  charts, and books, to the authors and proprietors  of such co-
pies. Juring the times therein mentioned," and  extending the b'enefits  thereof
to the arts of designing, engraving, and etching historical and other  prints."
                                                  D. CALDWELL,
                              Clerk of the Eastern District of Pennsylvania.
%*. • • H
I *
 
tfr.-J:
etDSNHHsras
BOOK IV.
                 CHAP. I.

        Of the Management of Children.

Section 1.  Of the Separation of the child, and the
  treatment of still-born Children    -    -    Page   9
Section 2.  Of Cleanliness, Dress, and Temperature    14
Section^  Of Diet......16

                 CHAP. II.
Of Congenite and Surgical Diseases.
Sect
Sect
Sect
Sect
Sect
Sect
Sect
Sect
Sect
Sect
    on 1.  Hare-Lip    -
    on 2.  Imperforated Anus, Urethra, &c.
    on 3.  Umbilical Hernia  -
    on 4.  Spina bifida  -
    on 5.  Marks   -
    on 6.  Swelling of the Scalp
    on 7.  Distortion of the Feet
    on 8.  Tongue-tied -    -
    on 9.  Malformed Heart  -
    on 10. Swelling of the Breasts, Hydrocele,
  Prolapsus Ani, Umbilical Hemorrhage, and Ex-
  coriation, &iC.
Section 11. Foetid excretion from the nose
Section 12. Ophthalmia   -    -     -     *»*
Section 13. Spongoid Disease of the Eye   «r^
Section 14. Scrofula     - ^  "^rf*
Section 15. Rickets
Mp0
20
21
22
23
24
26
26
27
27
31
31
32
32
33 
<        »
 s
     CHAP. III.

    Of Dentition

     CHAP. IV.

Of Cutaneous Diseases.
Page 34
Strophulus intertinctus   -     -
Strophulus albidus  -
Strophulus confertus
Strophulus candidus
Lichen       -
Intertrigo    -
Anomalous Eruptions, pustules and
 Section 1.
 Section 2.
 Section 3.
 Section 4.
 Section 5.
 Section 6.
 Section 7.
   boils  -
 Section 8.   Pompholyx and pemphigus
 Section 9.   Miliary Eruption
 Section 10. Prurigo      -
 Section 11. Scabies      -    -     -   .  ■
 Section 12. Herpes       -
 Section 13. Icthyosis     -
 Section 14. Psoriasis     -
 Section 15. Pityriasis     -
 Section 16. Lepra   -
 Section 17. Impetigo     -
 Section 18. Porrigo      -
 Section 19. Scabs from vermin
 Section 20. Alopecia and ophiasis
 Section 21. Purpura or petechia
 Section 22. Erysipelas and erythema
 Section 23. Excoriation behind the ears
 Section 24. Ulceration of the gums
^Section 25. Erosion of the cheek, sloughing
   ulceration of the pudendum
 Section 26. Afgggise
 Section 27. Aphthae onlbe tonsils
idiet
39
40
41
42
42
44

44
46
47
43
48
50
54
54
56
57
58
60
65
66
66
65
71
72

73
 75
 80 
Vll
Section 28. Malignant, aphthous, or ptitrid sore   ,      t
  throat.....'-.-■■  PagejSl
Section 29. Excoriation of the tongue, gums, and
  lips   -    -    -     -    -    -    -'-    82
Section 30. Syphilis      -    -   ■ -    -    -    82
Section 31. Skin-bound   -----    87
Section 32. Small-pox.....89
Section 33. Cow-pox   '.....95
Section 34. Chicken-pox      -    -    -    -    101
Section 35. Urticaria     -   -    -    -    -    104
Section 36. Scarlatina.....105
Section 37. Measles.....113
Section 38. Roseola.....118
                  CHAP. V.
        Of Cerebral and Spinal Irritation       -    120
                  CHAP. VI.
             Of Hydrocephalus    ~    -    -   141
                 CHAP. VII.
         Qf Convulsions and Eclampsia   -    -   153
                 CHAP. VHI.
            Of Chorea and Paralysis     -    -   160
                  CHAP. IX.
                   Of Croup       -    -    -   163
                  CHAP. X.
               Of Hooping Cough   -    -    -   175
                   CHAP. XI.
Of Catarrh, Bronchitis, Inflammation of the Pleura,
        and of the Stomach and Intestines       -   179
                  CHAP. xn.'                f
                 Of Vomiting      -    -    -   186
                  CHAP. XIII.J*
                 OfDiarrMf    -    -    -   187 
VM
                   CHAP. XIV.
                  Of Costiveness  -   -    Page 197
                  CHAP. XV.
                    Of Colic      -    -   -    198
                  CHAP. XVI.
                 Of Marasmus    -    -   -    199
                 CHAP.  XVII.
              Of Tabes Mesenterica     -   -    200
                 CHAP.  XVIII.
                  Of Worms                   204
                 CHAP. XIX.
                 Of Jaundice                   206
                  CHAP. XX.
               Of Diseased Liver   -             208
                 CHAP. XXI.
                  Of Fever                    211
DESCRIPTION OF PLATES                    213
INDEX........229
'v 
ROBERT. A . GORDON M.D
                                 THE


                        MANAGEMENT

                                AND






                            BOOK  IV.


                             CHAP. I.


                  Of the Management of Children.

 § 1. OF THE SEPARATION  OF THE  CHILD AND  TREATMENT OF
                      STILL-BORN CHILDREN.

    When a child is born, the first thing to be done is to ascertain
 if it breathe or be alive.   If it cry or breathe vigorously, then it
 may be safely separated from the mother.* This is done, by tying
 the navel-string about  half an inch from the navel ;(a) another

   * Dr. Denman, from observing that some children, after they had begun to
 breathe, had respiration checked, and died after the cord was tied, advises, that
 the ligature should never be applied till  the pulsation cease.  But when the
 child is vigorous and cries lustily, there is no occasion for delaying so long; nor
 have I  ever known any bad effect result from this practice. It has been sup-
 posed,  that as long as pulsation continued, the function of respiration was imper-
 fect ; but it is not so : the pulsation depends more on the  continuance of the
 vitality or action of the placenta, than on the state of the lungs.

  (~aj This is rather too near the navel, for in  case of the ligature cutting
 through the cord, and hemorrhage consequently taking place, which hat some-
 times been known to occur, there will  scarcely be room left to apply another
 ligature between the former  one, and the abdomen of the child,   it is  best
therefore to apply the ligature, in a general way, at about thee fingers breadth
 from the navel: this leaves sufficient space, jfcivthe application of another liga-
ture if necessary.
     Vol. II.                   2 
                             10
ligature is applied two inches nearer the placenta, and the cord is
divided between these with a pair of scissors.  In some countries,
the division is made with a sharp flint; in others, by  means of
fire."  The necessity of applying a ligature has been denied by dif-
ferent practitioners; but it has sometimes been found, that when
the ligature  had become slack, a considerable quantity of blood
was lost, and even fatal hemorrhage has taken place.
   When a child does not breathe soon after it  is born, it is not al-
ways easy to say whether it is alive, for we have, at this  time, no
criterion of death except putrefaction; and, therefore, it behooves
us always, unless this mark be present, to use means for preserving
the child, by which some have been saved,  after being laid past as
dead.   Children may be born apparently dead, in consequence of
the head having remained  long  in  the  pelvis,  or having been
squeezed in a deformed pelvis; or owing to the cord having been
compressed, either during the process of turning and delivering a
child, or from its having descended before the presenting  part of
the child, or being so situated during  labour, as to be compressed
by the uterus, especially during tedious labour.  Some children
die, owing to  the head being born, covered with the membranes,
some time before the body.   This is the consequence of inatten-
tion, for, if the membranes be removed, from the face,  there is no
risk of the child.   In whatever mode children are still-born, the
effect is referable, either to compression on the cord, first suspend-
ing and then  destroying animation; or to  pressure on the brain;
or to a state of  insensibility and feebleness, preventing the action
of respiration from taking place after  birth.
   In determining on our treatment of still-born children, our first
 object ought to be, to ascertain if the circulation be still going on
 in the cord.
    If the pulsation  have stopped, no good  can accrue from allow-
 ing the child  to remain connected  to the  mother.  The  cord is
 directly to  be divided, and means used, as shall immediately be
 mentioned, for  the production of respiration.
    If pulsation continue, the  child is not in danger  from want of
 respiration, for  the foetal mode of living is continuing.   The cause
 of stillness, then,  is mostnkfljr a  kind  of  syncope, or torpor. 
11
which  prevents the action of respiration from being established;
or it may be from compressed brain.   In both cases,  the skin is
purple, from the blood not having been arterialised, and we have
no mark of distinction till respiration begin.  It is very common,
in the first case, for  the  child  to be  still for a minute or more  ;
then it makes a slight sob, and breathes low, with  a sound of fluid
in the throat; and then, of a sudden, respiration becomes perfect.
In the second case,  respiration, after  it begins, continues longer
oppressed, and may perhaps stop, the child dying in a short time.
   When the cord pulsates at the time of birth, we are never to be
rash in dividing it.   It is of importance to keep up the foetal circu-
lation, till the  new mode of acting can be established, and we ought
not completely to divide the cord  in such cases, till pulsation stop;
because, if respiration should flag, we have the placenta as an auxi-
liary, if the connexion still exist,  and  the pulmonary action being
suspended, the foetal  mode  will continue, and support life till respi-
ration become vigorous ;  for the two modes of changing the blood
are not incompatible. Pulsation will no doubt at length stop, either
from the heart of the child  stopping, or the placenta being detach-
 ed from the uterus, and its  function  being lost; but as long as pul-
 sation continues, and the child does not breathe perfectly and re-
 gularly, no ligature should be applied.   If, however, respiration do
 not begin, we are to open with a  lancet or scissors one of the um-
 bilical arteries, from  which  blood  spouts in a small stream ; and,  in
 a short time  thereafter,  breathing commences.    If it  should not,
 some method must  be adopted  for exciting respiration,  such  as
 wrapping  the child in warm flannel whilst  it is still in bed; fric-
 tion, especially over the  thorax,  with the hand,  or strong spirits ;
 applying spirits to the nostrils  with a feather ; or giving  a  gentle
 concussion to the body, as  for instance, by slapping the back.  But
 the most effectual remedy  is inflating the lungs, by blowing either
 through the barrel of a quill, or applying the mouth directly to the
 child's mouth, at the same time that the nostrils  are held^and the
 cartilages of the trachea  pressed  gently back to obstruct  the oeso-
 phagus.   The  attempt at inflation is to be alternated with pressure
 on the thorax, to force the air  out,again.   If, by  this time, the pul-
 sation have stopped  in the cqrd.  and  the child  do not recover, the 
                               it
 cord is to be divided, for connexion with the placenta is useless
 after the circulation stops.  The cord is not to be tied, but only a
 loose ligature put round it; then it is to be divided, and the child
 removed to the fire, or put in warm water, and the artificial respi-
 ration sedulously continued.   An injection is also to be adminis-
 tered, and if electricity could  be  employed, there is ground for
 thinking that it would be beneficial.  Should the child, by these
 means, or after a longer time, begin to breathe,  a little blood will
 most probably issue from the cord, and the quantity will increase.
 If this seem to assist the breathing, and make the child more active,
 it is to be permitted to proceed, to the extent of two  or three tea
 spoonfuls;  but if it do not manifestly produce a good effect soon,
 it is to be  stopped with a ligature, that it may not throw the child
 back into a state of inaction.   Even when it is of service, it must
 be kept  within  bounds, otherwise dangerous debility  will be the
 consequence.*   It will be chiefly useful when the breathing does
 commence, but  is slow and oppressed, with  stupor, indicating
 affection of the brain.
   If the shape of the head be much altered, it has been proposed,
 whilst other means are employing, to attempt slowly and gently to
 press it into a more natural shape, but of the good effect of this I
 cannot speak from my own experience.   In footling cases, it has
 been supposed, that extention of the spine was a cause of death, but
 this, I apprehend, is seldom the case.
   It often is desirable to know, whether a child has been born alive,
 and destroyed afterwards; but the signs are not without ambi-
 guity.  When, therefore, the life of the mother is at stake, we must
 be very circumspect in forming our opinion.  If the lungs be solid
 and sink  in water, the child certainly has  not breathed;  and al-
 though respiration may, from the first, be prevented by the mid-
 wife, it cannot by the mother.  If the head be much mis-shapen,
..,-there is additional ground for believing the child  to have been still-
 born, and if clothes have been  made for the infant, it is to be pre-
 sumed, that the mother intended to have preserved it.  When, on
 the other hand, the child has a healthy look, and has been recently
   * It is occasionally of* service, in weakly performed respiration, to give some
 gentle cordials or stimulants.           u 
13
born, the lungs Swim in water,  and their air-cells universally con-
tain  some air, giving a frothy  appearance to the mucus squeezed
out of them, there is no doubt that the  child has breathed.  But
we cannot from these circumstances say, that it has been inten-
tionally deprived of life.  Some corroborating  facts must  be ne-
cessary to fix this point, such as the birth having been concealed,
and no preparation made for preserving the  infant; the cord being
untied, by which it has been allowed  to bleed  to  death ; or its
being cut longer or shorter than would  have been done by a  mid-
wife, marks of violence on the child, with the  total  want of all
exculpatory evidence.
   Physicians  are  much divided  in opinion as to the importance
to be attached to the circumstance of the lungs, with the heart at-
tached, swimming or sinking in cold water.—Dr. Hunter, amongst
other objections, states that the child may, when the head alone
has been born, breathe, but may die before the body be delivered.
M. Marc, on the other hand,  contends that the thorax being com-
pressed within the pelvis cannot expand,  and the air can  only
enter the trachea without fully inflating the  lungs.  In this, I think
him  wrong.  Again it has been stated,  that although the child was
born dead, yet artificial attempts having been made to  inflate the
lungs, they will swim, even if the child has never breathed.  But,
in reply to  this, it is with great justice urged, that although air may
be forced into the lungs, yet it is  more partially than in  respira-
tion, and the blood  vessels  will be found empty, or with very litde
blood, compared to the rest of the sanguiferous system.   Putre-
faction, it is  also said,  will make the lungs swim, although the
child has never breathed.   But Camper, Marc, and other excel-
lent  observers, agree that the lungs putrefy later in the still-born
child than most other parts of the body, and maintain that this pro-
cess  does not, even in summer, take place  in less than six days;
and  in winter, in less than as  many weeks.   On the whole, I  am
inclined to place very considerable reliance on this test, and  am
happy to find that my opinion is confirmed by  that of the latest
writer on medical jurisprudence, M. Fodere, who observes,  " La
supernatation  du  coeur avec les poumons  est une  preuve que la
respiration a ete tres prononcejj." 
14
  iPloucquet, from considering that the lungs in the foetus contain
much less blood than after respiration,  concludes,  that  it will  be
possible to determine whether the child  have respired,  by com-
paring the weight of the lungs with that of the rest of the body, by
means of an accurate balance.  The blood flowing into  the lungs,
by respiration, doubles their former weight.  Thus, before respi-
ration, the weight of the lungs to that of the body  is found  to  be
as one to seventy, whilst after respiration it  is as two to seventy.
Others, as Haartmann, give a different proportion,  making  it as
one to fifty-nine before, and  one to forty-eight after respiration.
Lecieux, again,  states from a multitude of experiments, that  there
is no constant relation.  The lungs of a full  grown  foetus, before
respiration,  are found to weigh nearly eight hundred grains.  The
absolute, as well as the relative weight of the lungs may, with pro- •
priety, be attended to.  By calling in the aid of all these tests, we
can seldom  be at a loss to decide, and our opinion will be confirm-
ed, if we observe signs of injury.*

       § 2. OF CLEANLINESS, DRESS, AND TEMPERATURE.

  After the child is separated from the placenta, it is to be wrap-
ped up in a piece of soft flannel called a receiver, and given to the
nurse.  Next, the soft white substance, which generally covers the
skin,  is to be gently and delicately removed by ablution with tepid
water, and the  use  of a sponge,  and sometimes of a  little  soap.
It is not necessary to remove every part of this, nor make such at-
tempts as will fret the skin ;  but in every instance, and  especially
if there be reason to suspect that the mother has had gonorrhoea or
chancre, the surface should be washed.   It is also customary, with
many nurses, to bathe the body, or at least the head, with  spirits,
a practice which can serve no useful purpose, but may be attend-
ed with mischief.   The child being dried,  it  is usual  to wrap a
bit of soft rag round the remains  of the  naval string,  and  retain
this by means of a  bandage brought round the belly.   It is  alleg-
  * There are some very good papers on infanticide by Mr. Hutcheson, in the
 Med. and Phys. Journ. No. 254. et seq.
  The reader is also referred to an Inaugural Desertation on Infanticide, by Dr.
John Beck of New York, published in 1817. 
15
ed, that this is necessary to prevent umbilical  hernia; but hernia
does not take place because the child is not bandaged, but because
the umbilicus is unusually wide;  and in those countries where no
compress is used, hernia is not a frequent complaint.  A tight ban-
dage produces pain,  difficulty of breathing, and  other deleterious
effects.  The only purpose to be derived from a bandage, is to re-
tain the rag, which is for the sake of cleanliness, applied round the
cord.
  It was at one  time the practice to wrap  the child very tightly
round  the  whole  body, and  to  stretch both  the arms and legs,
whilst the head was secured by tapes, passing from  the cap to the
body.   A more easy method is now adopted, and it seems to be
agreed upon, that the more simple and loose the dress is, the more
comfortable will the child be.   Nurses  are peculiarly afraid of the
head being cold, and therefore are apt  to keep it too warm.  In
summer one cotton cap, I believe,  is  sufficient to preserve  the
heat, but in winter an under cap may be added, but neither of these
ought to be secured by pins.   Soft  tapes  are preferable, for this
and every other part of a child's  dress.  The rest of the clothing
consists of  a short shift and a wrapper of fine flannel, which is bet-
ter  for a week or two than  the separate pieces of dress employed
by  many, and which add to t£he time and trouble of shifting  the
child.   All children cry when shifted and dressed, therefore the
shorter and simpler that the process can be made, the better. Last
of all,  a cloth  is to be  applied, to receive the faeces or urine,  and
this is to be removed  the moment it is soiled.   By attention, a
child may very early be taught to give  indication when he wishes
to void urine or faeces,  and can then be held over a pot or bason.
It is proper to encourage the child to use these  at regular  inter-
vals.   Children should have their bottom and  thighs washed and
wiped dry,  always after soiling themselves.  The whole body ought
likewise to be regularly  washed, morning and evening, with a sponge
and water, at first rather tepid, but soon brought to be cold, at least
of the temperature that cold water has in summer.   But although
this is a general  practice, yet some children do not agree with it,
being languid, cold, and pale, after being washed, and these ought
to have the water warmed a little. ' Plunging the child  into cold 
16
water is, perhaps, in this country, for some weeks, rather too vio*
lent a shock, but about the third month, it will be proper to do so
daily.
  The temperature in which children are kept, should be such as
neither to increase nor diminish the natural heat of the surface.
The child in utero is placed in  a temperature  of about 96  or 98
degrees ; but its power in generating heat  is probably much less
than after birth.  The heat of the room, and the quantity of bed-
clothes, should be nearly such as would be agreeable to a healthy
adult.  Depressing heat is to be avoided on the one hand, and ex-
posure to cold on the other.   The apartment should be well ven-
tilated, but the infant ought not  to be exposed to the open air,  for
nearly a month in winter, as it is apt to produce convulsions,  or
catarrh, with fever, or bowel complaints.

                        § 3. OF DIET.

  It is customary to give some food before the child be applied te
the breast, and very frequently  medicine also, such as salt,  mag-
nesia, or manna, to purge off the meconium.   The absolute ne-
cessity of either of these  practices may perhaps be  questioned^
especially if the mother be able to sickle at the usual time.   A
little milk and water is at all events sufficient: and with respect to
laxatives, I believe that they are seldom necessary.   If, however,
the meconium do not come freely away, and  the child have  no
stool in  twelve  or  sixteen  hours, or  seems to be oppressed,  or
troubled with pains, a little manna may be given with much advan-
tange ;(b) but generally  the milk which is first  secreted,  called
colostrum, is sufficiently powerful.  When the bowels begin to act,
and the bile is plentifully secreted,  it is usual for  the child, in con-
sequence of  absoption of bile, or perhaps of meconium, to have
a yellow tinge on the skin which is called the gum. This is some-
times attended with a drowsy state.    If it  require any medicine
3t all, it is a gentle laxative.
  All children are intended to be brought up on the breast, and

  f'bj Or what it is much better, a little mild oleum ricini, or even alive oil. 
17
they ought to be applied early, generally, betwixt twelve and twen-
ty-four  hours after birth.   Some mothers, however, cannot, and
others will not, suckle* their children, but employ another nurse,f
or bring the child up on the spoon.  If the latter mode is to be
adopted, it is necessary to determine the proper diet, and the best
mode of giving it.
   It is evident that the diejt which will be most suitable  for an in-
fant, is that which most nearly resembles the mother's milk.   It is
npt sufficient that we merely give it  milk, it must be  milk similar
to that of the human female.   It is  certain, that the  lacteal secre-
tion of  each species is best fitted for the young of  that species;
and we  know that there is a great diversity both in the flavour and
proportion of the  component  parts of different milk.  Yet,  in
many cases, the  milk of one animal will agree with the young of
a very different species. Thus a leveret has been suckled by a cat.

  * Van Helmont, and after him, Brouzet  and others, have advised, that chil-
dren should not be brought up on the breast, but fed on asses and goat's milk, or
a panado  made of bread boiled in small beer, and sweetened with honey.
  f In choosing a nurse, it is necessary to be  satisfied that she enjoys good health,
and has an adequate supply of milk.   Certain rules have been laid down to en-
able us to ascertain the quality of the milk by its appearance ; but it is sufficient
that it be not too thick, and have a good taste.   With regard to the quantity, we
cannot judge at first, for the milk may be kept up so as to distend the breast,
:md give  it a full appearance.  A woman who is above the age of 35 years, or
who has small flaccid breasts or excoriated  nipples, or who menstruates during
lactation, or who is of a passionate disposition, should not be employed as a
nurse.  The milk, during  menstruation, is  apt to disagree with the child, and
produce vomiting or purging, but this is not uniformly the case.  Violent pas-
sions of the mind affect the milk still more; it often becomes thin, and yellow-
ish and causes colic  or even fits.  Those who labour under hereditary disease
should, at least for prudential motives, be rejected.  The woman's child, if alive,
should be inspected to ascertain how it  has thriven, and both it and the nipple
should be examined, lest the nurse may have syphilis.  A woman who has al-
ready nursed several months is not to be chosen, as the milk is apt to go  away
in some time, or become bad. It is farther of great advantage to attend to the
moral conduct of the nurse, for those who get drunk, or are dissipated, may do
the child muoh mischief.
  With regard to the diet of a nurse, it is improper to pamper her, or make
much difference in the quality of the food, from what she has been accustomed
to.  It is also proper that  she be employed in  some little duty in the familv,
otherwise she becomes indolent and overgrown.
     Vol.  IJ.                      3 
18
 Milk consists of cream, curd, and whey; and the whey, the greatest
 portion of which is water, is the only part that becomes sour.  The
 quantity of cream is greatest in ewe's milk, next in that of woman,
 the goat, the cow; and then the ass and the mare.  The propor-
 tion of whey is grearer in the milk of mares and women, than of the
 cow or sheep.  With regard to the caseous part,  it is greatest in the
 milk of sheep, the goat, the cow, the ass, the mare, in the order in
 which they stand ;  and it is little in that of women.   Sugar again
 is most abundant in the milk of the mare and women, and less so
 in that of the goat, the sheep, and the cow.  Woman's milk con-
 tains more  cream than cow's  milk,  yet  no butter can be made
 from it.   It contains much whey, and yet it scarcely ever becomes
 sour by exposure to air, and does not pass either to the vinous or
 putrefactive fermentations.   Acids do not coagulate human milk.
   From these remarks it follows, that if a child  is not  suckled,
 the best  food will  be  milk, resembling that of women, and  the
 nearest is asses; but as this cannot always be  procured,  we must
 change that of cows, so as to diminish the proportion of curd, and
 increase that of  sugar  and  cream, which is done by adding an
 equal quantity of new  made whey, a sixth part  of fresh cream, or
 less if it be rich,  and a little sugar.fcj   Some dilute the milk with
 water gruel.  This is  to  be mixed just as it is required, for, by
 standing,  it acquires bad properties.   It is not to be given with  the
 spoon, but the child  is to suck it of a proper  heat, out of a pot
 which  is made for the purpose, and which has a piece of soft cloth
 tied over the perforated  mouth.  This  diet may  be  occasionally
 alternated  with a little weak veal or beef soup.  Panado made
 with crumbs of bread, is not proper; and  meat  made with  un-
 baked  flour is still worse.  In  the third month, we  may, besides
 the milk-mixture and  light soup,  give occasionally a little spoon
 meat, such as panado made with  the crust of fine bread, and a  lit-
  fcj Or a very good substitute may be found in the combination of equal parts
 ot barley-water and fresh cow's milk sweetened with the best refined loaf-sugar.
 And here we may mention, that brown sugar should never be used in the food
 of infants, as it readily runs on into fermentation, generating gaseous flatulency,
in the primae viae and often producing great uneasiness and colicky pains. When
the child is habitually costive, the food may be sweetened with manna instead
of sugar. 
19
tie salt, which is better than sugar, care being taken to break down
the lumps completely.  This to be mixed with milk.  Sago, salep,
calves-feet jelly, &c, are also  very proper; and  as the child ad-
vances in life, eggs, in the form of light custard, &c. are allowable.
Some  have proposed a panado made  with the flour  of wheat
malt.   By attention, a child may be taught to eat at pretty regu-
lar hours,* especially after he is a few months old; and great care
should be taken, that he do not  eat too much at a  time.   If the
child is not suckled,  we ascertain that the artificial diet is agreeing
with him, if he be lively and  easy, and  the bowels are correct.
But when it  does not suit, as  is too  often  the  case,  he is either
dull and  heavy, or cries much,  and often the bowels are either
bound  or too loose; and in  both states the stools are foetid, and
have a bad appearance.   If this condition of the bowels  cannot be
corrected hy  medicines, the child in all probability  will be lost, if
a nurse  be not procured; convulsions, or diarrhoea, will  carry
him off.
  When a cjiild is brought up on the breast, there is no occasion,
if the supply be abundant, to give him any other  nourishment for
three or  four months.   After this time,  however, it will be proper
to give a little food of the kinds mentioned  above, and the propor-
tion ought be gradually increased, as we  proceed to the  time  of
weaning, by which the organs of digestion are enabled to accommo-
date themselves better to the change of diet which  then takes place.
With regard to the age at which a child should be  weaned, it is
not possible to give  any absolute rule.   In general, the longer it is
delayed, if we do not go beyond a year, the better does the child
thrive, provided the milk be good.  When a child  is nursed  be-
yond a year, and receives little other food,  or when the milk  be-
comes earlier altered, he is apt to be injured.  At all times deli-
cate, should be  nursed longer than robust, children; and, if pos-
sible, weaning should not be made  to interfere  with the develop-
ment of teeth, nor be attempted in the  prospect  of, or soon after
the cure of, any debilitating  disease.    If the mother's health per-
  * It is also of advantage, that when a child is brought up  on the breast, he be
not applied at all hours indiscriminately; and no child should  be allowed to
suck whilst the nurse is asleep, as he is apt to surfeit himself. 
                             20

mit, children may be suckled from nine to twelve months.   Alter
the child is  weaned, the diet must be  carefully  attended to, and
should consist of light soup, eggs, bread, and milk.  In Ireland,
potatoes form a principal part of the  diet.   In Scotland, oat-meal
porridge is a common diet, and with many agrees very well; but
it is, notwithstanding, apt to  be heavy and binding, unless it have
an admixture of barley-meal, which corrects it.  As soon as teeth
sufficient to  masticate appear, a little animal food may be  given
once a-day.
  The dress of children, as they grow up,  must be  regulated,  in
some respect, by the custom of the country, and the  season of the
year.   It ought always to be easy and warm.  Mr. Locke advises,
that a child should wear thin shoes, and get wet feet, that he may
become hardy ;  but experience proves,  that the children  of the
poor, who are exposed to many privations and hardships, are not
improved  thereby.   Cleanliness is  essential  to health,  and the
whole surface should be washed once a-day at least,  and the hair
daily combed and brushed, which may prevent scald-head.  The
exercise should,be proportioned to the age.  Infants sleep  much,
and can take no exercise, if we  except that given by their nurses ;
but when they are about two months old, they may be placed on
the carpet, and encouraged to creep.  When they are able to walk,
they should  be allowed to run about freely ; and it will be of great
advantage, where circumstances permit, that the first years of life
be spent in the country.
           CHAP. II.

Of Congenite and Surgical Diseases.

          § 1. HARE-LIP.
  When a child is born, it is necessary to ascertain that it have no
congenite imperfection, or have met with no accident during birth. 
21
I can here only make a few short  remarks on some  of the  most
frequent and important imperfections.   The first 1 shall notice,  is
the hare-lip, which may exist in different degrees, and be accom-
panied with a vacancy in the palate. " Sometimes an operation has
been performed soon after birth, but it often fails, and occasional-
ly the child dies.   It is better to delay it for ten or twelve months,
or even longer.   In the mean time, the child must be brought up
on the spoon, unless the defect be  so trifling, as to permit him to
suck a large nipple.

            § 2.  IMPERFORATED ANUS, URETHRA, &c.

   Imperforated anus may  exist in different degrees.  There may
be an appearance of anus, but an obliteration a little  higher up.
This is discovered, by introducing a bit of oiled paper rolled up,
which ought always to be  done when the child is long  of voiding
the meconium.   If the paper be  soiled  with faeces, we may be
sure that the rectum is pervious.   A blunt probe, cautiously intro-
duced, will also ascertain the state  of the gut.   Sometimes the anus
is covered with a  thin membrane only.  In other cases, a  great
part of the rectum is wanting, or it terminates  in the bladder of the
male, or vagina  of the female, which last is not a fatal deviation.
It is proper always to make an incision at the anus, or  at the spot
where it ought to open, if there be no mark of it; and this is to be
carried  about half  an  inch or  an  inch deep.   If no intestine be
found, a trocar or lancet may be passed a little deeper in the pro-
per course of the rectum.   If, by any of these  means,  the bowel be
opened, a tent should be employed to keep the aperture from clos-
ing.*  But if it be not thus found, we are not to prosecute the dis-
section farther, but must form an artificial anus, by making an in-
cision at the lower part of the left  iliac region, sufficiendy large to

  * In a case operated on by M. Cervenon, where the incision was obliged to be
carried an inch high, it was necessary to use a bougie for a year.  The child was
enabled to retain the faeces, but the anus appeared as  if it were sunk an inch
deeper than usual.  Recueil Period. Tom. I. p. 36. 
                             22
allow the colon to be brought out,  opened, and the extremity re-
tained to the wound.*
  Imperforated urethra is rare, for generally the canal opens m
supposed cases of imperforate, about midway, between the scro-
tum and glans  penis.  There is seldom  occasion to do any thing
instantly, but, in due time, an operation may be performed to carry
on the urethra to the point.  Retention of urine, not dependent on
malformation,  is readily removed, by introducing a probe into the
bladder.  Deviations in the structure of the vagina and hymen have
already been considered.
  Imperforated meatus auditorius is very rare, and can seldom be
remedied, except  there  be  merely a membrane stretched  across
the canal.  Adhesion of the eye-lid is often complicated with a
defect in the eye-ball itself; but when this is not the case, an ope-
ration will be advfsable.

                   § 3. UMBILICAL HERNIA.

   Sometimes the  umbilicus is peculiarly large, and hernia takes
place soon after birth, but still  more frequently betwixt the second
and  fourth month.  Two modes  of treatment may be  adopted.
The first is compression, carefully maintained, which should be
always tried.   This, in some  instances, produces a radical cure ;
the umbilical  opening contracting, which it never does in adults.
The second mode is reducing the intestine,  and tying the sac with
a single or double ligature.   It has also been proposed, to open the
sac, and close the umbilical aperture by pins or stitches ;  but this
has  no advantage  over the double ligature.  Sometimes,  a very
great portion of the intestines  is found protruded at birth, into the
sheath of the cord.  This may be complicated with an imperfect or
transparent state of part of the abdominal parietes; but whether it
be or not, the child generally dies within forty-eight hours. The ab-
domen is too small to receive back the intestine quickly; and even
although it could be reduced, the child, if we  may judge from ex-

  * Vide Observations on this subject, by Dumas and Allan, in the Recueil Period.
Tom. III. p. 46. and 123. and a case in point by Duret, in Tom. IV.p. 45. 
23
perience, has no great probability of existing.   In one  case, Mr.
Hey found the tumour burst during labour.
  Other species of hernia, are to be treated on general principles.
The bowels are to  be kept open, and  violent exertion avoided.
The propriety of endeavouring to retain the bowel with a bandage,
must depend on our being able to do it effectually; for  if the
bowel protrude, it is pinched by the pad.   This produces pain and
local inflammation, and not unfrequently convulsions.

                      § 4. SPINA  BIFIDA.

  Spina bifida  is an imperfection of the vertebral  canal and the
spinal marrow.   The bone is deficient  generally about the lum-
bar  vertebrae: a tumour is formed externally, which  contains a
fluid, and  the skin is  usually  livid.  The marrow stops,  at the
commencement  of the tumour, but sometimes begins again  below
it;  or small nervous twigs arise from the inner surface  of the sac,
and  pass out to form the nerves of the  inferior part of the body.
This is a fatal disease, and death is generally preceded by inflam-
mation  or gangrene of the  tumour.  In  some instances, the sac is
open at the time of birth.   The tumour may either be or not be
connected with hydrocephalus internus.   If the head be enlarged,
there can be no doubt of the  existence of the latter disease, and
nothing ought to be done to the tumour of the spine.  If the urine
or faeces be expelled involuntarily, or the inferior extremities be
paralytic, or the tumour have burst, or sloughed, no attempt need
be made for  relief.   Where these unfavourable circumstances are
absent,  then two modes of treatment offer for consideration, pal-
liative and radical.   The first  consists in treating the tumour as
a hernia, that is, gradually getting the contents to retire within the
vertebral sheath, if  they are not so great as to produce  compres-
sion of the brain, and then a compress or truss is applied.   Or, if
the tumour be larger than to permit of this,  then a hollow  com-
press, or hollow piece of plaster of Paris, may be applied, at least
in the first instance.   This plan is only  palliative, and never cures
the complaint, but it prevents increase.   The  second exposes the
patient  to great danger from  constitutional irritation, but if it sue- 
24
ceed, the cure is radical.   It consists in repeatedly puncturing the
tumour with a needle, and drawing off the water.   At last, adhe-
sion of the sides of the sac is produced,  and the opening from the
spine  is  closed,  the skin hanging  shrivelled over it, or  becoming
puckered at the  pan.(d)
                             § 5. MARKS.

   Marks and blemishes are very frequent, and may be placed on
any part of the body.   They are of two kinds :  First,  simple dis-
coloured patches, generally of  a red  colour,  and  not  elevated.

  (~dj The very ingenious Astley Cooper, in some observations published in
the Medico-Chirurgical  Transactions, vol. ii.  has  recommended two modes of
treating spina bifida, which in his hands have been attended with very encourag-
ing success;  one mode may be considered as palliative only, the other as radical.
  The first consists  in treating the case as a hernia, and applying a truss to pre-
vent its descent.  This truss, in the first instance, may  consist  of a piece of
plaster of Paris, somewhat hollowed, and that hollow partly filled with a piece
of lint, which is to be placed upon the surface of the tumour; a strip of adhe-
sive plaster is then to be applied, to prevent its changing its situation, and a
roller is to be carried round the waist, to bind the plaster of Paris firmly upon
the back, and to compress the tumour as much as the child will bear; after some
months, a truss may be applied,  similar in form to  that which is sometimes used
for umbilical hernia in children, which must be constantly worn.
  The second mode of treatment, which is to be considered as radical, consists
in producing adhesion of the sides of the sac, so as to close the opening from the
spine, and stop the  disease altogether.  This is done by puncturing the tumour
with a needle, or any very  fine pointed instrument, and thus discharging the
fluid contained in it.  Pressure by means of a roller, &c. is then  to be applied,
and the operation of puncturing is to be repeated as often as the fluid re-collects.
   The first mode Mr. Cooper observes, is attended  with no risk.   The truss
forms an artificial vertebra, when the natural is defective, a buttres which sup-
ports the part, and  prevents the increase of  the  disease; but in this mode of
treatment, the truss is required in future life ; for if discontinued, the tumour
re-appears, and will grow as hernia does, to great  magnitude, but with more
fatal consequences.   On the contrary, the  adhesive mode of cure exposes  the
patient to much constitutional irritation, but leaves him without the apprehen-
sion of the future  retum of the  disease.  It may also be  observed, that this
mode does not prevent the subsequent attempt at the palliative treatment, if
the radical should  not be successful.  Nevertheless, it is confessed, that there
are  many cases of  spina bifida,  which do not  admit of a cure by these, or j>nv
other means.  See  Eclectic Repertory, vol. hi. p. 438, and seq. 
25
 These are not dangerous, but rarely admit of cure.   Second, ele-
 vated  discoloured marks, which are of a purple hue and very vas-
 cular.   These are apt to increase, and at last bursting,  a fatal  he-
 morrhage may take  place.   They may  be seated on the face, or
 in the  lip, eye-lid, &c. or on the  spine, resembling spina  bifida,
 but are more solid or spongy, and the bone is not deficient.  These
 ought  to be extirpated, as soon as they begin in  the smallest degree
 to increase.   Small marks  have occasionally  been removed by
 raising the skin with a blister, and then applying mild escharotics,
 or by  means of caustic*

   * These  congenite deformities have hitherto  been considered as incurable.
 This is  true with regard to many cases;  but there are  others which may un-
 doubtedly  be relieved.  They seem to consist, as has  been  very ingeniously
 suggested by Mr. J. Bell, in an aneurismal enlargement of the vessels of the
 part.  Adopting this suggestion,  the celebrated  Mr. Abernethy has deduced a
 very plausible mode  of treating these affections.   There can  be no doubt, he
 says, " that the repletion, distension, and consequent enlargement of the dilated
 vessels,  depend upon a kind of inflammatory action of the surrounding arteries;
 for if that be wanting, the mark ceases to enlarge, and if  present, it increases in
 size in proportion to the degree  of inflammatory action."   The success of his
 practice is shown by the following cases.
   A child  about two months old was  brought to  St. Bartholomew's Hospital,
 says Mr. Abernethy, with this unnatural enlargement  of vessels, distributed
 every where, beneath the fore-arm, from the wrist to the elbow j in  a short time
 it had swollen to that degree,  that the circumference of the affected fore-arm
 was twice the size of the other, the vessels being large and contorted.
  The skin was of a dusky hue, and had not its natural smoothness of surface.
 The heat of this fore-arm was much greater than that of the corresponding sound
 one.  Pressure forced the blood out of the vessels, and temporarily diminished
 the bulk of the limb, and made it of a paler colour.  The  effect of the following
 treatment, which it appeared  to Mr. Abernethy, right to  institute, was tried.
 First, he was desirous of ascertaining whether a permanent and equable pressure
 would not prevent the  distention, and  consequent enlargement of the turgid
 vessels;  secondly, whether reducing the temperature of the  limb would  not
 diminish the inflammatory action, upon which their repletion seemed to depend.
 These two  intentions admitted of  being readily  accomplished. A many-tailed
 bandage of sticking plaster seemed adequate to effect the first, and wetting the
 limb with water the latter.  These measures were judiciously carried into effect;
 the pressure was first made slightly, and afterwards more forcibly, as the part
seemed  to bear it without inconvenience.  A roller was applied over the plaster
and kept wet, if the limb felt hotter than natural, so as to regulate its tempera*
lure.  The success of these  measures exceeded the  most sanguine expectations.
     Vol. IT.                     4 
26
                •j 6. SWELLING OF THE  SCALP.

   Children may, especially after  tedious labour, be born  with a
circumscribed  swelling on  the  head.   This  seems to  contain  a
fluid, and has so well  defined  hard  edges, that one, who, for the
first time saw a case of it, would suppose that the bone was defi-
cient.   It requires no particular  treatment.   By applying  cloths
dipped in brandy, the effused fluid is soon absorbed.


                 § 7. DISTORTION  OF THE FEET.

   Distortions of  the feet  are not uncommon.   They are  called


The size of the limb gradually diminished, and its temperature became natural
After six months, the bandages were removed, which it was not necessary to
continue any longer.  The limb was in some degree wasted from  pressure and
disease, but it soon gradually re-acquired its natural size.   After  the bandages
bad been left off for a month, the skin was pale, and had a slightly shrivelled
appearance.  The contorted vessels felt like solid chords interposed between it
and the fascia of the fore-arm.
   A child had this unnatural state of the vessels in the orbit of the eye.  They
gradually increased in magnitude, and extended themselves into the upper eye-
lid, so as to keep it permanently closed.  The clustered vessels also projected
out of the orbit, at the upper part, and made the integuments protrude, forming
a tumour as large as a walnut.  Of course the removal of this disease did not
seem practicable.  Pressure to any extent was here  evidently impossible ; but
the abstraction of heat, and consequent diminution of inflammatory action, might
be attempted.  Folded linen, wet with rose  water, saturated with alum, was
bound  on to the projecting part, and  kept constantly damp.  Under this treat-
ment, the disorder as regularly receded as it had before increased.  After about
three months it had gradually sunk within the orbit, and  the child could open
its eye.  Shortly after all medical treatment was discontinued, and no appear-
ance of this unnatural structure remains.
   A third case of a very extensive mark of this description, covering the back
and shoulder appears to have gotten well by the same treatment. It appears
probable, from the foregoing cases, that if the preternatural distention of the
vessels could be prevented,  the blood might coagulate in  them; and  thus this
unnatural contexture of vessels, being rendered impervious, might become ob-
literated.
   Vide Abernethy's Surgical Observations on Injuries of the Head, and on Mis-
cellaneous Subjects.  [Art. on  the treatment  of one species of Naevi Materni.]
page 140, Dobson's Edition. 
27
 vari, when  the  foot  is turned inwards:  valgi, when  outwards.
 These, and similar deviations, are to be cured by pressure, applied
 with proper bandages adapted to the nature of the  case.  They
 must operate constantly, but gradually, and ought to be applied as
 early as possible.  It is a bad case, indeed, which  cannot thus be
 cured by a good mechanic*

                       § 8. TONGUE TIED.

   When the frenum linguae is too short, or attached  far forward,
 the child can neither suck well, nor speak  distinctly.   It is very
 rare in  its occurrence.   I have not seen two children where it was
 really necessary  to perform any operation ;  for in  all the rest the
 child sucked the finger,^) or a good nipple very  readily.  The
 operation consists in dividing, to a sufficient extept, the frenum,
 with a  pair of  blunt pointed  scissors.   If the  artery be impru-
 dendy cut, the hemorrhage is  to be checked by compression or
 cautery.

                    § 9. MALFORMED HEART.

 '  Imperfection or malformation of the heart is a  very  frequent
 occurrence; or the foetal structure may continue long after birth.
 If the imperfection  be great, the symptoms  come on almost im-
 mediately after birth ; but if slight, or consisting merely in a con-
 tinuation of the foetal structure, they may not come on till the child
 begin to walk, or get teeth, or even later.  The child is  dark-co-
 loured,  or the skin has a dirty appearance, the naijs and  lips are
 livid, the breathing is more or less difficult, and he is subject to at-
 tacks of asthma, or a kind of suffocating cough, like  that in peri-
 pneumonia, or hooping-cough ; and whenever this  attacks an  in-
 fant, I augur very ill.  I have no remedy to propose.   Compara-
 tive ease may be obtained, by keeping the child as quiet  as possi-

  * For the anatomy of the club-foot vide Scarpa.
  (ej This is a good test; for, if upon the insertion of the finger into  the
child's mouth it sucks it  readily, division of the fraenum cannot be necessary. 
                              It
 ble, avoiding a loaded stomach, or costive state of the bowels. For
 an account of the different kinds of malformation, I refer to my
 brother's excellent Work on the Diseases of the Heart.

             § 10. SWELLING OF THE BREASTS, &c.

   Children have sometimes a swelling of the breasts after  birth.
 This is chiefly ownig to  a secretion of a milky fluid,  and  much
 injury is often done by attempting to squeeze it out.  Gentle fric-
 tion with warm oil is of  service; but if inflammation  come on
 from rude treatment, a tepid  poultice must be employed.
   Hydrocele generally goes off, by applying compresses  dipt  in
 solution of muriate of ammonia.  A puncture is rarely necessary.
 Phymosis requires astringent lotions.
   Prolapsus ani is to be cured, by keeping the bowels easy, using
 the cold bath, and returning the gut whenever it protrudes.   The
 child should also be prevented from remaining  long at stool.  If
 the  prolapsus prove  obstinate,  injecting a little decoction  of oak
 bark may be proper.
   Serous discharge  from the navel  sometimes  takes place, after
 the separation of the cord; and, in  general, it will be found  to
 arise from a small fungus not larger than  a cherry stone.   This is
 removed by a little powdered alum, or, if that fail, by a little red
 precipitate, or by a ligature.
   Excoriation of the naval is different;  for there is no fungus, but
 rather inflammation  and superficial  ulceration.   It is to be re-
 moved by opening the bowels,  keeping  the  part very clean, and
bathing  it  occasionally with Port wine; after which it is  to be
 dressed with cerussa ointment.  If neglected, or the bowels be not
 attended to, the inflammation may become erysipelatous, and end
 in gangrene.   If this be threatened, gentle laxatives, a good nurse,
 and mild dressings, poultices, or spirituous applications, according
 to their effects, can alone save the child.
   Sometimes a day or two after the cord separates, or at the time
of separation, hemorrhage takes place from the navel.  This may
yield very  readily to compression, or astringents ; but,  neverthe-
less, may also prove obstinate and fatal.   The actual cautery has 
29
been proposed, or nitrate of silver, or cutting at the navel and ap-
plying a  ligature on  the end of the  vein, which is supposed  to
bleed oftener than the arteries.  1 know, from experience, that no
compress can at all times be depended on, except the point of the
finger, and that cannot well  be steadily applied for hours or days
in succession ;  yet, in obstinate cases, I know no safer nor better
plan, the assistant being  relieved at proper intervals, for some time,
both night and  day.  I give this opinion, from finding other means,
apparently more powerful fail.  Strong astringents, or escharotics,
caustic applied so as to form an eschar,  a ligature  carried, by
means of a needle, round  the umbilical aperture, and tied tightly,
the twisted suture made  by crossing two needles, and  working
the whole navel over tightly with thread, have  all failed, and ap-
peared, by propagating  inflammation to the peritoneum, to hasten
death.
   Discharges of blood,  but much more  frequently of mucus  or
muco-purulent  matter, from the vagina, occur in infancy, but still
oftener in childhood, and sometimes  are very protracted; they are
not however hazardous.  The bowels  are to be kept regular, by
the administration of rhubarb and magnesia, and  sometimes small
doses  of calomel.  Tincture of steel is also useful in childhood.
The cold bath should be employed.   The discharge is carefully to
be removed by frequent ablution ; and if these means fail, some
mild  astringent solution is  to be injected frequently into the va-
gina.
   Incontinence of urine, during the night, often depends on a bad
habit,  and is to be treated accordingly.   When it continues long,
the cold bath is proper.
   Scalds and burns are best cured,  by  applying  instantly cloths
wet with strong vinegar.  This is the proper  practice, whatever
part is injured ; but when the face or neck are scalded or burned,
it is of the utmost importance to prevent a mark, and nothing does
so more effectually than the instant application of strong vinegar.
This,  if the injury be slight, prevents the part from blistering,  or
only a very slight vesication takes place.   After  a few hours, the
vinegar may be discontinued, and the part dusted frequently with
cerussa, or we  dress with  cerussa ointment, or anoint the spot with 
30
  this, and then make it dry with cerussa or chalk.   The part is to
  be  washed  at least once a day, to remove any irritating matter
  which might fret it.
    If vesications have formed, they are to be opened with a very
  small puncture, to let out the fluid, and then vinegar is to be ap-
  plied ; or if this give much pain, a thin cloth dipped in oil  may
  be interposed between the tender parts and the vinegar.d/")
    In more extensive and severe burns, oil of turpentine alone, or
  mixed with unguentum  resinosum,  forms the best  dressing for
  some  time,  and then the sore is to  be covered with powdered
  chalk, which is to be continued till it heals.  It represses fungus,
  and  forms an artificial scab.  In all cases pain is to be allayed by
  opiates, and the bowels are to be kept open.
    Ear-ach is a very frequent and  painful disease of children.  It
  is  discovered, if the child be old enough, by his complaining of his
 ear; but if he is too young to do this, it may be suspected, by his
 being seized  with a sudden and severe fit of crying as if he had
 colic, and like it, the  pain seems to remit occasionally.  He does
 not,  however, spur with his feet,  nor is the belly hard, but he is
 restless with  his head, and complains if his ear be touched.  In
 some time he falls asleep, and next day perhaps his cap is stained
 with  matter.  Nothing gives so much relief as heat.   Warm oil
 or  a warm poultice is to be early applied, or the outside of the ear
 b to  be rubbed with warm laudanum.  If a foetid discharge suc-
 ceed this disease,  and the  child be  deaf, the  ear is to be daily
 washed out with milk and water, by means of a syringe.  Small
 blisters may be applied behind the ear,  and the constitution  is to
 be  invigorated.   The bowels in particular are to be kept regular.
 Many children have occasional  discharges of matter from their
 ear's,  upon catching cold, without much pain, and at that time they
 are deaf.  But by keeping the ear warm, and by scrupulous atten-
 tion to cleanliness, the discharge stops, and the hearing returns.

  CfJ A very mikl and useful application in  burns, particularly in those of
children, is a liniment composed of equal parts of mild olive oil and lime water,
well mixed together by agitation ; this may be laid on with a feather, and after-
wards a piece of fine old linen, dipt in the liniment applied to the part, which
:s to be constantly kept moist by means of the feather. 
31
           $ 11. FCBT1D SECRETION FROM THE NOSE.

   The mucous secretion of the nostril is sometimes exceedingly
foetid, so that it is disagreeable to come near the child.   The mu-
cus dries, and comes away in thin pieces.  Astringent injections,
stimulating liniments, and a variety of local applications,  as well
as internal remedies, such as tonics, mercury, &c have been tried.
These have not always, however, a good effect.   At the age of
puberty, the foetor sometimes spontaneously ceases.
   Foetid discharge from the ears generally  is accompanied with a
destruction  of the membrana tympani,  and a  caries of the small
bones.  It is usually attended with deafness, and is very obstinate.
Great attention is to be paid to cleanliness, and to the state of the
constitution.

                      § 12. OPHTHALMIA.

   Infants are subject to inflammation of the eye,  which is  most
frequently  of the kind called purulent ophthalmy.  This begins
with redness of the eyelids, which soon swell .so  much as to pre-
vent their being opened.   Then a copious and constant discharge
of thick yellow matter takes place.   This is found also  spread
over the eye.  If the disease continue, and increase, slough is apt
to take place.   In bad cases, the eye-lids are also turned out, es-
pecially when the child cries.   Both eyes  are generally affected.
This disease is too well marked to be ever mistaken.  The cause
is sometimes obscure, but frequently it is evidently owing to the ap-
plication,  during birth, of leucorrhoeal matter.  The treatment
which I have found most effectual,  and which has always pro-
duced a perfect, although not a rapid  cure, is the application of a
leech to the temple, or root of the nose, and repeating this accord-
ing to the degree of inflammation ; the  administration of  regular
laxatives;  the injection, by means of a small syringe, of tepid milk
and water into the eyes to wash out the matter, and then throwing
in a syringeful of some astringent solution.  This is to be done
three or four times a day.  But what  appears to be of most deci-
ded advantage,  is the application of a small blister to the back o. 
32
the head,(g) to be kept open by savine ointment.  Amongst  the
topical applications,  none  seem to claim a  decided preference.
Solution of  sulphate of zinc, or copper, in the proportion of two,
and afterwards three grains to the ounce, or nitrate of silver,  in the
proportion of one grain to  the ounce, or  muriate of mercury, in
half that  strength, have all been occasionally useful.   The eye-
lashes may  be  anointed every night  with lard, containing a very
little red precipitate, or a little ung. hyd. nit.

            § 13. SPONGOID DISEASE OF  THE EYE.

  Children  are subject to spongoid disease of the eye.   The  ball
becomes slowly diseased, and its structure changed, so that all the
parts are confounded, and the optic nerve becomes black or brown.
The tumour bursts, and a fungus shoots out.  The bones become
carious, the disease spreads to the brain, and the patient dies, af-
ter much suffering.   This has been improperly called cancer.   It
admits of no cure, except by very early extirpation.  Every ope-
ration that I have seen  has been too long delayed, and the patients
have all had a relapse.

                       § 14. SCROFULA.

  Scrofula is dependent on a peculiarity of constitution, derived at
conception.   This is often marked by a very fine skin,  light hair,
large blue eyes, with  dull sclerotica, and  delicate complexion.
Others have the skin darker, or of a  rough dirty appearance, the
hair is dark, the upper  lip tumid, and the countenance sallow,  and
sometimes swelled.   When the  scrofulous  constitution is  not
strongly marked, the person may pass through life without any in-
convenience.  But when it exists in force, different parts of the
body are apt, without  any  evident cause, to have their action  de-
ranged ;  their structure is changed, and then inflammation slowly
takes place.  The glands are most frequently affected,  but  the

  CsJ Blisters are sometimes applied in these cases to the temples, and even oc
casionally over the closed eyelids, with the best effects. 
                              33

joints or viscera may also suffer.  I  do not think it necessary to
describe these changes, especially as 1 have  elsewhere entered
pretty fully into  this subject.  I shall merely state what ought to
be' done as a preventive, or as a cure.  In the  first view, we ad-
vise whatever can strengthen the system, and preserve the differ-
ent parts vigorous and in health ; such as the cold, or when  that
produces languor or chillness, the warm bath daily, gentle friction
over the whole surface for half an hour every evening, regular ex-
ercise in the open air, great attention to cleanliness, an open state
of the bowels, and good nourishing diet, with a  small proportion of
wine.   Animal food is much recommended.  Sea-bathing is use-
ful.   When the glands are  swelled, or other parts are enlarged,  it
is of service to rub them gently  with oil for half an hour three times
a-day, and apply, in the intervals,  pledgits  dipped in  a solution of
cerussa acetata.   Hemlock poultices are also useful.   Electricity
or galvanism are sometimes of  service.  When the tumours tend
to suppurate, that process should be assisted by poultices, blisters,
and electricity.   The  abscess  should be  early opened,  provided
there is an appearance, from the  skin  becoming very thin,  that
there will be an  extensive destruction of the surface, and conse-
quently a  large sore produced.   If  this be not the case it is per-
haps better to let  the  abscess  burst itself:  gentle stimulants are
then proper.   The constitution is to be treated  in the  way already
mentioned.   Muriate of lime, or of  barytes, cicuta,  bark, and a
great yariety of medicines, have been advised,  but I  do  not know
that any one can be depended  on.   Medicines  are chiefly useful
to obviate existing symptoms, such as costiveness, &c.
   Diseases of the  joints and spine are to be managed chiefly by
issues.

                        § 15. RICKETS.

  The disease called  rickets is characterized by flabby  muscles,
relaxed skin, sallow or bloated  countenance, debility, listjessness,
and softening of the bones, so that the long bones become more or
less curved, and their extremities apparently enlarged.   The an-
kles and wrists swell first,  then the  back changes its shape,  and
    Vol. II.                  5 
                            34
the breast protrudes.    The bones of the pelvis approach more
nearly together, the sacrum  coming forward.   The  head is  in-
creased in size, and the belly becomes large and hard.  The ap-
petite and digestion are impaired, the bowels are bound, or foetid
stools are passed.   The pulse is weak  and  frequent.  The teeth
are late of appearing, and are not good.  The  mind  is often pre-
maturely advanced.  This disease  may  prove  fatal, by ending
with water of the head, convulsions,  or  hectic fever;  but it is
often  cured spontaneously,  or  with  assistance.  It usually  at-
tacks betwixt the  sixth month and second year, but  it has been
known to affect even the foetus in utero.  It is to be  treated by a
course of laxatives, to bring the  bowels into a  proper state,  the
cold bath, regular exercise, nourishing diet  of animal food, gene-
ral friction  over  the  body, chalybeate medicines, and  warm
clothing.
                        CHAP. 111.

                        Of Dentition.

  The  formation  of the teeth  is  begun long  before  the fcetu:--
leaves the uterus.  It is carried on  slowly,  and is not completed
for several months  after birth.  The parts concerned in this pro-
cess, are the jaw, the gum, and the soft rudiments of the tooth  it-
self.  The jaw, at  first, has only a channel  running along its sur-
face ; but this afterwards is  divided by transverse  septa, into se-
parate cells, which are the origins of the alveolar processes.   In
each of these is lodged a membranous bag, containing a soft pulp.
The bags consist of two lamina, both of which,  especially the
outer one, are vascular.  These sacs adhere firmly to the gum, so
that if it be pulled  away from the jaw, the sacs come with it: the
pulp is also vascular, and assumes nearly the size and shape which
the body of the tooth is to have when ossification has commenced. 
35
 The tooth consists of two parts, bony mater, and cortex striatus,
 or crystallized enamel, covering the bone.   The bone is formed
 on the1 pulp, which gradually ossifies ; and in the eighth or ninth
 month of the foetal life,  all the pulps have begun to ossify, and at
 birth the shell is considerably advanced.   Soon after this process
 begins, the inner surface of the sac  deposits a  soft  earthy  sub-
 stance, which crystallizes and forms  enamel.   When  ossification
 is advanced so far as  to form the  shell of the  body of the tooth,
 the lower part becomes  contracted, so as to form the  neck; and
 as the shell thickens, the pulp, though diminished in quantity, pro-
 trudes through the neck, forming a kind of stalk or mould for the fang.
 If the tooth is to have two fangs, then a septum is stretched across
 the cavity of the neck, and the pulp protrudes in  two divisions.
 As ossification advances  on the root, the body rises  in the socket,
 and the sac rises with it; but in proportion as the enamel is crys-
 tallized,  the sac becomes less vascular and thinner,  and at last is
 absorbed ; and when the tooth has acquired its proper height, die
 whole membrane is destroyed.   Thus it appears, that the sac  is
 not stretched, and hursts by distention, but is absorbed, and being
 fixed to  the neck of the  tooth, and not to the jaw, it rises with the
 tooth.
   There are only twenty teeth evolved in infancy, ten in each jaw,
 and these are not permanent.   They are shed, to  give  place  to
 others more durable and  more numerous, as the jaws are longer in
 the adult.   The permanent teeth begin to be formed even before
 birth.  Like the fang of  the tooth, they are set off from the  body
 of the temporary tooth.   A small process or sac is sent off back-
 wards.   This is lodged at the back part of the socket, where a lit-
 tle niche is first formed for its reception, and then a distinct socket.
 Hence the temporary and permanent teeth are connected together,
 and this  connexion remains for a considerable time.   In the foetus,
 there are, besides the temporary teeth, the rudiments  of the two
 first permanent grinders, therefore there are twelve  sacs  in  each
jaw.  The sac of the anterior  permanent grinder sends, when the
jaw lengthens, a process  backward, to form the next grinder;  and
 it again,  in course of time, sends off the third grinder.
   Generally, teeth cut the gum about the sixth  or  eighth month 
36
 after birth.  The two middle incisors of the lower jaw first appear,
 and in about a month those of the upper jaw come through.  Then
 the two lateral incisors of the lower jaw, and next those of the up-
 per one, appear.   About the twelfth or fourteenth month, the an-
 terior grinders of the lower, and soon those  of the upper jaw, cut
 the gum.   Between the sixteenth and twentieth month,  the cus-
 pidati appear; and from  that period  to  the thirtieth month, the
 posterior grinders come through; so that the cnild, when about
 two years and a half old, usually has all the  first  set  of teeth.
 These continue till the sixth or seventh year; and as the perma-
 nent teeth are in progress all this time, we find, besides the twenty
 teeth which are  visible,  twenty-eight below the gums.   At this
 time, the two first permanent grinders appear at the back part  of
 the jaw, and the middle incisors of the lower jaw loosen  and drop
 out; and by degrees, all the  milk teeth give place to others which
 are larger, stronger, and better adapted to the increased size of the
jaws.   In this curious process, which strongly displays the wisdom
 of God, we are early  taught  the  perishable  nature  of our frame.
 But it is also a pleasing reflection, that dissolution is succeeded by
 a state of greater perfection.
   Many  children cut their teeth with great ease  and regularity,
 but some suffer considerably.  It is  usual for  the child to have
 some irritation of the mouth  during dentition.   The gums are hot
 and itchy, and somewhat swelled or  full  over the tooth, and the
 anterior edge is not sharp as  formerly, but is rounded, and the  in-
 vesting membrane  unfolded.   The secretion of saliva is increased :
 and the  stomach and  bowels sometimes are rendered  irritable.
 Partly from this cause producing gripes, and partly from pain dart-
 ing through the gum, the child is seized with frequent and sudden
 fits of crying.  The symptoms seldom continue urgent above  ten
 days at a time.   If the child be  very  irritable, and the tooth ad-
 vance fast, or several teeth come forward at the  same time, very
 unpleasant effects may be produced,  such as severe bowel com-
 plaints or fever, or spasmodic cough,  or convulsions ; or  the  skin
 is affected, an eruption appearing on  different  parts, which  is a
 much more trifling effect than any of the former, or the gums  ul-
 cerate, or  sometimes the tongue and mouth become aphthous. 
37
The urine is often scanty, but on the other hand,  it may be too
abundant; and this superabundant discharge is productive of de-
bility.   Costiveness adds to the danger of dentition.   When the
first grinders and cuspidati are cutting, and come forward  quickly,
there is great irritation, for there are then eight teeth making pres-'
sure  on the  gums.  In every pase of  troublesome dentition, we
have three indications to  attend to.  First, to allay local irritation.
Second, to alleviite urgent or symptomatic complaints.  Third, to
support the  strength.
  The first is  accomplished most effectually, by dividing the gum
with a lancet,  completely down to the  tooth, if it be considerably
advanced.   Even when  it is not  so far advanced,  as to be near
the surface, the division of the gum gives temporary relief.  Gum-
sticks act something in the  same  fugacious manner; by  enabling
the child to  press, or rub the gum a little, he obtains a short relief.
All children  instinctively  thrust their fingers into the mouth, and
this may be  permitted ; nor is there any risk of a bad habit  being
induced.  This is as useful as the gum-stick, and safer; for a hard
gum-stick is apt to be thrust into the eye, or the gum may  be bruis-
ed by it.  A crust of bread is often used, but part of it may break
off, and choke the child.   An ivory ring is safer.
  Second, We allay general irritation,  or  fretfulness,  by keeping
the bowels open,  and exposing  the child freely to cool air.  The
cold bath is  also useful  every morning, and at  night, the  child,  if
hot,  may be sponged with cold water.   If this  do not prove effec-
tual, we may rub  the spine  and belly  with laudanum, which acts
as an opiate without inducing the injurious effects on the stomach,
which  the internal exhibition too often causes."  Fever, if high, 4s
to be abated by the use of the tepid bath, morning and evening;
the bowels  are to  be kept open  ; if the  child be  plethoric and
drowsy, besides giving a smart purge, either  one or two leeches
ought to be  applied to the forehead ;  and if the determination to
the head continue, the  scalp should be shaved, and a small blister
laid  upon the occiput.  Diarrhoea, if considerable, and detrimental,
is to be abated by those means which will hereafter be pointed out,
and  especially, if it be  severe, by mild  opiate clysters; at the same
time that we, if the stools are very bad, give small doses of calomel 
                             38
at proper intervals, to bring the bowels into a better state,   lhe
greatest number of  children who die during dentition,  perish in
consequence of obstinate or neglected diarrhoea.  Sickness, loath-
ing at food, and ill-smelled breath, require a gentle emetic. Spas-
modic and convulsive affections require the warm bath, purgatives,
antispasmodics, and the general treatment which will hereafter be
pointed out.  Opiates are not to be  given without much  circum-
spection.  They are always  hurtful, when there 4s much vascular
excitement, and are only admissible  when this is absent; and there
is, at the same time, great irritation of the nervous  system, or
pain of the bowels.  They ought in general to be combined either
with oil of anise or assafoetida,  or with both.   It is not easy to de-
scribe  the different  symptoms which occur  during dentition, or
may be connected with it; but one general rule must be laid down,
namely, to treat them, as we would do in any other circumstance,
with the additional practice of cutting the gum. Delicate and slen-
der children suffer chiefly from bowel complaints, and spasmodic
affections; stout or plethoric children are  more apt to suffer from
acute fever, with determination to the head.
   Third, We support the strength directly by the breast milk, ar-
row root, beef tea, or, if necessary, by clysters of veal soup, or
calves'-feet jelly; and indirectly by restraining immoderate evacua-
tions.   If the child have been recently weaned, it is often of ser-
vice to apply him again to the breast.
                         CHAP. IV.

                   Of Cutaneous Diseases.

  In the following short account of cutaneous diseases, I may per-
haps have  committed  some errors respecting the names of erup-
tions *  Nosological writers, unfortunately, do not agree in giving
uniformly the same name to the same disease, and perhaps it is not

  * I adopt the terms of Dr. Willan, not that I think his arrangement free from 
39
always easy to give a perfect definition by words alone.  I have,
however, endeavoured to detail faithfully, so far as I am able, the
symptoms characterizing the eruptions which I describe, by what-
ever name they may be called, and also to  point out the mode of
treatment  commonly employed,

                § 1.  STROPHULUS 1NTERTINCTUS.

  The  first eruption which I shall mention, is well known under
the name of red gum, and is described very accurately  by Dr.
Willan, as his first variety of strophulus, a papulous eruption.  The
strophulus intertinctus, or red gum, consists of a number of acu-
minated elevations of the skin, of a vivid red colour, not, in gene-
ral confluent, and sometimes even pretty distant from each other.
The papulae are surrounded with a red base.   This redness is of-
ten the most evident part of the eruption,  in  very young infants,
and the disease  much resembles measles.  It covers a great part of
the trunk, and keeps almost entirely off the  face.  In the centre of
the spot, we may observe a very minute elevation,  or papula, with
a clear top.  There is no fever, nor has the child catarrhal symp-
toms. <  The eruption comes out irregularly, and is  either more du-
rable,  more fugacious, or more partial, than the measles.  On the
feet, the papulae are still more distinct.  The papulae of strophulus
are often  intermixed with small red specks, not elevated above the
surface.  They are hard, and contain  no fluid, or only a very
small quantity  under the cuticle  at the apex, giving it. a glistening
appearance; but they seldom discharge any fluid, and scarcely ever
form pus.  This eruption appears generally on the face and supe-
rior extremities, but sometimes it spreads universally over the body.
On the back part of the hand, the papulae occasionally contain a
little yellow serum, but this is presently absorbed, and the cuticle

many objections, but because it is now best known. If any  of my readers have
leisure and opportunity to form a more correct division, I  would suggest the
practical utility of introducing, as part of their improvement, an arrangement of
those mixed diseases, where there is a resemblance  in character to two different
genera; and the nomenclature, in this case, might be similar to that of the che-
mist exhibiting the composition. 
40
 is thrown off like a slight scurf.  This variety of strophulus gene-
 rally appears during the first ten weeks* of life, and is not produc-
 tive of any  inconvenience.  It seems to be  connected with the
 state of the stomach and bowels; and any uneasiness the child may
 suffer, during the continuance of the eruption, or  previous to its
 appearance,  seems referable to this source.   The particular con-
 nexion existing betwixt the chylopoetic viscera and  the surface, I
 do not pretend here to explain or investigate.  I hold the fact to
 be established, and  from no circumstances more  decidedly than
 these, viz. that, in adults, certain kinds of food do, with individuals,
 invariably produce an eruption on the surface; and that, in chil-
 dren, where all the system is much more irritable, trifling irritation
of the bowels is followed by cutaneous eruption, whilst the sudden
 disappearance of the eruption,  on the other hand, is succeeded ge-
nerally by sickness and visceral disorder.   I am inclined  to  attri-
bute to a cause within the abdomen, all those  eruptions which are
not produced by the  direct application  of irritations to the surface.f
The affection at present under consideration requires no particular
remedies.  It is sufficient to avoid the application of cold, which
might  suddenly repel  the eruption; and  filth or other irritation,
which might  increase it, or superinduce another affection.  Should
the stomach  or bowels be affected, or the child be oppressed,  a
very gentle laxative  may be occasionally administered; or should
the bowels be  too open,  and the child flabby, a little  tincture of
myrrh, or myrrh with lime water, may be given, and, if necessary,
an opiate.  If the eruption be repelled, and the child thereafter be
disordered, the warm bath, with a gentle  laxative,  will be proper.

                  §  2. STROPHULUS ALBIDUS.

   The next variety is the strophulus albidus, which is an eruption
consisting of minute whitish specks, hard, and a  little elevated;
  • Sometimes  a few spots of this kind may be observed on the forehead of chil-
dren, at the time of birth.
  t Dr. Underwood is inclined to think, that when children are subject to re-
peated eruptions, the milk does not agree  with the stomach, and ought to be
changed.  I am very much disposed to adopt  his opinion.—See also Turner on
the Diseases of the Skin, p. 69. 
41
sometimes, but not always, surrounded by a very slight and narrow
border of redness.   No fluid is contained in the papula?, which ap-
pear chiefly on the face, neck, and breast.   This generally is met
with after the period at which children are subject to red gum; it
remains rather longer, but requires  no peculiarity  of treatment.
Sometimes children, at a more advanced period, have this kind of
eruption on the neck, which is exposed to the sun in warm wea-
ther.   It has sometimes been mistaken for the itch.

                § 3. STROPHULUS CONFERTUS.

   The strophulus confertus is  a very frequent affection during
dentition, but seldom appears before that period, though it may
occur after it.  It consists of- papulae, often set extremely close to-
gether, forming patches, varying from the size of a sixpence to  a
dollar.  Such, at least, is  the appearance on the face and arms, to
which parts it is often confined, especially to the  former. But it
sometimes appears on the trunk, and there the  papulae are larger,
flatter, and surrounded with more inflammation, than those on the
face or arms, looking at  a distance like measles.   This eruption
not only varies a little, according as it appears on  the trunk or ex-
tremities,  but also according to the age of the child.  For after
the  seventh month, we find, especially on  the arms,  the papulae
pretty large ; and  either red,  with  scarcely any appearance of
lymph at  the top, or of a  light yellow  colour, but the  base  sur-
rounded with a halo  or inflamed rim.  These  papulae may, on
some  parts, be  distinct  from each  other, whilst elsewhere  they
form clusters so close, that the redness surrounding one, communi-
cates with that of another,  forming  altogether a large  inflamed
ground-work.  In some cases, the red patch is the prominent fea-
ture ; it may be as large  as a dollar, with innumerable little  dots
within it, like pin heads, with clear or watery-looking tops, or lar-
ger red hard papulae.  This eruption is sometimes precejdgji^by
 sickness, and, in certain circumstances, has been mistaken for mea-
 sles ;  but it is attended with little or no fever, and has none of the
 catarrhal symptoms met with in measles.   By  not attending to the
 characters of the two diseases,  they may be confounded; and not
      Vol.  II.                  6 
43
unfrequently, when young children take measles, the strophulus
confertus appears on the arms, previous to the proper eruption, or
even along with it.   Dr. Underwood says,  this eruption does not
dry off like measles ; but as Dr. Willan remarks, it often does ter-
minate with a slight exfoliation of the cuticle.  A variety of this
disease appears like red patches on different parts of the  body,
particularly on the arm, and often coming out in succession. They
are as large as a split pea, and- a very little raised toward the cen-
tre.  By near examination, several small papulae may be discov-
ered, which are something  like vesicular points.  In three or fpur
days, the patches become yellowish or brown, and covered with
small  scurf.  This  is  denominated  by  Dr.  Willan, strophulus
volaticus, and is said not to  be very common, but 1 think it is fre-
quently met with.  It is seldom  necessary  to give any  medicine
for this complaint.  If, however, it be troublesome, it is usual to
prescribe gentle laxatives, and testacious powders.   Some advise
emetics, and the use of the  bark ; but neither, I believe,  are in
general necessary.

                 § 4. STROPHULUS CANDIDUS.

   Strophulus candidus consists of papula  having  a smooth shi-
ning surface, which appears of a paler colour than the rest of the
skin, and the base is not surrounded by any inflammation. It is de-
scribed by  Dr. Underwood as resembling itch,  but is neither
red nor itchy.  It generally either attends dentition,  or  succeeds
some acute disease of children, and is justly considered as a very
favourable symptom.   It is most frequently met with on the trunk
of the body, the arms, or forehead. In a few days the papulae die
away.  No particular treatment is necessary.          i

                        § 5. LICHEN.

   A different eruption from any of the foregoing is the lichen,  a
term restricted  by Dr. Willan, in his elaborate work, to  a papu-
lous eruption, chiefly affecting adults.   It  may, however, appear
also in children; and I have seen it succeed some of their febrile 
43
 diseases, as for instance, measles.   It consists of numerous distinct
 papulae, some of which are pale at  the top, but very slightly red
 at the base ;  these are generally small like pin heads.   Others are
 larger and flatter, and more inflamed, but have  always at first a
 clear apex, and do not end in ulceration, but die away in slight
 scurf.   Sometimes on the body, there are small shining or silvery-
 looking patches, from exfoliation of the cuticle;  or the skin may
 peel off more extensively, as if  it had been blistered.  They re-
 semble  often the papula? in strophulus, but seldom form in clusters,
and have  not, in general, any diffused redness connecting one pa-
 pulae to another.  There is, however, sometimes  about  the joints
 or fore-arm, a considerable degree  of red  efflorescence, covered
 with scurf.   This eruption may  be  produced by exposure to heat,
 and by  drinking cold  water when  heated, or other less obvious
 causes.   It is frequent in warm weather, and  a  species  of this  is
 known under the name of prickly heat.   It is preceded often by
 febrile symptoms, and the eruption  itself may last for more than a
 fortnight,  but in a few cases it goes of in a day or two.   These pa-
 pulae, at  different stages, bear  a resemblance to two  very  dis-
 similar diseases, the itch and the measles;  but it is  not pustular
 like the itch, neither does it ulcerate ; it is not very itchy,  and  if
 scratched  so as to take off the top, it does not yield matter, but a
 little bloody scab is formed.  It  differs from the measles in being
 papulous,  and having on the spots, before they form slight scurf, a
 clear-looking top ;  it in general lasts longer than the measles,  and
is not attended with catarrh.  Further, it is  sometimes  accompa-
 nied with  a broad scurfy efflorescence about the  elbow joint,  or
 other flexures.  A suitable dose of calomel is the best remedy, or,
sjiould the patient be oppressed,  an  emetic and saline mixture may
be given.,  When there is no febrile affection, it will be sufficient
to keep the surface clean, by means of the tepid bath.   A variety
of this, named  lichen urticatus, by  Dr. Bateman, resembles the
bites of bugs, and appears in irregular wheals, which are very itchy.
This ends in small elevated papulae, and the whole body may be
 successively covered with these papulae.  The itching is intolerable
 at night.  It seems to be relieved by small doses of sulphur, and. 
                             44

if the child be weak, by tonics and chalybeates.   No external ap-
plication is useful, if we, perhaps, except tepid oil.

                      § 6. INTERTRIGO.

  Intertrigo is a kind of erythematic affection of those parts of the
body where the skin forms folds or sinuosities, as, for instance, the
joints of fat children.   It  also is very common about the nates and
inside of the  thighs, in consequence of the  urine fretting these
parts.   The  inflamed  surface  Ought to be  washed occasionally
with tepid  milk and water, and the child should never be allowed
to remain wet, but ought to be bathed,  and gently dried after mak-
ing water, when the thighs are affected.  Afterward the  parts are
to be dusted with some cool  powder, such as tutty, white lead, le-   ^
vigated flowers of zinc, he.   It is not  usual  for intertrigo to end
in gangrene or suppuration, but sometimes the form of the disease
changes, and the cellular  substance inflames; either of these ter-
minations may then take  place, and will require the usual treat-
ment.

                 § 7. ANOMALOUS ERUPTIONS.

  During dentition, or in consequence  of affections of the bowels,
different anomalous eruptions may appear, which are not distinctly
referable to any well defined species.  Sometimes we find  upon
the arm, one, two, or three inflamed  portions of the skin, some-
thing like  small pox, but rather larger,  with a  small acuminated
speck  of lymph beneath the cuticle at the  apex, or sometimes the
top is flattened and shrivelled.  Occasionally, a greater number of
pustules appear on  the body, pretty large, hard, and inflamed round
the base, with a white  top.   This kind of  eruption  is not attended
with fever, and is neither painful nor itchy;  it goes off in  a few
 days without any medicine.
   Infants, who are supplied with deficient nourishment, or bad
 milk, are subject to troublesome and successive crops of ecthymata,
 or  inflamed  pustules,  which slowly suppurate,  burst,  and  form
 brown scabs which presently fall off.   They affect every  part of 
45
the body, and sometimes are combined with one or  two pustules,
so large and hard that they may be called  boils.  The colour  is
dependent on the constitution, the  exhausted having the pustules
lurid or purple;  the stronger having them of a more  arterial co-
lour.  This eruption, named ecthyma infantile, requires a more nu-
tritive diet, or a new nurse, with all the usual means for invigorat-
ing the system ; amongst which, 1 particularly mention, attention to
the bowels, and removal to the country.   If necessary, the pus-
tules may be defended with a  little mild salve.  Young people,
after much exertion, or from gross  feeding,  are sometimes affected
with a similar eruption  of pustules.   Laxatives, with vegetable
tonics, cure  this.   Ripe fruits, particularly  gooseberries, are pro-
per.
   Another kind of eruption attacks children above two years of age,
suddenly covering the greater part of the  body.  It consists of red ,
elevated spots, at first sight something like  a kind of pock.  The
spots are  distinct, and  most numerous  on the thighs and legs.
They are of a dark red colour, pretty flat, with a smooth  flatted
vesicular-looking top, which does not  burst, nor discharge matter,
but gradually dries and desquamates.   The eruption  is scarcely
painful or itchy,  and is not attended with fever.  It  may continue
for four or five weeks, and is sometimes combined with lichen, or
other cutaneous diseases.   The bowels should be kept open, and
some advise antimonial wine to be  given, with a little tincture of
cantharides.
   There is a small and very itchy pustule, which  begins  with a
black spot on the skin,  and contains a sebaceous fluid, which can
be squeezed out in a worm-like shape;  such pustules are not un-
common in youth, and have been called crinones.  They are cured
by applying ung.  hyd.  nit.  and washing with almond  emulsion,
containing a little muriate of mercury, or with soap  and water.
   Boils have been divided  into the furunculus, or acute boil, and
the phyma,  which is more tedious.  They are hard, usually flat,
with an extended base,  and of  a purple colour.  They are  some-
times solitary, and very large, but  occasionally they are scattered
in considerable numbers over the body.   They generally proceed
from a bad state of health, and, in place of requiring, as some sup- 
46
 pose, an abstemious diet,  they demand  more nourishment, but it
 must be easily digested, and the bowels should be attended to.  A
 bread and milk poultice is to be applied to the  boil,  until the top
 open, which it does by a kind of sloughing.   Scarcely any matter
 comes out, but a kind  of ash-coloured, or yellow core, is gradually
 thrown out, after which  the part heals.  Resinous ointment is the
 best application during this process.  Those large indolent boils,
 or small abscesses, which  succeed small pox, or other debilitating
 diseases, require hot poultices, and then, when  they burst, or arc
 opened, and the pus they contain evacuated, stimulating dressings,
 with moderate pressure, are proper.   Good diet, and even wine,
 may be required.

              § 8. POMPHOLYX AND PEMPHIGUS.

  Authors describe some  other eruptive diseases, which may be
noticed here with propriety : one of these, called pompholyx, con-
sists of a number of vesications of different sizes, appearing on the
belly, ribs, and thighs, and containing a sharp lymph; they  may
appear during teething, or in bowel complaints, and  continue for
several days.  These  vesications are not uncommon in very warm
weather; and 1 think boys are  more  subject to them, especially
about the ankles, if they do not wear stockings. Lory considers
this disease as a  kind  of erysipelatous affection, produced by the
heat of the sun.   It requires no medicine, but the lymph ought to
be let out by a small puncture.
  A similar appearance, generally attended with fever, and some-
times with  aphthae, is  more serious.   The vesicles, at first small,
presently become pretty large and oval,  and their contents turgid.
They appear soon after birth, generally in emaciated infants, affect
both the trunk and extremities, are surrounded with a livid inflam-
ed halo, and when broken, are succeeded by spreading ulceration.
Notwithstanding  bark  and cordials, the  fever and  irritation gene-
rally prove  fatal in about a week; and only those children  are
saved, who  are  previously possessed of  a tolerable degree  of
strength.  This may be  mistaken for  syphilis.  Some have con- 
47
sidered it as pampholyx, under a different modification ; others at
a distinct disease, under the name of pemphigus.

                    § 9.  MILIARY ERUPTION.

  Sennertus describes, under the name of sudamina, an eruption
like millet seed, fretting the skin, and affecting children  about the
neck, arms, &c.  Plenk  defines it in  the following terms.   Sunt
vesicula granis milii magnitudine et similis, subito  absque febre
erumpentes.  The.child  should be  bathed occasionally in tepid
water.  This eruption often takes place in hot weather.   A similar
eruption, attended with fever, is also met with, which I find very
well described by Dr. Willan, in his reports on the diseases of
London,  under the  name of acute  miliaris.  It does not affect
infants, but children old enough to take active  amusement.   It
begins with a  febrile attack, attended with head-ach and pain in
the back.  The tongue is of a  dark red colour  at the edges, with
the papillae prominent as in scarlatina;  the rest of the  tongue is
covered with white fur.  The pulse is small and frequent.  Pre-
sently the patient complains of heat and pricking at the surface, is
sick at  stomach, and perspires freely through the  night.  At a
period varying from the third to the sixth  day of the fever, an erup-
tion appears, of small pustules like millet seeds.  These are of a
red colour, but contain at the top a white lymph, and are either
diffused over the body, or  collected in patches on different parts,
especially the back and breast; they may  alternately appear  and
disappear, and though the same pustule does not continue long, it
may be speedily replaced. They  may  sometimes  be combined
with small red efflorescences, and generally vesicles appear on  the
tongue and fauces, ending in aphthous ulceration.   The complaint
often  terminates in about ten days, but it may be prolonged even
to twenty. It is frequently the consequence of being overheated,
or drinking cold water in  that state.  It requires first  of all an
emetic, and then a purgative.   During the course of the disease,
the patient should be kept moderately  cool, and use acidulated
drinks freely. 
48
                        § 10. PRURIGO.

   Itchy  eruptions are frequently met with on children, but these
are not always the true itch, nor  the consequence  of infection.
The prurigo mitis, described and  delineated very accurately by
Dr. Willan, is a disease often met with in spring.   It appears with-
out any  previous indisposition, and consists of soft smooth eleva-
tions of the skin, or papulae, differing in colour very little from the
surrounding integuments.  When they do become red, it is in con-
sequence of friction.   If the top be  rubbed off, a clear lymph oozes
out,  which forms a thin scab, of a dark, or almost black colour.
The eruption is itchy, especially  on going to bed, and if scratched,
it may become pustular and contagious, which it is not in its early
stage.  At first, it  may be removed, by washing frequently with
tepid  water and a little soap or lemon juice ; but if neglected,  it
requires  the application of sulphur.
  A variety of this disease consists of minute red acuminated pa-
pulae, with a  very small vesicle at the top, terminating not in sup-
puration, but yielding, when scratched, only a little clear  serum.
Sulphureous  preparations give relief, and time, with attention to
cleanliness, confirms  the  cure.    Sometimes very  little itching
attends this eruption, and it disappears by using  the tepid bath.

                         § 11.  SCABIES.

   The scabies,* or true itGh, is contagious,  and consists of small
pustules, which have a hard hot base, with a watery-looking top.
They are attended  with an intolerable desire to scratch; in conse-
quence of which, the  tops are  rubbed off the pustules, and scabs
come to  be formed, partly by blood, and partly by a kind of mat-
ter, furnished by the little ulcers.   But if  the pustules be not dis-
turbed, but removed  by proper  applications, they end in a slight
desquamation of the cuticle, " qua. vix furfur aliquod  ostendat."

  * Children, in consequence of handling mangy dogs or kittens, are sometimes
affected with an obstinate itchy eruption, which is not scabies, but may be cured
by the remedies used for the Itch*. 
                              49

 The itch first appears betwixt the fingers, on the wrists and hams,
 but, if neglected, it may spread over the whole trunk and extre-
 mities, and, in consequence of the continual irritation, impairs the
 health,  nay, some children die in consequence of it.  In neglect-
 ed cases, the inflammation surrounding one pustule spreads to ano-
 ther, and the part becomes, universally red, with pustules or scab9,
 according to  circumstances, scattered over it.  This is often the
 case on the back of the hand,  and fore-part of the feet   Some-
 times small boils, and phymata, appear in the course of the disease,
 on the thighs or body, or about the face.   The itch has not always
 the same appearance, being, in some cases, more vesicular, or more
 pustular, than in others.  Four different varieties have, accord-
 ingly, been admitted by Dr. Willan:—1st, The scabies papuliformis,
 where the eruption  looks like papulae, but really consists of small
 pointed inflamed vesicles, which are very  itchy; when these break,
 they are succeeded  by scabs.  This variety is apt to be confound-
 ed with lichen, or prurigo, when there has been much scratching,
 but these are more  distinctly papular.  2d, The scabies lympha-
 tica, or  eruption of  vesicles of considerable size, without inflamed
 base, but  extremely itchy.   These may heal by  scabbing, but
 eften suppurate, and form small ulcerated  blotches, and, in the
 same part,  we have all the intermediate steps from vesicle to small
 ©pen ulcer.  The disease with which this is most apt to be con-
 founded, is eczema.  3d, Scabies purulenta, or eruption of distinct
 prominent pustules,  about the size of a split pea, filled with yellow
 matter, and having a slightly inflamed base.   These ulcerate in a
 day or two, and become then more painful.  They are not unlike
 small pox,  but are very itchy.   The scabs are thin and hard, of a
yellow colour, or inclining to brown.   They are surrounded by a
 diffused redness of the skin, which often has a puckered appear-
 ance, as if  drawn toward the scab.  These pustules are most fre-
quently  situated between the thumb and fore-finger, or about the
wrist.  4th, Scabies cachectica combines the character of the for-
mer varieties, which it exhibits at the same time, in different por-
tions of the  skin.  It originates in  cachectic  children,  without
 infection.
  The cure may generally be accomplished, by frequent ablution,
     Vol. If..                  7 
                              50
and rubbing the parts affected with sulphur-vivum ointment,* which,
in obstinate cases, may be rendered more effectual by the addition
of powdered  hellebore, or sulphate  of zinc or sal-ammoniac.   Ro-
senstein says, that the hands are very  soon cleared, by washing
them with a  strong decoction of juniper-berries; and that  when
the eruption  is great,  as for instance, on  the feet, he has  applied
cabbage leaves with advantage.   They cause at first a great dis-
charge, but the parts  heal afterwards.
   Sometimes the friction excites an eruption different from itch,
and kept up by the remedies intended to cure it.  M- Burdin re-
marks respecting this, that it consists of small round pustules, " qui
" se remplissent quelquefois de serosite, et dont la cicatrice  laisse
" le plus souvent une tache d'un rouge brun, le prurit qu'elle oc-
" casione est aussi moins fort que celui de la gale."   In inveterate
cases, the use of Harrowgate water is of great benefit, or a sulphur
vapour bath has been used.   In order to avoid the smell of sulphur,
other applicationsf have been employed,  such as sulphuric acid,
or nitrous acid combined with hog's lard, ointment of nitrated mer-
cury,  camphorated  ointment,  hellebore, or corrosive sublimate,
mixed with hog's lard, &c.   These often fail, and even when they
do remove the eruption, the cure is said frequently not to  be per-
manent.  Ointment containing white precipitate is sometimes use-
ful, particularly in the pustular  variety.   Itch  may   be combined
with other diseases, such as herpes, syphilis, &ic.  in  which  cases,
it js more obstinate than usual, and may sometimes require the
use of mercury.

                         § 12. HERPES.

   Herpes is  a vesicular  disease, of short duration.  It consists of
irregular clusters of small vesicles,  which arise in close approxima-

  * Dr. Joseph Clarke considers it as dangerous to use  sulphur ointment with
infants, lest the eruption be suddenly repelled : and advises rather to boil apiece
of stick brimstone in water, in order to make a bath.
  f M. Becu advises the following lotion : Take of tobacco leaves two pounds,
sal-ammoniac one ounce, ammonia two ounces, water three Paris pints.  Infuse
for two hours. 
51
tion to each other, from an inflamed surface, and the inflammation
surrounds also the base of the cluster,  to a small breadth.  The
vesicles, which appear rapidly, contain  a pellucid fluid that pre-
sently becomes turbid, oozes gently from the opening or declining
vesicle, and forms a yellowish or brownish scab  on  the part.  Iu
some instances,  however, the vesicle ends  in ulceration, and  the
discharge is copious and thin.   If the scab be prematurely forced
off, the surface below is found raw and glossy.   In slight cases,
the sensation is that of heat or itching, but,  when more  extensive
or severe, the neighbouring parts are pained, and the eruption it-
self is preceded by some degree of fever.
  A great number of  affections have been  comprehended under
this name,  many  of them of very  opposite  characters,  and even
our most correct nosologists, who have excluded those  which  are
not vesicular, have admitted,  as  species,  mere varieties of  the
complaint.  The  first species, for example, of Alibert, is  the
herpes furfuraceus, or dartre furfuracee, which is a scaly, and  not
a vesicular disease, and his other species are also very doubtful in
their nature.   The subdivisions, again, of  Willan and  Bateman,
are often founded on mere situation, or arrangement of vesicles.
The herpes phlyctaenodes, the first species of Willan, and the sixth
of Alibert, is, perhaps, the only one  to  be  admitted, all the rest
being varieties.   This, when well  marked,  is preceded by slight
febrile irritation, for about three days.   Then irregular clusters of
vesicles appear, which become opaque in the course of a day.  By
the fourth day, the surrounding inflammation becomes less,  and
the areola fades, whilst the vesicles themselves begin to scab, and
continue in this state till the end of the week, or  sometimes a day
or two longer, when the scabs  fall, and leave the surface below
red.   The size of the vesicles varies.  When small, they are call-
ed miliary, and, in this case, the clusters often spread over a con-
siderable part of the body;  and, as they do not  appear  all at  the
same time, the disease may last altogether a fortnight.   When the
vesicles are larger, their clusters are not in  general numerous, and
sometimes are solitary.   Within a day  or two after the appearance
of the  vesicles, the slight general indisposition goes off.
   A slight degree of this complaint is common about the  lips, or 
52
 chin, or side of the nose, and is  called by  Dr.  Willan,  herpes
 labialis.  It is  not, in general, attended with  indisposition,  but,
 popularly, is attributed to cold, which is  then said to strike  out.
   In some cases, however, there is a degree of fever, and succes-
 sive crops come out, round the mouth, accompanied with swelling,
 hardness, and sensation of heat in  the lips.*  In such cases, the
 fauces may be  affected with  a similar vesication.
   Another variety has  vesicles, arranged in the form of a ring,
 the central portion being only very slightly inflamed.  As the ve-
 sicles break and scab, and the scabs fall off, this central portion
 throws  off the cuticle in form of fine exfoliations, like bran.    The
 size of the ring also often increases, by the successive formation of
 concentric circles of vescicles.  Successive circles of this kind ap-
 pear on different parts, particularly on the face, and  upper  extre-
 mities,  so that the disorder is prolonged, for, perhaps three weeks.
 This is most frequently  met with in children who are also subject
 to the last variety, the herpes labialis.  It forms one  kind of ring-
 worm, of which there are different varieties.  It is named  by Dr.
 Willan, herpes  circinatus, and is supposed to be infectious ; but I
 believe that every variety of herpes may be   inoculated.   The
 herpes  circinatus of Alibert,  is a furfuraceous disease.
   Another variety, also met  with in youth, but not often  in  infan-
 cy,  is popularly named the  shingles, or, by Dr. Willan,  herpes
 zoster, and, by  Alibert,  herpes zonaeformis.   It is  preceded, for
 two or three days, by febrile symptoms, accompanied with  shoot-
 ing pain about the stomach, or lower part of the chest, and  smart-
ing- sensation  in the  skin.   This  sensation  is  perceived  chiefly
 about the trunk, and is soon attended with an eruption of irregular
 patches, of a red colour,  a little distant from each other, and on
■which small  vesicles soon arise.   These run the usual course of
 herpes.  Successive clusters appear, so disposed as  ultimately to
 encircle nearly the part where they are situated, travelling,  for in-
 stance,  like a zone round the waist, but seldom  completing the cir-

  * Under this name Alibert describes an eruption, to which young girls, near
puberty, are subject, and which he makes a variety of his pustular herpes. At
 a little distance it looks like measles, but is smaller, and pustular 
53
cle.   Alibert has selected, as a specimen of this, in his  superb
plates, the disease passing round the thigh.   I do not consider it
as necessary here to describe any other varieties.
   With regard to the causes of herpes, we are much in  the dark.
It sometimes appears to follow exposure  to cold, or to be conse-
quent to violent exertion; but, perhaps, it most frequently is con-
nected with some particular condition of the abdominal  viscera.
   The treatment of this disease is very  simple, consisting in  the
administration of gentle purgatives, restricting the patient from in-
digestible diet, and from the use of stimulants.   Nothing can, with
much advantage, at  first be applied to the  vesicles, unless it be
with  a view to prevent their abrasion.   If any thing more active
be employed, it should only be some weak astringent wash.  When
crusts are formed, the  application of a little  ung. hyd. nit. appears
to accelerate their fall, to  heal sooner the surface below,  and to
abate heat and itching.   When there is much glutinous  discharge,
either this or some other milder ointment is  useful, to prevent  the
linen from adhering to the part.*

   * There are two diseases, which are apt to affect females, even when young,
but which I have never seen in infancy.  They are of the mixed character, and
cannot strictly be included here.  The herpes orbicularis of Alibert appears often
on the cheek, as a very  superficial excoriation, ending in broad thin scabs, or
scales. The part is red, and a little itchy, and the scabs are generally thickest
at the circumference.  It is a very obstinate disease, and lasts  for  years.   The
herpes crustaceus of Alibert appears like a crust of dried honey, on an erysipe-
latous ground.  It arises from a raw surface, with thickened margins of a purple
colour.  There is often swelling, and induration of the  neighbouring cellular
matter, and the crust itself is elevated.  On  the  cheek it forms a thick
yellowish crust; on the wing of the nose it is still thicker, so that this has been
called stalactiform herpes.  These diseases are often connecied with  a scrofu-
lous habit, and, after remaining long stationary, sometimes end  in corroding ul-
ceration, caries,  and fatal exhaustion, or hectic.  Mercury may do harm, but
never does good, except in a few cases, where very  small doses of muriate of
mercury have  altered the habit.  Sarsaparilla, with arsenic, is  more useful,
and aperient waters, containing sulphur, are  also  employed.  Hemlock has not
maintained its reputation.  Only mild local applications should be prescribed. 
54
                       § 13. ICTHYOSIS.

  Children are sometimes affected  with ichthyosis, a  disease in
which the skin becomes dry, and covered with scales,  resembling
in their distribution, and sometimes in their appearance, those of a
fish.  This disease may come on at any  period  of life ;  it may
even be connate, but this is very rare.  It is proper to employ the
warm bath, and, during its use, to pick  off the  scales.   Their re-
generation is to be prevented by friction, and repeated  bathing.
Sometimes children have this disease conjoined with boils.

                       § 14. PSORIASIS.

  The scaly tetter, dry itch, or psoriasis of Dr. Willan, consists of
red rough spots, which are very  soon covered with  a laminated
scale, sometimes as thick as paper, but generally thin, and very
like a bit of the dried scale of a herring.  They  are irregular in
their shape and size, occasionally not larger than a coriander-seed;
sometimes as large as the nail of the little finger, resembling a dried
fish scale pasted on the skin; and frequently they are interspersed
with shining silvery-looking portions of the surface.  These scales
are formed by the  exudation of a whitish matter, which is very
glutinous, and, as Sylvius observes, stiffens the linen, when it hap-
pens to exude in sufficient quantity.  In adults, some portions of
the surface yield so much fluid, that the parts are  quite moist, and
scales do not form.  The spots on  children generally begin like
papulae, of small size, and vesicular at the top.   These end some-
times in scurf, oftener in thin scales, as has  been described.  On
the back of  the hand, the vesicles  are sometimes pretty large;
whilst, in the palm of the hand, the eruption is rather pustular, and
ends in broad thin rough scabs of a yellow colour.  In the early
stage, it is sometimes combined with strophulus.  The parts are
itchy, but when they  are scratched, matter does not come out by
the removal of the scales, but a little blood flows. This eruption
often begins on the face or neck, and spreads to the body and ex-
tremities.  It is very obstinate, and sometimes destroys the  nails. 
55
  When it has continued for some time, the skin,  especially  abqpt
  the hands and feet, is found to be  universally  red, with  dark-
  coloured scales interspersed.  The skin  looks as if it  had been
  scalded, and partly covered with thin scabs, or scales, in different
  degrees of adhesion; and, in some  cases, the whole of the  ex-
  tremities, und  even the body itself, or the  head, become red, par-
  tially excoriated,  and covered partly with scales and scurf, and
  partly with scabs, which are yellow, and pretty  thickly set, 'often
  loose, and easily detached.   Sometimes, on different parts of the
  body, particularly on the arms or legs, there  are many soft red
  indolent bumps, more especially if the child have been seized with
  this disease  soon after the  small-pox or chicken-pox.  The ap-
  pearance on the  head is nearly  the same as  in pityriasis, but in
  general it wants the white scurf.  It is rare not to find  the  head
  affected in this disease.   Different species of this have been enu-
  merated  by Dr. WiUan, which however may perhaps be  viewed
  rather as varieties.   I do not mean to notice all those here, as it
  does  not consist with the  object of this work.-  1st.  Pso'riasis
  guttata is not uncommon in  children, and often  spreads rapidly
  over the  whole body, and even the face.  It is occasionally  pre-
  ceded by slight constitutional disturbance.   The eruption consists
 of small distinct scaly patches, of an  irregular, shape, resembling
 lepra in appearance, but differing from it in wanting  the elevated
 border, inflamed margin, distinct  circular or oval shape, and, in
 the surface below,  being  more irritable.   2d. Psoriasis' diffusa
 forming in large patches, which sometimes become confluent and
 possess the  general character  of  the  disease.   A more  severe
 variety is termed inveterata, and others are named from their situa-
 tion.
   Excoriation sometimes also takes place about the anus, with a
 slightly elevated state  of the  surface ; in consequence of which
 and the disease  of the skin taking place  soon after birth, I have
 been consulted  respecting  children given out to nurse, who were
 apprehended to  have syphilis.  Dr. Willan remarks the syphilitic
appearance of this disease, but justly observes, that all other marks
are absent.   The syphilitic form of-this disease is  attended with
hoarseness, and  the  patches are of a livid colour, with a slighter 
56
 degree of scaliness, and  the margin  is sometimes higher than the
 centre.
   It is not, like the itch, very contagious, nor is it easy to say what
 occasions it; but we know, that inattention to cleanliness is favour-
 able to  its production.   The  application of preparations of sul-
 phur, and ointment of nitrated mercury, with the use of the tepid
 bath, especially  made  with  sea-water, daily, will often cure this
 disease; but, in obstinate cases, we must give some sudorific, such
 as antimonials, or  decoction of sarsaparilla, or have recourse  to
 the Harrowgate or Moffat waters, which have great efficacy. They
 should be used both  externally and internally.   The  internal use
 of arsenic, as in lepra, will also be proper, if the other means fail.
 Solutions of soap, or of alkali,  or of sulphuret of potash, form very
 useful baths.   Decoctions of hellebore, or solution of muriate of
 ammonia, or of oxymuriate of mercury, are also proper, as exter-
nal applications.   The application of cloths wet with butter-milk,
 or of a poultice of butter-milk and oat-meal, sometimes facilitates
the cure, and indeed when there is much irritation, only the mildest
 application can be borne.  Mercury  internally  does more  harm
 than good; when it is beneficial,  it has been in the  form of oxy-
 muriate, in such  small doses as have  kept the bowels regular.  In
 adult females, whose chylopoetic viscera  had been defective in
 action, I have known the disease  very severe and obstinate,  and,
though mitigated by laxatives,  seem to be removed onlyby time.

                       § 15. PITYRIASIS.

   The  pityriasis is a disease known  commonly under  the name
 of the dandriff.  It consists of a dry, scurfy, and scaly eruption on
the head, amongst the hairs.    Near the forehead,  the skin is
covered  with  a  thick white scurf, which  can  be removed  in a
powdery form; farther back,  larger  scales are  formed.  This is
cured by cutting  and shaving the hair, and brushing the  head daily
with a hard  brush, washing  it with soap and water,  and applying
ung. hyd. nit.  If neglected, ulcers may form, and the  disease be
converted into the one next to be described.  Pityriasis is some-
times infectious.   A variety of it appears like small red marks on 
57
 the scalp.   The circumference extends, and continues red, whilst
 the centre becomes pale and scaly.  It is accompanied with falling
 off of the hair.
   This disease is not confined to the head, but affects other parts.
 That variety named pityriasis rubra by Dr. Willan, is of frequent
 occurrence at all ages, although said to be most apt to  appear at
 advanced age.  It begins with a redness of variable size, and in-
 definite shape.  It may be  small,  or extensively diffused; the
colour becomes deeper and the surface rough; then it  puts  on  a
 mealy appearance, from  commencing exfoliation of the cuticle.
 As this advances, the part is,  in  a great measure, covered  with
small branny scales, which, as they in  different spots fall off, dis-
cover the skin red below.  Repeated  exfoliation may  then take
place, and when the surface is extensive, the patient's bed is often
found covered with  small  scales.   The  affected parts  are itchy,
and sometimes feel stiff.   The skin is dry, and no perspiration can
be in general naturally or artificially procured.
   There is a great analogy between all  scaly diseases, and often
the same person exhibits, in different parts, different species.  In
some, the disorder has more the appearance  of psoriasis,  and  in
others, there are distinct patches of the  nature of lepra.   Some-
times it is not very easy to say, whether the disorder belongs most
to one species, or to another.  It is this pityriasis, and its modifi-
cations, which are most frequently misnamed herpes farinosus; an
application also given to modifications  of psoriasis, and  indeed  to
every superficial scaly disease.
  The treatment consists in regulating  the bowels, avoiding a sa-
line or irritating diet, the frequent use of the tepid bath, gentle
friction with ung. hyd. nit.; the exhibition of some  diaphoretics,
such as decoction  of sarsaparilla,  with a little  antimonial wine,
arsenic, sulphureous waters, internally  and externally.

                         § 16. LEPRA.

  Lepra is a very  common disease amongst children, and is vul-
garly  known under the name of scurvy  spots; others commonly
call it ring-worm,  or herpes farinosus.  The species to which
    Vol,  II.                  8 
53
 young people are subject, is  the  lepra alphoides.   This appears
 in the form of small patches,  of nearly a circular form, seldom ex-
 ceeding half an inch, but more frequently less.  The  spots are
 first red, but soon become covered with small shining scales.  The
 margin is a little elevated, and usually somewhat inflamed.  These
 patches are generally confined to  the extremities, particularly the
 inferior, but they may also appear on the trunk.  This,  however,
 is oftener the case with some  §f the other scaly  diseases already
 noticed.  They also,  much more  rarely, become confluent.  The
 causes of this obstinate disease are obscure.   The treatment which
 I have found most useful, consists in the constant application of
 ung. hyd. nit., frequent ablution, or rather the tepid bath, mild diet,
 the use of tonic laxatives and the administration of arsenic.  A
 dram of the common  solution may be  added, to four ounces of
 water, and of this mixture a tea-spoonful may be  given  in  a  glass
 of water, three times a-day, to a child three years old.   It should
 always be given after  eating, and not when the stomach is  empty.
 If it produce  sickness or griping, the quantity is to be diminished,
 after suspending it altogether for a short time.  If  it produce  no
 such effect, the dose may be gradually increased  to  double the
 quantity prescribed, watching, however, the state of the stomach.
 It requires sometimes to be continued for several weeks, before a
 salutary effect be produced, but we must not abandon it too has-
 tily on that account.


                       § 17. IMPETIGO.

  Impetigo is a term differently applied by writers, and hence un-
 certain in its  meaning.  Some confine  it to a pustular, and others
 extend it to a vesicular, or herpetic eruption.   It appears in  clus-
 ters of  small pustules, which are rather flat, filled with  yellow
 matter, somewhat  irregular in their shape,  and  inflamed at  their
 margin.  These are set pretty close to  each other,  and the whole
group seems a very little higher than the surrounding skin.  They
are itchy,  and pungent, and soon break, discharging much ichor.
The surface has a raw glossy appearance.  Then the part becomes
covered with  scabs of a  greenish yellow colour,  and, after some 
                               59

 weeks, the surface below healing, they fall off,  and discover it to
 be red and scabrous, and easily fretted, so that the discharge and
 scabbing may be again renewed.   The healing process  generally
 begins in the centre of the patch,  and occasionally, as it heals,
 these concentric and enlarging circles of pustules, successively ap-
 pear as in ring-worm, and  this variety has been called impetigin-
 ous ring-worm.  The pustules are often mixed with distinct vesi-
 cles, filled with transparent fluid, which presently becomes  dark,
 or even bloody, and then crusts form, which are rough, of a yellow
 colour, inclining to brown.   There is a good deal of surrounding
 redness, and radiation of the skin.  The vesicles are generally, in
 this case, the chief portion  of the eruption, and are more  distant
 or scattered than the pustules.  This variety is oftenest met with
 on the hand, and about the  knuckles  and  fingers.  This bears  a
 resemblance to the scabies purulenta, but  the pustules are smaller,
 and more  clustered, and  it is not  infectious : the discharge is
 greater, and the skin rougher and redder.   This variety is more fre-
 quent with children, whilst they are seldom affected with the other
 kinds.  It has been divided into the impetigo figurata, and sparsa;
 the former, however, differing only from the latter in the  pustules
 being clustered, whereas, in the sparsa, they are scattered distantly,
 and especially over the inferior extremities.  Other varieties have
been enumerated, but do not fall to be noticed here, as they rarely
occur in childhood, such as the erysipelatous, beginning like rose,
and then in place of blisters forming, an eruption of psydraceous
pustules  appears;  the scabida,  where the whole limb becomes
eased in a crust; the rodens, which is a malignant and spreading
sore.   The best internal remedy is sulphur:  if that fail, mild  dia-
phoretics  and sarsaparilla may be given.   Topical  stimulants do
harm ; mild applications, such as sulphur ointment, or cerussa oint-
ment are better.  In very irritable cases, ablution with tepid water,
and smearing  the  parts with cream,  or fresh oil, is more useful.
In the scabby state, sulphureous waters, as  a lotion, and also taken
internally, are useful.  When  cured,  the cold bath prevents a re-
lapse. 
60
                       § 18. PORRIGO.

  Porrigo, or tinea, is a collection of achores, or  pustules, con-
taining a yellowish-coloured fluid, something like honey, and end-
ing sometimes in the  production of a raw and secreting surface,
but oftener in the formation of scabs, which are generally white or
yellow, but sometimes darker, from an admixture of blood.  The
pustules begin on the face or head, and have their chief seat some-
times in the one, sometimes in the other of  these parts, or occa-
sionally both are pretty equally affected.   The  pustules there are
pretty large, and have a red  margin.  They are not in general
painful, but are itchy,  especially at night.  The matter discharged
is often abundant, and sometimes so  irritating, that the  absorbent
glands about the lower jaw or neck swell, and suppurate. Glands
on distant parts of the body, or on the mesentery, are sometimes,
in unhealty subjects, enlarged, as a concomitant symptom.  Over
the body there  are also many pustules, which  are smaller than
those on the head.   They have a red  base, and lymphatic  top,
and are  itchy.   Presently the straw-coloured  fluid they contain
exudes, and forms flat ragged crusts, of a bloody,  or dirty-brown
colour.  The proportion is, however, not always the same between
cuticular redness and incrustation ; for often, especially about the
back of the neck, the whole surface is of  a  dark-red colour, with
only  small loose scabs, scattered pretty  thickly over it.   In other
instances it is  intermixed,  in  various parts,  with furfuraceous
patches,  and  with  papulous eruption,  like porrigo.   When the
scabs fall off, the skin below  is left red, but no scar  remains, un-
less  in very bad cases, where  deep ulceration has taken  place.
Very extensive  excoriation, yielding much  secretion, and having
an alarming  appearance,  leaves no permanent  mark, or cicatrix.
This disease is infectious, and is generally,  if not  always, depen-
dent on a scrofulous constitution.
   This  disease has been divided into  many species, but no ar-
rangement, that I  have seen, is  free from objection ; and I have
no wish to add  to  the number, but will describe what I have met
with, under the  names employed by  Dr. Willan. 
61
  Neither tlie names nor the descriptions of different writers agree,
and many seem to form distinct species of cases, which, from des-
cription,  appear to have no dissimilitude.  Alibert and Gallot say,
that nine-tenths of cases are tinea favosa,  most of the other tenth,
tinea granulata, and that the remainder consists of rarer species,
including the tinea  muciflua, which is a mere variety of Dr. Wil-
lan's porrigo favosa.
  1st.  Porrigo larvalis, so named on account of the crusts cover-
ing the  face like a  mask.  It  is also known  under the name of
crusta lactea, or milk blotch, ignis  sylvestris, or volaticus.   The
tinea muciflua of  Alibert may be considered as synonimous, both
with this and with  the last species  of Willan, the porrigo  favosa,
which  is a mere  variety, differing  in nothing  except in the pus-
tules being  a little longer.   It usually begins  on  the  brow  and
cheeks, by an eruption of clusters  of small  achores, from an in-
flamed or red surface ; or of larger  and rather sparser mellicerous-
looking pustules, called favi, and in that case constituting the por-
rigo favosa of Willan.  The pustules spread on the face, and amongst
the hair, over a great part perhaps of the scalp, or they may be
more confined round the margin of the scalp, and about the ears.
Numerous pustules are also often scattered over the body and ex-
tremities, but these are seldom so large as those on the head. The
pustules, which are itchy, soon break, and  the viscid  fluid they
eontain hardens into a crust, sometimes thin,  sometimes  pretty
thick, but generally yellowish, if not tinged with blood.   When
the scabs are rubbed off, or drop, the surface below is red or pur-
ple, but not chopped, and many places are found covered still with
little fragments of crust.   In other  cases  the discharge is so pro-
fuse, that time is not allowed for scabbing, but the whole surface,
except the upper margin, or one  or two small patches of c*hist, is
raw and  excoriated, and the discharge  falls in large drops.  In a
few instances, where there  is greater irritation, or the part  has
been deeply and hastily scratched, little cup-like ulcers form; and,
except in such spots, no cicatrix is  ever left by this disease.  Even
in those  cases, the health does not  suffer, farther, than  from want
of rest, and  fretting from the itchiness.  When the urine acquires
a peculiar smell, like that of cats, the disease is supposed to be on 
6%
 the wane.  This eruption, if it do not depend on, is at least very
 prevalent in scrofulous habits.  It has been attributed to the rich-
 ness of the milk, but it is just as frequent in those who are sparingly
 fed.  It seems to be more  connected  with indigestion, Or bad
 state of the bowels, and  also is often associated with, if not excited
 by, the irritation of teething.
   In the treatment of the milder varieties of this complaint, it is
 sufficient  to  give regularly some  gentle  laxative, as rhubarb and
 magnesia, interposing occasionally gentle doses of calomel, or dif-
 ferent preparations of sulphur may be given for the same  purpose.
 The diet is to be attended to, and if the child be plethoric, barley
 meal, as  being less nourishing than  some  other grains, may be
 given as food ; a decoction of the viola tricolor, has been advised
 by Strack and  Stoll, but I do not  know that any internal medicine
 is useful, farther than as  required by the bowels.   Soda or potash,
 in such doses as keep the bowels open,  are  useful.   As for bark
 and other tonics, it is difficult to get them administered, and I have
 seen little cause to have confidence in  them.  The same may be
said of  cicuta.   Local applications in slight cases are not demand-
 ed ; but when  they are, on  account of the  number of the crusts,
and the itching, preparations of sulphur and mercury  are proper.
 The sulphur ointment,  or sulphur with oil of bays,  or charcoal
 ointment,* or ung. hyd.  nit.  may  be applied three times  a-day ;
 and the red portions which are  not defended by crusts,  may  be
washed with lime-water, or  water in which quick-lime and  sul-
phur has been boiled, or a weak solution of muriate  of mercury,
 or solution of acetate of lead.   When there are few scabs, but
 much excoriation,  and,  indeed, wherever there is an irritable sur-
face, mild applications must  be employed along with laxatives.
The salve I have found most useful in such states, is ung. cerussa?,
 whilst the parts have been also  bathed with a very weak solution
  * Powdered charcoal, mixed with as much lard as makes it into a salve or paste,
 has at least the effect of destroying the bad smell. Some use it, in tbeproportion of
 only afifth part of charcoal, and Alibert prefers that made of pitcoal. Others mix it
 with sulphur, both Capuron and Gardien join in testimony to its advantage; but
 I fear I must say of it as of other applications, that it cannot be certainly depend-
 ed on.  An opposite prescription, namely, a salve made with manganese, instead
 of charcoal, has been advised, but I am less disposed to trust to it. 
63
  of muriate  of mercury, in emulsion  of almonds.   Some have
  proposed to establish a counter-irritation elsewhere, by a small
  blister or issue, but this is not always safe, in such a state of the
  skin.
    2d.  Porrigo furfurans is  more  frequently met  with in women
  than in children.   It  is confined to the scalp,  and  the pustules
  are small, contain little fluid, and soon form  thin  scales, so that
  the disease very much  resembles pityriasis, but differs from it
  in its origin, and also in the occasional re-appearance of the pus-
  tules, with moisture.   The hair becomes thinner and more  brittle.
  The treatment consists in  shaving the head, and removing  the
  scabs or scales by ablution with  a sponge, and soap  and  water.
 Then,  if the skin be tender, or irritable, cerussa ointment may be
  applied, or lard mixed with a fourth part of its weight of cocculus
 Indicus, or of charcoal.  If less tender, some stimulating applica-
 tion may be made, as, for instance, ung. hyd. nit.  or decoction of
 hellebore, which has been recommended by Dr. Heberden.
   3d. Porrigo lupinosa, or the tinea granulata, and tinea favosa of
 Alibert, is  a tedious and obstinate form of the  disease.   It is
 chiefly confined to the  scalp, but  occasionally small patches ap-
 pear on the extremities.  On the head many  separate clusters of
 achores form, and produce  crusts or scabs,  about the size of a
 sixpence.   Those are more elevated at the margin than  the cen-
 tre, which is depressed and  powdery  in its appearance.   The
 colour is dirty white, unless when tinged  with blood, and the ap-
 pearance like dried mortar:  The smell has been compared to ran-
 cid butter.   These  patches are not confluent, but the intervening
 skin is furfuraceous,  or scabby, and if neglected, almost an entire
 encrustation may cover the head.   It is  named from a supposed
 resemblance to the seeds of lupines.
   It is necessary to have the hair removed, which it has been pro-
posed to effect, in this and all the other species of the disease, by
applying a pitch plaster to the  scalp, and  then forcibly tearing  it
off, that it might pull out the hair.  This  barbarous practice is now
abandoned.   Depilatories, as quick-lime, have also been propo-
sed ;  but it is always practicable,  by softening the  scabs, and re-
peated clipping and shaving, to get the hair removed.   Both for 
64
 this purpose, and also to expose the diseased surface, it is necessa-
 ry to apply saponaceous lotions, poultices, and mild ointment, to
 soften and loosen the scabs; afterwards the surface, is to be frequently
 anointed with an ointment consisting of oil of bays, sulphur vivum,
 and camphor, or axunge  with hyd. precip. alb., or ung. hyd. nit.,
 or ointment containing hellebore.   Dr. Underwood recommends
 the Iotio saponacea,  or decoction of tobacco, but this is danger-
 ous, if the skin be abraded.   Mr.  Barlow advises  the  following
 lotion : R. kali  sulph. 3iii., sap. alb. ^iss., aq. calcis ^vii ss., spt.
 vini 3 ii., M.   An oiled cap has been advised in porrigo, to retain
 the applications, and  keep the parts warm, but I qnestion if it be
 of utility.
   4th. Porrigo  scutulata, or  ring-worm of the scalp, seldom oc-
 curs before the age of three or four years;  but when it does take
 place,  often  continues not only for many months, but in varying
 degrees, for  years.   It begins with distinct clusters of very small
 itchy yellow  achores, which  break  and form thin scabs, covering
 the original patch, which is somewhat of a circular  shape.   The
 base of each little achor is red.  The clusters  are thickest at the
 margin, and the pustules  fewest  toward  the centre,  where 4the
 scabs are thinnest  and drop off first.   When the scabs or  scurfs
 fall off, the skin is found to be red and  shining, and very speedi-
 ly red  pustules appear, with a more extended  margin, whilst the
 centre  becomes first a little redder, and then more scurfy.   The
 hair, at the affected part,  becomes lighter in colour, and more
 woolly, thinner,  and presently at the central part falls quite off.
Many of these rings form over the scalp, so that we  have at last,
at different parts, numerous patches which are bald,  or thinly co-
vered with hair, and exhibiting the  disease in all its steps; some
bare and shining, sprinkled with scurf; others, with the exterior
circle of yellow achores, and inflamed margins ; others, in a state
of crust or scab, and so long  as the surface  retains any unnatural
appearance, we  may be sure that  the disease is still to return.
Similar appearances are observed on other  parts of the body, or
there may be modification of  herpes or lepra.
   This disease may appear without any evident cause, but  most 
65
 frequently it  occurs from infection, by using the same comb, Or
 towel, or cap, with one Who has already the disease.
   In this, as in the other species, it is necessary to keep the head
 shaved ; but this is to be done with as little irritation  as possible.
 Various applications have been proposed, but when there is much
 tenderness, we  must begin with the mildest, or perhaps be satis-
 fied with frequent ablution, or the  use of very weak solution of
 muriate of mercury in emulsion of almonds, or cerussa ointment,
 or charcoal ointment.   When there is little inflammation or ten-
 derness, and we have the dry  scurfy or scaly state most prominent,
 we must use more stimulating applications, and these are  always
 necessary sooner  or later.  They  must  be varied according to
 their effects, and so  must their strength.   The mildest, perhaps,
 is the manganese ointment, already  noticed in a note.   More acrid
 are prepared from muriate of  mercury, acetate  of copper, cantha-
 rides, tobacco, capsicum, hellebore, arsenic, gunpowder,  nitrous
 acid, alum, &c.   Dr. Hamilton strongly advises the  ointment of
 Banyer* alone, or diluted with lard-.  Some have employed undi-
 luted muriatic or sulphuric acid, or  strong solution of common salt.
 All of these, or other stimulating applications, have  succeeded;
 but not unless prudently employed, the strength never being greater
 than the part could bear.   In  too many other cases,  as  Capuron
 observes, when speaking of irritants,  after having more or less
 " martyrisee la tete," they have failed.  The disease at last wears
 itself out.

                  § 19. SCABS FROM VERMIN.

  The bloody scabs which are formed on different  parts of the
 head, especially in the hollow near the neck, in consequence of ver-
 min, are cured by combing and washing the hair  daily, and rub-
bing some mercurial preparation on  the scabs ; whilst an ointment,
composed of oil of bays and stavesacre, should be rubbed over the
  *  R. cerus. Ibss. litharg. aur. §ii. alum. ust. ^iss. mer. sublim. cor. ana. ^iss.
axungiae lbii. terebinth, venet. Ibss. m. fiat  ung. ad scabiem.
     Vol. II.                  9 
66
scalp among the hair, or the powder of stavesacre may be  dusted
in among the hair.

                § 20. ALOPECIA AND OPHIASIS.

   Children and adults are occasionally affected with baldness with-
out any of the foregoing complaints  being evident.   Celsus terms
this area, which consists of two varieties, the alopecia, where the
baldness occupies irregular portions of the scalp ;  and ophiasis,
where it spreads from the occiput round the head, in a  serpentine
direction.   Usually the patches are nearly circular, and the skin
is quite  bare, shining, and smooth, whilst the  neighbourhood has
the ordinary appearance of the  scalp, and the hair is healthy.
This has been considered as a species of porrigo  by Dr.  Willan,
and is called porrigo decalvans, but there is no proof that it is either
necessarily or frequently preceded by the formation of achores.
The patches increase in size and number, and  at last, perhaps, the
whole head, with the exception of one or two tufts, is bare.   Then,
without any evident cause, the skin assumes a  more natural look,
and hair grows.   The treatment consists in having the head shav-
ed once a-week, and rubbing the surface twice or thrice daily with
some stimulating substance, such as olive oil, with  as much nitrous
or muriatic acids as makes it gendy pungent, but not acrid.   Strong
eamphorated embrocation, or spirits and oil of turpentine, may be
used, or some other essential oils, or tincture of  cantharides, or
blisters, or solution of nitrate of silver, so strong  as to irritate  a
little.

                 § 21. PURPURA OR PETECHIiE.

   Purpura, or petechia? sine  febre, is a  disease  not uncommon
 with children, particularly those who live in  confined houses,  or
 are fed on poor or improper diet.  It consists of an eruption  of
 small purple spots, which are circular, not at all elevated,  seldom
 larger than the diameter of a coriander seed,  more  frequently  of
 the size of the head of a pin.   They are scattered over the whole
 body, and even over the hairy scalp.  They come out suddenly, 
tr<
 without any  fever or apparent indisposition,  and go off slowly.
 They are not in general attended with foul tongue, spongy gums,
 or foetid breath, and the faeces do not become unnatural, but they
 sometimes are so before the disease takes place, and the belly may
 be very tumid, but these are not  essential symptoms.   By good
 diet, the use of acids, and removal to the  country, together with
 moderate exercise in the open air, this disease is easily removed ;
 or sometimes  it goes off without any particular change being made
 in the mode of treatment.  I have never seen this disease affect chil-
 dren till after they were weaned.   This eruption is sometimes in-
 termixed with hard papulae, forming a disease described separately,
under the name of lichen lividus, by Dr. Willan.   These continue
 for a  considerable time, and end by slight exfoliation of the cuticle,
 but afterwards may be succeeded by a new crop.   No peculiarity
 of treatment is required.  A worse species of this  disease  affects
 children as well as adults, and attacks more slowly.  For a con-
 siderable time before the spots appear, the patient is languid, and
 feels  uneasy at the stomach.  Then red spots, larger than  in the
 former species, appear on the extremities, especially the legs, which
 are  painful before the  eruption comes out.   The  body  is next
 affected, and the spots very soon become livid ; sometimes vibices
 are also observed on the skin.  This disease is attended with fre-
 quent and  daily hemorrhage from the nose,  mouth, alimentary
 canal, or vagina, and sometimes even from  the toes.   This species
 occasionally proves fatal, but it is often cured by the  use of bark,
 wine, acids, good diet,  and country air.   It is, h&wever, frequent-
 ly very tedious.  In worse cases, and in feeble children, the dis-
 ease often begins with livid blotches on the scalp, which presently
 have the skin abraded ;  and then we may find some of them moist,
 and discharging blood or bloody matter; others dry, but widiout
 any scab or a cuticle;  others covered  with a thin  black crust.
 Gangrenous sores form  behind the ears; and the gums, especially
 near the symphysis of the jaws, become foul, and covered  with a
 brown lymph.   An eruption  of petechias  then suddenly appears,
 and the child  generally dies. 
68
               § 22. ERYSIPELAS AND ERYTHEMA.

   Erysipelas*  sometimes affects children and even infants very
soon after birth.f  This disease appears to have been noticed by
Avicenna, under the name of undimiam, or humid erysipelas, and
afterwards  at different times by other writers; but was first accu-
rately described by Drs. Underwood, Garthshore, andBroomfield.
Dr. Underwood conceives, that it rarely makes its attack after the
child  is  two months  old, oftener a few days after  birth.   Dr.
Broomfield, however, saw it in a child much older, and I have met
with the same circumstance. It makes its attack  in general quick-
ly, and the worst kind begins  about the pubis,  and spreads along
the belly and down the thighs.   There is not a great swelling, but
the parts become hard, purple, and often end in mortification; so
that the organs of generation drop off.  This kind very frequently
proves fatal, the peritoneum and intestines partaking of the disease.
It is a variety of  the erysipelas gangraenosum  of Dr. Willan.   A
milder kind, which 1 have met with  much  oftener, begins about
the hands and feet, or not unfrequently the neck or face; and it is
worthy of observation, that  this frequently  ends in suppuration;
and on the neck especially,  a very large collection of matter  may
be formed.
   In the milder kind,  the redness is more  bright, and the heat
greater than in that  which tends to gangrene ; but, if there be
much tumefaction or hardness  of the subjacent cellular substance.
it is difficult to prevent the formation of pus.  The treatment  con-
sists in giving a smart  purgative, and keeping the child cool.  The
heat of the part is to be  abated by the application  of cold water,
which is better and safer than any more  medicated lotions.   The

   * Erysipelas is attended with fever, and the part affected is red and hot, with
soft diffused swelling.  The redness disappears when pressure is made with the
finger, but immediately returns when that is removed.  There is a tendency to
the formation of vesicles, which bursting, form either scabs or troublesome
ulcers.
   f Dr. Underwood says, he once saw a child born of healthy parents, with sub-
livid inflammatory patches, and ichorous vesications, about the belly and thighs ;
but by the use of bark, and especially the mother's milk, it recovered. 
69
usual remedy is flour, which does no good, unless as a medium for
the frequent application of cold.  The prejudice against washing
the skin is quite unfounded.   If suppuration take place,  a bread
and milk poultice is to be applied, and the matter should be early
let out, and the parts gently supported with a proper roller, applied
over mild dressings, in order to prevent the formation  of  sinuses.
If these take place, they must be opened.   The strength  is to be
preserved by means of a good nurse, and giving cordials, as for in-
stance, white wine  whey.
  In the worst kind, or that which tends to mortification,  the co-
lour is, from the first, or, at least, very soon becomes,  darker, or
purple ;  there is less heat, nay, sometimes the skin speedily feels
colder than natural, the subjacent cellular substance is first pretty
hard, and then  becomes more flaccid, without fluctuation, and the
most prominent points become livid or blue.  The constitutional
debility, and the advancement toward  mortification, and spreading
of that state, keep pace with  each other.   It is evident,  that the
local  treatment applicable to the former species would be hurtful
here, unless in  those few cases, where this is preceded  by more
distinct symptoms of increased arterial, action than is usual,  such
as heat.   In these,  cold may, at the outset, be applied cautiously,
but never after the  temperature has become natural, or nearly so.
In general the best  application, from first to  last, is camphorated
spirit of  wine, which was long ago  recommended by the late in-
telligent  Dr. Garthshore.  If sloughs form, and the child still sur-
vive,  a bread and  m\lk poultice, with charcoal, will  be  proper.
Ammonia, given early, in doses of  from five to ten grains every
three hours, has been of service ; but I have  derived more advan-
tage from calomel, in such doses as to act on the bowels, than from
any other medicine.  Green  foetid stools  are  generally  brought
away.  Bark has also been given, but the  precise degree of advan-
tage derived from  this  medicine in infantile diseases, is not yet
fully ascertained.  Still when  it  can be  easily given, and agrees
with the  stomach and bowels, or when it can be administered *md
retained  as a clyster, I am disposed to advise it, and  would em-
ploy it.   I need not add,  that the greatest care must be taken to
support the strength by  suitable  nourishment,  and cordials  pr r 
70
dently exhibited.   The  best of these is wine whey ; opiates are
only useful when there is much irritation, or a diarrhoea.   It is an
error to give them indiscriminately as part of the cordial plan, for
they are of no service except in these two views.   Mineral acids
are rarely, if ever, proper for infants.
   Erythema, according to nosologists,  differs from erysipelas, in
not being attended with the same diffused swelling, nor having the
same tendency to form vesications; neither is it preceded or ac-
companied by any regular fever, though the system may be occa-
sionally disordered during its appearance.  In some cases, the in-
flamed part seems at first to be  rough, as if covered with innume-
rable papulae, but this appearance presently goes off.   The treat-
ment is nearly the same as in erysipelas.  Sometimes small, irre-
gular, erythematic patches, accompanied with oedematous swel-
ling, appear about the joints, eye-lids,  or  different parts  of chil-
dren,* with fretfulness or feverishness.  They in general require
only to be kept clean, by being  bathed with tepid milk and water,
and  dusted with  some  cool absorbent powder,  or bathed  with
Vinegar.   Calomel is of service, and should be given pretty freely.
   After the cow-pox, erythematic patches sometimes appear, not
only on the arm, where the inoculation was performed, but even
on  more distant parts.   This is  most apt to take place after the
vesicle  has arrived at the height,  or is on the decjine.   The in-
flammation sometimes ends, if not in gangrene, at least in a livid
state of the parts,  with fatal debility.   Spirituous applications are
soon necessary.   When the part becomes livid, the strength  must
be carefully supported, and the bowels opened. In the commence-
ment of this affection, saturnine lotions are proper,, and often re-
move the disease.   Calomel is  useful.   Dr. Willan describes this
as a species'of roseola.
   There is a species of erythema, erythema nodosum of Dr. Wil-
lan, in which the patches are raised toward the centre.  This ele-
vation takes place  gradually.  In a few days, hard and painful tu-
mours are formed, which threaten to suppurate, but they presently

  * The erythematic patches produced by the bites of bugs, &c. in those whose
skin is delicate, are distinguished by having a small mark or speck in the middle. 
71
   subside, soften, and end in desquamation.   These are most fre-
   quent on the chin, but they may affect any part of the body. Lax-
   atives are proper.

               § 23. EXCORIATION BEHIND THE EARS.

     Excoriations frequently take place behind the ears, especially
   during dentition.  The  skin  under the lap of the ear is covered
   with small  pustules,  and the inflammation extends from one to
   another.   Sometimes a kind of erythematic inflammation takes
   place without pustules, and ends  in vesications, which discharge
   thin matter.  This complaint is not generally dangerous, but it is
   sometimes  troublesome, and  causes swelling  of the lymphatic
   glands about the jaw and neck.. Occasionally, however, the parts
   become first  livid, and  then gangrenous; and  in  such cases the
   child  generally sinks, even although the sloughs begin to separate.
   In mild cases of sore ears, it is seldom necessary to do more than
   wash  the surface frequently with milk and water, and apply a litde
   lint spread with spermaceti ointment, mixed with the white oxyde
   of mercury.  If the part be very itchy, and not healed by this ap-
   plication,  it may be bathed with  rose water, containing a little
   tincture of opium,  or weak solution of acetate of lead; but  as-
   tringent lotions, or such applications as tend to heal  the surface
   speedily, if it have  been long abraded or  discharging  much, are,
   unless purges be frequently given, justly esteemed  dangerous, and
   apt to excite  disease within the cranium, especially in those who
   are predisposed to convulsions or hydrocephalus.
      If other applications are necessary, the citrine ointment, or lini-
   ments containing acetate of lead, calx of zinc, juice of scrofularia,
   sulphur, charcoal, cerussa, &c. have been employed.  The last of
   these is often the best.
      When the  parts become livid, or threaten to  mortify,  campho-
   rated spirit of wine should be applied with a small brush, and  the
   part dressed with mild salve ; afterwards, when slough has formed,
   the fermenting  poultice is to  be used.   The strength  must  be
i   carefully supported.  The bowels should be kept regular. 
72
                4 21. ULCERATION OF THE GUMS.

    The  gums, about the time  of dentition, or  sometimes when
 the first set of teeth are shedding, become spongy and ulcerated,
 discharging  a  quantity of thin foetid matter.   This at first may
 generally be stopped, by applying a mixture of muriatic acid and
 honey, in such proportions, as  to taste  pretty sour; or the parts
 may be frequently washed  with equal parts of lime-water  and
 tincture of myrrh, or with a solution of sulphate of zinc.
   If neglected, the ulceration becomes either fungous, and is called
 scorbutic ;*  or sometimes of the kind which resembles sloughing
 phagedena, that  is, a foul, foetid, spreading ulcer, destroying the
 gums, and in some cases the jaw-bone  and cheek; so that if the
 child survive, no teeth  are afterwards formed  in that part of the
jaw.   Occasionally, from the very first, this disease assumes  a
 malignant  form,  beginning with  some degree of inflammation of
 the gum, generally where the incisors should appear.  The part
 is not  swelled, but bright, and of a pale red colour, and this ex-
 tends along the gums a considerable way.  This soon ulcerates,
 forming  a  line along the gum,  marked by a white or brownish
slough; whilst exterior to this, the surface is inflamed, and this
inflamed part next ulcerates; so that inflammation precedes ulce-
ration, till  the  mouth and cheeks be  affected and a large foetid
sore formed, which soon injures  the bones. This disease has been
called the  canker.   It is attended with considerable discharge of
saliva, and the breath is very foetid.   Good diet, the  internal use
of acids, and great attention to cleanliness, at the same time that
we use mildly acid or spirituous applications locally, are the most
likely means of cure.
   In some  families many of the children are  subject to a spongy
and ulcerated state of the gums, which thus expose the teeth down
to the jaw, or these become loose.  The gums bleed, and  some-

  * In this case, some have recommended stimulants and astringent  lotions,
others compression.  M. Berthe advises the part to be cut off; and Capdeville  '
proposes actual cautery. 
73
 times hemorrhage takes place from the nose,  and there  are livid
 spots on the skin.   This is best remedied by removal to the coun-
 try, the free use of ripe fruit, and vegetable acids, bark, laxatives,
 and nourishing  diet.  Solution of borax is one of the best local
 applications.

                § 25. EROSION OF THE CHEEK, &c.

   Another corroding disease begins in the cheek itself, or the lip.
 It commences with some degree of swelling,  which is hard, and
 firm, and shining.  It generally begins on the cheek, which becomes
 larger than the other, and the upper lip becomes rigid, swollen, and
 glossy.  On some part of the minified skin, generally on the cheek,
 we observe presently a livid spot, which ulcerates and spreads, but
 laterally and downwards.   Being generally seated near the mouth,
 it soon reaches the gums;  and even the  tongue  partakes or this
 disease, which is of horrible aspect.   We often find a great part of
 the upper or under lip destroyed, perhaps only a flap or portion of
 the prolabium left,  all the rest being eaten away.  The gums are
 foul, the teeth loose, the tongue thickened, partly destroyed, and
 lying so  0lose on other  diseased parts, that we cannot say what is
 tongue or what gum, except by the child moving the tongue ; and
 the mouth itself is filled with saliva.   The ulcer is foul, shows no
 granulations,  but appears covered with a rough irregular coat of
 brown lymph.   The surrounding parts are somewhat  swelled:
 near the ulcer they are hard and red; farther  out on the cheek,
 they are paler, and have more of an oedematous look. These local
 appearances are accompanied with emaciation and fever, and the
 child is either restless, or lies moaning in a drowsy state.  This
 disease often proves fatal; sometimes, indeed, the parts cicatrize,  or
 the patient recovers after an exfoliation of part of the jaw-bone.  This
 ulcer is best managed with stimulants, such as diluted muriatic acid,
 solution of nitrate of silver, camphorated spirit of wine,  tincture  of
 opium, &c. but sometimes it is necessary to give these up for a car-
 rot  or a fermenting poultice.  The bowels are to be kept open,
 the strength supported by milk, soups, and wine ; and acids, with
ripe fruit, given liberally.   Before ulceration takes place, the best
    Vol. II.                 10 
                              74

 application is camphorated spirit of wine, or we employ friction,
 with camphorated liniment.  A course of gentle laxatives is use-
 ful.
   Another disease, destroying the parts, is called  noma, which
 differs from the former, in destroying rather by gangrene than ul-
 ceration.   It attacks chiefly the cheeks and labia pudendi of chil-
 dren, and begins with a livid spot without pain, heat, or swelling,
 or with very little; and is not preceded by fever.   It ends in gan-
 grene, which destroys the part, and the patient often dies in a few
 days.  It is to be treated with saturnine applications, or a ferment-
 ing poultice, whilst opium and wine are given internally,  with or
 without bark, according as the stomach will bear.  The bowels
 must also be excited to action.
  Some children, more especially those of a scrofulous habit, suf-
 fer  much from a fretting and inflammation, which often, at the
 same1 time, affect the  nostrils, upper lip, and labia pudendi.   The
 mons veneris and labia, are tumified, red, and very itchy.  They
 sometimes are covered with  minute blisters,  or little scabs, or
 yield serous discharge.  The internal  parts furnish muco-puru-
 lent matter, and there is pain in voiding the urine.   The child is
 pale, the bowels in bad order, the pulse frequent, the appetite bad.,
 and the sleep  disturbed.
  I  have never found any thing so useful as the  application of
 white lead  ointment, and bathing the parts frequently with  solution
 of sugar of lead, having a small proportion of vinegar added to it.
 The bowels require also to be carefully attended to.
  A more  formidable  affection I have occasionally  found to  suc-
 ceed measles or scarlatina,  but it may likewise occur without any
preceding disease of a formed or specific kind.  The labia,  par-
ticularly within, are inflamed and livid, and vesicated, and  yield as
in the former  case  a  thin muco-purulent discharge; and  there is
great pain in passing the urine.  Very speedily the internal surface
of the labia, the nymphae, and clitoris, are covered with ulcerations,
succeeded by  brown foetid sloughs.  There is, from the first,  lan-
guor, paleness, and  debility, with small, frequent pulse, and de-
 praved action of the bowels.  As the disease advances, the debili-
 ty increases;  sloughing  and ulceration  spread, and the  patient 
75
 gradually sinks.   It is a very fatal disorder.   It is sometimes con-
 joined with the affection of the cheek, already described.   It re-
 quires the use of mild laxatives, sedulous attention to nourishment,
 and the judicious exhibition of wine and laudanum, to allay irrita-
 tion. The parts must be kept very clean, bathed frequently with so-
 lution of acetate of lead, and dressed with salves, containing oxyde
 of lead, or of zinc.   If  the slough be deep, or extensive, the fer-
 menting poultice is proper. The actual cautery has been employed
 on the continent, but never in  this country.   A variety of this dis-
 ease, differing in no essential symptom, is attended with a fever sui
 generis.*

                          § 26. APHTHA'.

   Aphthae are small white  specks  or vesicles,  appearing on the
 tongue,  inside of the cheeks, and the fauces.  They are extreme-
 ly common, and almost every child has at one period or other an
 attack.  This disease appears under two forms.   The mild, in
 which the eruption on  the mouth is slight, and the symptoms com-
 paratively trifling ; and the severe, in which the  local  disease is
 extensive,  and  the constitution  greatly affected.   In the first or
 milder form, a few scattered spots appear on the mouth, as if little
 bits of curds were sticking to  the surface of the tongue, or within
 the lips.   These in a  short time  become  yellowish, and then fall
 off, but may be renewed  for three or four times.   They leave the

  * Mr. Wood describes a  very severe variety of this disease, affecting the ex-
 ternal parts. It is preceded by febrile symptoms, but soon there is pain in mak-
 ing water, and the  parts are found to be inflamed and dark coloured.   In a few
 hours afterwards vesication appears, which ends in ulceration, and the surface
 becomes excessively tender. The fever increases, and along with it the debility.
 The ulceration spreads and becomes deep and foul, but mortification rarely oc-
curs.  It is a fatal disease, but by the use of bark, cordials, and laxatives,  with te-
pid saturnine poultices, and afterwards dressing with mild  salves, several recov-
ered after the end of perhaps three weeks. Purulent discharge from the vagina
is apt to remain for  some time, and contributes to keep up the debility.  Med.
Chir. Trans. Vol. VII. p. 84. A similar disease is described by Dr. Hall, in the
Edin. Journal for Oct. 1819.  M. Cevoule maintains that it\s almost always the
consequence of a solitary ulceration on the inside of the mouth, or labia, and is
not preceded by fever, the constitutional symptoms being merely symptomatic. 
76
 parts below of a red or pink colour.   The child, in this complaint,
 is generally spmewhat fretful, the mouth is warmer than usual, and
 the bowels rather more open,  and sometimes griped,  which has
 been attributed to an acid  state of the  saliva.  The stools are al-
 tered in their appearance, being green,  or containing  undigested
 milk, or of an offensive smell.  There is no fever or general in-
 disposition, except what may proceed merely from irritation of the
 bowels.  It is most frequent within the first month, but may occur
 later.
   In the severe or worst form of  this disease, a fever,* even of a
 contagious nature, precedes, or attends the aphthae; and the child
is sometimes drowsy and oppressed for some hours, or even a day
or two before the spots appear, and  occasionally is affected with
spasms.  The fever  and oppression are sometimes mitigated on
the appearance of the aphthae.  The eruption is pretty copious in
the mouth, and  may become confluent, so that almost the whole
surface is covered with curdy-looking matter.  The stomach and
the bowels are very  much disordered,  and the child  vomits  and
purges.  The stools are generally green, sour-smelled, and  some-
times acrid, so that the anus is excoriated.   The aphthae may not
be confined to the mouth, but may descend along the trachea, pro-
ducing cough, and great difficulty of breathing ; but much oftener
they go along the oesophagus to the stomach, which becomes ve-
ry sensible,  is painful to the  touch, and the child vomits speedily
after sucking.  The  mouth  is likewise tender, so that the child
 sucks with pain,  and with difficulty,  if the crusts become hard, the
 tongue being rigid.   After a short time, the  aphthae change their
 colour, and begin to fall off; but  they may be renewed, and the

  * Dr. Underwood is of opinion, that fever very rarely attends aphthae, when it
 appears as an original disease.   Foreign writers have divided this form of the
 disease into four stages :—1st, What they call the  incubation or invasion of the
 aphthae, marked by fever, restlessness, sickness, burning heat of the epigastri-
 um, hoarseness, and hot, tender  state of the  mouth.  2d, The  pullulation or
 eruption.  The  membrane of the mouth  becomes red, the aphthae  appear,
 and spread, with cough, difficult deglutition, diarrhoea, &c. 3d, The symptoms
 increase.  4th, The apnthx change into  crusts, and fall off in fragments. They
 deny that the eruption is ever attended with mitigation of the constitutional af-
 fection. 
77
abdominal symptoms may increase, so that the child is exhausted,
and dies.
   There are two sources of danger, in bad cases of aphthae :  the
first proceeds from the disorder of the  alimentary  canal, which
always attends the disease; and the second arises from the par-
ticular state of the system, connected with the local disease, as in
malignant sore throat, and many  other diseases.  It behooves us
then, in forming  our judgment, to attend to the  sensibility of the
stomach and bowels, and pay attention to the egesta.  Frequent
vomiting, repeated thin stools with griping, and  a tender  state of
the abdomen, with or without tumour,  are  very unfavourable ;
drowsiness, oppressed breathing, moaning, spasms, and great  lan-
guor,  with frequent  pulse,  are  likewise dangerous symptoms.
With regard to the local disease we find, that  if  the  spots be  few
and distinct, and become a little yellow, and then in three or  four
days fall off, leaving the part below clean and moist,  we may  ex-
pect that the eruption will not be renewed, or  will  become  still
more  mild.  But if the aphthae turn brown or  black,* which last is
not a  common colour, the prospect is not so good, and is worse in
proportion to the rapidity with which  they  change.   The longer
that the aphthae adhere, the more apt are they to become brown;
and the case is worse, than when one crop succeeds another more
speedily.  If the succeeding crop be more sparing than the former,
we augur well, and vice versa.  When the aphthae fall off, we ex-
pect their renewal, if the  parts below are  parched and  look foul.
If, however, in this state, the  eruption do not  take place,  and the
oppression, weakness, and drowsiness continue, the  danger of the
case is increased; and in such circumstances, it has been observ-
ed, if the eruption afterwards appear, the child is relieved.   It is
also unfavourable, if a new eruption come out before the former
one be thrown off.  When the aphthae fall off, the mouth becomes
very tender, so that the mildest fluids sometimes give pain.   Oc-
casionally a salivation takes place, and  the  inside  of the  cheek
bleeds.  Dr. Armstrong remarks, that he has  seen the  tongue
  • Sometimes mortification takes place, and even the palate bones have been
known, to suffer. 
78
 covered with a crust of aphthae, and the cheeks and  gums full ot
 angry pustules, and  little fungous excrescences.
   Now with regard  to the causes, we  find that this disease is pro-
 duced by derangement of the stomach and bowels, excited by im-
 proper diet, exposure to cold, Sic. and sometimes slight attacks are
 occasioned  by giving spoon-meat too  warm.  The tongue  and
 mouth sympathize very much with  the state of  the  alimentary
 canal, in every period  of life ;  but in  early infancy,  the changes
 produced in the membrane lining the  mouth,  by derangement of
 the function of digestion, are great and  sudden.   Whenever the
 diet is deficient, or improper, or the action of the stomach is  im-
 paired, aphthae are produced, especially during the  first montri;
 afterwards, at least,  when the infant is considerably older, the
 tongue merely becomes foul or furred, when  the digestion is in-
jured.  It is  rather  with  the  stomach than the bowels  that the
 mouth at first sympathizes ; but the bowels also are  generally af-
 fected, either from a  propagation of diseased action from  the  sto-
 mach to them, or from the operation of causes directly on them,
 as well as on  the stomach.  Hence the stools are  generally  bad,
 when the mouth is aphthous, and  hence a change of diet, or medi-
 cines, which stimulate and invigorate the whole tract of the canal,
 and remove the affection of the mouth.  If a child  be brought up
 on the spoon, or the milk be bad, one of the most early indications
of injury is the appearance of aphthae,  or white exudations on  the
tongue.  Some particular states of the  atmosphere  would seem
either to excite this disease, or predispose to it, for it is most  fre-
quent in damp situations,  and   in spring and autumn; and  Van
Swieten tells  us,  that it is peculiarly prevalent in Holland.   It
would appear also to  be produced by sucking  an excoriated  nip-
ple ; and on  the  other hand,  an  aphthous mouth  may infect  the
nurse.  It has been said by Dr. Moss,  that a healthy  child, suck-
ing a breast immediately after a diseased child, receives the infec-
tion ; and I believe it to be the  case.
  In the treatment of aphthae, the cause is often overlooked, and
local applications  are expected to remove  the disease.  The first
object, however,  is to  remove  the cause, which  most frequent-
ly is resident in the stomach and bowels.  For this  purpose, strict 
79
attention ought to be paid to the ingesta, for many nurses,  instead
of bringing the child up at first entirely, or almost  entirely on the
breast, give spoon-meat, and that in too great quantity, and  not un-
frequently  combined  with an  anodyne,  to keep the child quiet.
Emetics have been strongly recommended by Arneman and others,
in this disease.  A little of the vinum ipecacuanhae may  be em-
ployed, which is preferable to antimony.  This may be given early
in the disease  if it require interference with active medicines,  or do
not yield to mild laxatives ; but if relief  be not  soon obtained, it
should  not be repeated : and on the whole, I am not very partial
to the use of emetics.   Gentle laxatives are highly proper,  such
as manna, cassia fistularis, or  a little magnesia ; indeed, Dr. Un-
derwood seems to trust chiefly to absorbents.  A small proportion
of rhubarb may, together with an aromatic, be occasionally added
to the magnesia.  Small doses of calomel may be  given with ad-
vantage.  The remedy I chiefly recommend is laxatives,  such as
rhubarb, magnesia, or calomel,  given so as  to evacuate all offen-
sive  matter,  and excite  the  action  of  the whole  canal.  The
operation is to be gentle, but must perhaps be repeated for  some
days.  Emollient clysters, made pretty large, and without stimu-
lating ingredients, are likewise useful.   Milk or soup may  also  be
injected, to support the strength, when the  child does not  suck or
take food by the mouth.  If, however, the child have a purging,
then we must proceed according to the directions which  will be
given respecting diarrhoea.  In the worst species,  we must  very
early give  a gentle laxative, or a mild emetic, if the child be much
oppressed ; and afterwards the bowels must be regulated, and me-
dicine given according to the appearance of the faeces, and the
state of sensibility.  Nourishment is to be given carefully,  or if
the child cannot suck, clysters must be administered  twice a-day.
Where the debility is considerable, the strength must be supported
by cordials, such as white-wine posset.  Bark has  been  recom-
mended when the debility is great, and especially when the mouth
has a sloughy gangrenous appearance, or tendency thereto.  Chil-
dren, however, cannot take it so  as to do good ;  and therefore,
when it  is employed, it should be in the form of  clyster mixed 
80
 with starch* or mucilage, but I cannot speak  decidedly as to its
 benefit.   Small doses of calomel, with opiates, are useful.
   Local applications have been always employed, and in slight
 cases are trusted to by the nurse, without any internal medicine.
 The most common remedy  is borax, in the form of a saturated
 solution in water, or mixed with honey or syrup; or a little of the
 powder may be put into the mouth, and  it seems to have a better
 effect than could be expected from its  sensible properties.  It can-
 not, however, as Dr. Bisset observes,  be expected to remove the
 aphthae until they  are about to separate, when it ought to be  em-
 ployed, and may  prevent a  renewal.  Until this period, a little
 veal soup, or white of egg beat up with water, may be given.  Van
 Swieten recommends syrup of turnips.   Applications which force
 off the aphthae prematurely,  do harm to the part, and seem to
 produce a renewal of the exudation.   A solution of the sulphate
 of zinc, or diluted muriatic acid have been proposed as lotions,
 and may occasionally be of service ;  but it is  highly improper to
 wash the mouth roughly with  a cloth dipped in these or any other
 lotions.

               §  27. APHTHJE ON THE TONSILS.

  Aphthae sometimes appear  on the tonsils of children and adults,
 with or without fever;  and from an apprehension of the existence
 of a malignant sore throat, give much  alarm.  There is, however,
 very little inflammation, and no lividity of the  parts; the fever is
 very moderate, the strength not impaired, and the aphthae do not
 spread, but, becoming brown,  presently fall off.   This is cured by
 acid gargles and laxatives.  Another kind of sore throat is attend-
 ed with  the usual  symptoms  of inflammation, accompanied with
 an exudation  of tough yellow mucus.  It  yields readily to the
 same treatment.

  • From a scruple to a drachm of bark may  be given to a young child, mixed
with half an ounce of fluid.  Sometimes a little laudanum may be added to the
clyster, to make it be retained. 
81
    § 28. MALIGNANT, APHTHOUS OR PUTRID SORE THROAT.

   A malignant and highly infectious species of aphthae, is one of
the most formidable diseases to which children are liable.  It con-
stitutes the putrid sore throat, which is quite different from the
scarlatina maligna, in as much as there is no efflorescence, but
rather a deadly  paleness of the surface; unless in those  cases
where purpura or vibices appear.  The child becomes first of all,
and rather suddenly, sick, listless, and cold;  his pulse  is quick
and feeble ; his eye heavy, and his countenance pale.  The throat
is  seldom complained of, but if inspected is of a  deep red colour,
and ash-coloured vesications are visible on the tonsils.  Even at
this time, the breath has a bad smell.   SoOn  the skin becomes
hot, and, perhaps, for  a short time, the cheeks  are flushed, but
they soon become either pale or livid, and the heat is never ardent.
The pulse is extremely frequent and very feeble.  The  throat is
covered with a slough, and filled with viscid phlegm.   The tongue
is  brown or dry  and  livid.  The nostrils discharge acrid  ichor.
There is foetor of the breath, hoarse cough, and stridulous breath-
ing as in croup.  In every bad case this affection of the larynx
takes place, and few, if any, recover, who are thus seized, for it
runs the same course as croup; there  is the same hoarse cough,
the same sonorous breathing, the same  fits of suffocation.  These
symptoms increase, the stools  are dark and offensive, the breath
putrid, the sloughs spread, the pulse  becomes fluttering, and often
within forty-eight hours, sometimes in twenty-four, the child dies.
Death, however, rather takes place thus speedily, from the  inten-
sity of the laryngeal affection,  than from the mere debility conse-
quent to the operation  of the infectious virus.  Various remedies
have been tried.  Emetics, purgatives, the early application of
leeches to the throat, blisters, and calomel, have all failed.   Some
of them have perhaps aggravated, none of them have relieved the
symptoms; nor do  I know any plan which  can  be depended on
with the least  confidence after the  croupy symptoms have de-
cidedly appeared.  If these have not  taken place,  or are only
slightly threatened, the practice I have  found most useful, consists
     Vol. II.                   U 
82
  in the administration of gentle purgatives, and the instant use of
  bark by the mouth, or in clysters, with such nourishment and cor-
  dials as the child can swallow or retain; as auxiliaries, we  may
  endeavour to have the throat and mouth cleared by washing, at-
  tend to ventilation,  and shifting the bed linen,  and give ripe fruit.
  In desperate cases, would tracheotomy be of any avail ?

             § 29. EXCORIATION OF THE TONGUE, 6ic.

   About the time of dentition, the tongue, gums, and inside of the
 lips, are sometimes spotted  over with superficial  excoriations.
 They are seldom larger than a coriander  seed, of an  irregular
 shape, and covered with  yellow or  brownish mucus, adhering so
 firmly, and being so thin, as to resemble the solid base of the sore
 itself.  They are tender,  and  generally accompanied with saliva-
 tion.  They are cured by being  touched with  alumen ustum, or
 lightly with  a pencil, dipped in weak solution of nitrate of silver.
 Borax also, or tincture of myrrh,  seem to do  good.   But perhaps
 these would always heal easily, if left to follow their own  course.

                        § 30. SYPHILIS.

   Infants may be affected with syphilis in different ways.  They
 may be  diseased in  utero, in consequence of the state of one or
 both of the parents.   They may be  infected  by passing  through
 the vagina, when the mother has chancres; or by sucking a wo-
 man who has the nipple affected.   Of all these methods,  the first
 is the most frequent; and it is worthy of remark, that  this mode
 of infection may take place, when neither of the parents has at the
 time any venereal swelling or ulceration, and perhaps many years
 after a cure has  been apparently  effected.   I do not pretend to
explain here the theory of syphilis, but content  myself with relat-
 ing well established facts.
   In such cases, it is very common for the  mother to misccarry,
or have  a premature labour, without any evident cause;  and when
this takes place, the child is found to have the epidermis wrinkled,
or peeled off, as  if it  had been macerated, and sometimes deeper 
83
ulcerations are discovered.   The liquor amnii is turbid and foetid.
We are not,  however, to suppose, in every instance, where these
appearances  are met  with,  that the child  is syphilitic; for any
cause, producing the death of the foetus, a considerable time ante-
cedent to its  expulsion, will  produce nearly the same appearance.
The diagnosis then, must depend much upon the repetition of the
premature labour,  the, circumstances  attending  it, the history  of
the parents,  and the jlistinct appearance of ulceration.  In such
cases, the parent originally affected ought to undergo a mercurial
course;  and  if the other parent have any  suspicious symptoms,
mercury should be administered to both.   Sometimes the disease
seems to wear itself out, without any remedies being employed ;
and the children born in future are healthy.   But it often happens,
that the child, though it have  received  the venereal  disease  i*
utero, and probably possessed  it as a peculiarity  of constitution
from the time of conception, is  born alive, and has even no appa-
rent disease on the skin, or in the mouth.   Frequently, indeed, it
is born before the time, and  perhaps it has been preceded by one
or two dead  children. ■  It may be clean and healthy, and continue
so  for even  a month or two, but oftener it is  feeble, and rather
emaciated; and sometimes it has at the time of  birth, or soon af-
terwards acquires, a wrinkled countenance, having the appearance
of old age in miniature, so very remarkably, that no one who has
ever seen such  a child  can  possibly forget the  look of the petit
vieillard.  In such a case, the  child has scarcely  any hair upon
the head, but may have pretty long hairs  on the  body ; it cries  in
a low murmuring tone, and  appears so weak, that  it cannot suck
for a minute at  a  time.  But  whether the child  be apparently
healthy or emaciated  at the time of birth, other symptoms pre-
sently appear ;*  and of 4hese  the most  frequent and earliest  is
generally an inflammation of the eyes, accompanied with ulceration
of the tarsi, and purulent discharge.  This appears a few days at-

  * M. Mahon,  from his observations in 1'Hospice de Vaugirard, says, that the
symptoms appear as follows, the most frequent being put first.  Ophthalray;
purulent spots ; ulcerations ; tumours; chancres on the  mouth, and aphthz ;
livid, ulcerating, and scabbing pustules; chancres on the genitals, and about the
•»nus;  excrpcences; peeling off of the nails of the feet and hands. 
                               84
 ter birth.  The  eye presently, if neglected, becomes ulcerated,
 and the cornea opaque.  Copper-coloured blotches, ending in ul-
 ceration, appear on the surface; or numerous, livid, flat, suppurat-
 ing pustules, cover the surface; or many clusters of livid  papulae
 appear, which presently have the top depressed, and  then end in
 ulceration.   These papulae are sometimes attended by an eruption
 of pale shining pimples on the face, which  enlarge, become  red,
 and often run together.   Children have  sometimes an eruption of
 leprous or scaly spots, which I have formerly described, and which
 resemble syphilis.   The syphilitic blotches are  of a darker colour,
 are more apt to end in ulceration than in scurf, or. to form crusts or
 scabs, and seldom disappear without the use of mercury ; or if they
 do, they soon return, and become worse by  continuance, and pre-
 sently are combined with additional symptoms of the disease.
 ' The  genitals and anus*  become ulcerated, and sometimes  ex-
 crescences sprout out from these parts.   Foul sores, having retort-
ed edges, and a centre pale and like lard, cover the  inside of the
 mouth; and chancrous ulceration takes place on the lips, especially
 about the angle of the mouth.   These  sores and chops are often
 surrounded pretty extensively with a whiteness of the skin, as if the
 part had been scalded, or recently rubbed with lunar caustie, and
 perhaps, from this circumstance, these  sores  have been called,
 though  improperly, aphthae.   They  may, however,  be combined
with aphthae.   In some cases,  the  white  or dusky patches cover
 the whole palate  and inside of the cheeks, whilst the gums are
  * Children may have ulceration about the anus, genitals,  and groins, succeeding
intertrigo, owing to neglect of cleanliness, without any venereal affection.  But
the absence of other symptoms, particularly of sore throat, or ulcer of the mouth,
and the amendment experienced by the use oflotions, and keeping the parts dry
and clean, will enable the practitioner to form a diagnosis, and the aspect of the
 sores will assist him.  This fretting of the parts, and even some degree of excres-
cence may attend psoriasis, and the leprous spots of children formerly described;
and in this case, especially if the child belong to a poor person, the disease is toe
often decided to be syphilis.  There is, however, perhaps no individual symptom.
 which can decidedly characterize syphilis in children; and the diagnosis must be
formed by the combination of symptoms, and often by the progress of the disease.
Many children are rashly put upon a course of mercury who do not require it;
perhaps, because the practitioner thinks it a point of honour, to determine the na-
 ture of the disease at the first glance.  . 
85
 ulcerated, or even nearly gangrenous.  The ulceration of the gums
 has always a very angry look.  The nostrils become stuffed, and
 discharge purulent matter.  On the face and hands  we see obsti-
 nate sores covered with pus, others with crusts, whilst the interven-
 ing skin is sallow.  The child early becomes hoarse, and the glands
 of the neck, with those below the jaw, are often swelled.  Children,
 like adults, have in general the surface affected, and  then the ton-
 sils and mouth, but sometimes the one follows the other quickly.
 They seldom live long enough to have the bones diseased.  They
 are always  in great danger, and those who are much diseased never
 recover.  Mahon, with great justice, ranks among incurable symp-
 toms, the old decrepid visage, great destruction of the globe of the
 eye, chancres on the middle of the lip,  spreading to the franum,
 and extensive .ulceration of the mouth.   It must be  remembered
 that syphilis not only may appear under its own peculiar characters,
 but may also exist under the form of some of the eruptions com-
 mon to children; such as crusta lactea, lepra, psoriasis, &c.   These
 are known to be venereal, by their being of a more livid colour than
 usual;  they tend slowly to ulceration, and when the  scab or crust
 with which they are furnished comes off, a foul honey-comb like
 ulceration is observed below.  But the best diagnostic is, that they
 are soon attended with other symptoms,  such as hoarseness, ulce-
 ration of the mouth  and throat, &c.  We must take  up our judg-
 ment slowly, and with deliberation.
   When a child is infected during delivery, the  disease appears
 more promptly on the surface, in the form of ulcers; and the usual
 train of symptoms follow,  the mouth and genitals  becoming pre-
 sently affected.   The disease  generally appears within a fortnight
 after delivery, sometimes so early as on the fourth day.
   If the child  receive the infection from the  nurse, we discover
 ulcers on her nipples, and the disease appears on the child's mouth,
 before the surface of the body  be affected.
   It has been proposed to  cure this disease by giving mercury to
 the nurse alone, but this mode is now abandoned, mercury being
 given directly to the child; and it ought to  be remembered,' that
this medicine produces less violent effects on the bowels in children,
than in  adults, and scarcely ever excites a salivation.   But if eiven 
86
 too  long or too liberally, it may kill the child by its irritation, or
 may excite convulsions.   Calomel is very often  employed,  and
 with great benefit, a quarter or half a grain being given three times
 a f'ay.  Others advise frictions, which are equally useful.  Fifteen
 grains of mercurial ointment are rubbed on the thighs alternately
 once in two days,  until the mouth be found hot, when it is  inter-
 mitted  or  continued,  according to the state of the system,  and
 the  effect  on  the  disease ; it must be  used till  the  disease  be
 removed.   It  has been remarked,  that children apparently  cured
 when on the breast, have had a relapse after being weaned.   If the
 child be griped, a gentle purge, and then an opiate, will give relief.
 Some have used  the ung.  acid, nitros.  in place of the mercurial
 ointment, but  it is not to be depended on.  It is,  however, useful
 as an auxiliary, when applied to the affected part of the surface.  It
 often happens, that after all appearances are removed,  the disease
 returns some weeks or months afterwards.  It is, therefore, neces-
 sary to continue the medicine for some time after an apparent cure.
  Sometimes, in consequence of the use of mercury, a peculiar
 eruption, called the eczema mercuriale, takes place.  This gene-
 rally begins on the lower extremities, and spreads to the body.  It
 consists of very small vesicles, which at first are like papulae.  Each
 vesicle may with a glass be seen  to be  surrounded with redness;
and  if they are not disturbed, they acquire the size of pins' heads,
then their contents become opaque.   They are attended with heat
and itching, and a general tumefaction of the part affected.  Pre-
sently, even if not scratched, the  vesicles burst,  discharging thin
acrid fluid, which stiffens the linen, and sometimes excoriates the
 part.  When the  discharge ceases, the cuticle becomes of a pale
brown  colour, .and then blacker;  and separating  in pretty large
flakes, leaves the skin below of a bright red colour.  After this, the
skin comes off in scales or  scurfs, perhaps  two or three times.
 The disease ceases  of  itself, sometimes  within ten  days;  often.
 however, it is  protracted longer.  Those  parts  which are first af-
 fected,  are  first cured.  Relief may be  obtained,  by applying
 saturnine lotions, or weak saturnine ointment.^

  (~hj Vide Alley on Hydrargyria, and Mathias on the Mercurial Disease, als« 
87
                      § 31. SKIN-BOUND.

  The disease termed skin-bound, is not distinctly mentioned till
1718, when a case was published by Uzembozius; since then many
accounts have appeared.  It may be divided into the acute  and
chronic, the last being chiefly met with in private practice.  The
acute species generally appears soon after birth,  and proves fatal
in the course of a few days.  The best description of this disease
is given by Dr. Underwood, and by M. Andry, as it appeared in
the hospitals of London and Paris.  In London, the children were
seized at no regular period; but it was -observed, that, whenever
the disease appeared, several children were attacked within a short
time, and especially those in the last stage of bowel complaints, in
which the stools were of a clayey consistence, and  of which the
induration of the skin appeared to  be only a sequel.  The skin
was of a yellowish white colour, like wax, and it felt hard and re-
sisting to the touch, but not  oedematous.   It was so fixed to the
subjacent flesh, that it would not slide, nor could it be pinched up.
This state was found to extend over the body, but  the  skin  was
peculiarly rigid about the face  and extremities.  The child was
always cold, did not cry, but made a moaning noise, and had con-
stantly the.appearance  of dying immediately.  In the French hos-
pitals, the disease differed, in being more frequently attended with
spasm, or tetanus, and always with erysipelas, especially about the
pubis, which, though purple, was very cold.  These erysipelatous
parts rarely suppurated, but sometimes mortified.  The legs were
oedematous, and the children died on the third or fourth day, or at
farthest, on the seventh day from birth.  This disease differs, then,
principally from that observed in this country, in being combined
with erysipelas and tetanus, which are by no means essential symp-
toms ; and perhaps the erysipelas of children has sometimes been
mistaken for the disease called skin-bound.
   In private practice, the disease appears under a more chronic
though not less dangerous form.  The children  affected, are gen-

Spens on Erythema Mercuriale in Edin. Med. and Surg. Journal, Vol. I. and
 M'Mullin'sin same work, Vol. II. 
88
 erally delicate; and in such cases as I have seen, the  skin from
 birth, was not so pliable as it generally is, being most rigid about
 the mouth, which had more  of the orbicular shape than usual.
 The skin gradually becomes tight, hard, and shining, and of a co-
 lour a little inclined to yellow.   In some cases, the whole skin is
 thus affected; in others,  chiefly that about the jaws,  neck, and
joints.  The scalp is often bald and shining, and the  veins of the
 head peculiarly large and distinct.   In some instances, parts of the
 skin are rough and slightly leprous.   The appetite, at first, is not
 greatly impaired, and the bowels are sometimes uniformly regular.
 Presently  the child becomes dull  and listless, and moans, and
 gradually sinks, or is carried off by fits.  The complaint lasts for
several weeks.  In some cases, the  disease is  less severe,  the ap-
pearance of the  child being healthy, and the thickening  and rigidi-
ty of the skin  confined to the joints of the extremities.*   No light
 is thrown on the nature of this complaint by dissection, which sim-
ply discovers a deficiency  of oil in the cellular substance, with in-
duration.   In the acute species, the liver has been found enlarged,
and the gall bladder distended.  Camper says, there is always, or
at least very frequently, a little hard tubercle found in the cheek,
under the malar bone.  Sometimes  more children than one in the
 same family have  been affected; and in  such cases, /hey  have
been always of the same sex.  A variety of remedies have  been
 made use of, such as mercury, laxatives, aromatic baths, and emol-
lient frictions; but seldom with any advantage..  Gardien advises
vinegar, having gum ammoniac dissolved in it, to be poured on hot
bricks, and the vapour applied to the indurated part.   When there
is stupor or determination  to the head or lungs, a  blister applied
on the indurated part has been proposed, but I have  no  evidence

  ' Adults are sometimes seized with this disease.  A very remarkable case of
this kind is recorded in the 48th vol. of the Phil. Trans.—The subject of it was a
girl, aged 17 years. She had excessive tension and hardness of the skin, all over
the body, so that she could hardly move. The skin felt like a dry hide or piece
of wood, but she had some sensation when pressed with the nail or a pin.  It was
cold and dry, the pulse was deep and obscure, but the digestion good. It began
in the neck, then affected the face and forehead, and at last she could scarcely
open her mouth. 
89
 »f its utility; others have, as a remedy for the induration, advised
 blisters to be applied to distant parts, with a  view of producing
 counter-irritation.   A gentle course of calomel has appeared to do
 good, when the affection is confined  to  the extremities.  Decoc-
 tion of sarsaparilla, with the frequent use of the warm bath, decoc-
 tion of mezerion, and a variety of diaphoretics may be tried ;  and in
 cases where more  children than one, in the same family, have been
 affected with the chronic species of this disease, it might be worth
 while to try the effects of mercury, and  some other medicines, on
 the parents.

                       § 32. SMALL-POX.

   The small-pox begins with a febrile  attack,, which  commences
 generally about mid-day.   It is marked by chilliness,  listlessness,
 pain in the back and loins, drowsiness, vomiting, pain in the region
 of the stomach, which is increased by pressure, starting, and cold-
 ness of the extremities.   As the fever advances, the pulse becomes
 more frequent, the skin  hotter, the face  flushed, the eyes tender,
 and the thirst considerable.   The child starts, grinds his teeth,  or
 has one or more eclamptic  fits, or sometimes complains of severe
 cramp in the legs,  or lies in a kind of comatose  state.  On the
 evening of the third, or morning of the fourth day, an eruption ap-
 pears on the face,  and then on the neck, from which it spreads  to
 the body.   In mild cases, the eruption is completed by the even-
 ing of the fourth, but sometimes not till the fifth day, or even later,
 if the pustules be very numerous; and then the fever declines,  or
goes off altogether.  The eruption consists, at first, of small hard
red pustules of a fiery appearance.   On  the second day, the top is
 clear, and a very small vesicle is observed to be forming.   On the
 face, we frequently find patches like measles, but containing many
 minute vesicles.   Next day, if the eruption is  to be copious, the
 number of pustules  is farther increased,  especially on  the face,
 where we often find more patches.   These patches and the  suc-
 ceeding confluent  vesicles,  seldom appear in the inoculated  small-
 pox, or in the natural small-pox, when  very distinct.   They are
 numerous, in proportion to the tendency to the confluent form  of
     Vol.  II.                12 
90
the disease.  The  pustules on the body  are more raised  and
rounder, though in some places they are flatter, and more extend-
ed.  The base  is surrounded with an inflamed rim ; and presently!
if the eruption be copious, this inflammation spreads from one pus-
tule to another,  so that all the surface appears to be red.  The cu-
ticle of the vesicle, at this time, is somewhat opaque,  but its con-
tents are limpid, like water.  On the fourth day, if there be  any
patches on the face, they are evidently covered with flat confluent
vesicles; on the body and arms the vesicles are larger and rounder
than the day before.   The surrounding redness is a little paler, the
skin of the vesicle is whiter, and more of the pearl  appearance;
so that at the first glance, the eruption seems  to  consist of white
elevations.  The vesicles  are full and smooth.  On the fifth day,
they are rather  flatter.  On the sixth day, the skin of the vesicles
on the  body and extremities, is drier arid harder, and the contents
still limpid; all those on the body are entire,  but about the chin
some have broken, and crusts are formed.   If tliere have been
patches on the face, these are now covered with  flat vesications.
On the  seventh day,  the vesicles on the body  and extremities are
of a dead white colour at the circumference, but more glossy, like
candied sugar, at the centre.   Their contents are a little turbid ;
more crusts are formed on the  face.   On the eighth day, the fluid
on the extremities is whitish.  On the ninth day, the crusts  on the
face  are more numerous, and  they begin to be formed about the
bend of the arm, &c.  The pustules on the extremities are whiter,
as if filled with  pus, but the fluid is thin and  milky ; the skin of
the vesicles is thick.   On the tenth day, the pustules  on the face
are covered with scabs, and many are formed  on the extremities.
On the breast, the vesicles are prominent, like two-thirds of a
sphere, but compressed, and have no redness around them.   Many
vesicles are empty and covered with thin brown skin.   Scabs are
formed, by the  skin becoming  dry, hard, and brown, or sloughing.
The contained  fluid is partly absorbed, and partly effused by exu-
dation, so as to  add a crust to the slough of the vesicle.
  When the scabs are picked off, about the seventeenth day, the
base of the mark is in general elevated above  the rest of the skin,
but the centre is depressed a little below the margin.   The colour 
91
 is  light red.  On the twentieth day, the blanes on the body and
 extremities are  smooth, flat, or slightly scurfy, so that they some-
 what resemble leprous spots.
   The process is not always regular;  for, in very  mild cases, the
 suppuration is indistinct, and the scab thin; the pustule dries with-
 out forming much matter, so that inoculators can scarcely get their
 lancet weL  This is a favourable condition.  Sometimes the mat-
 ter, though considerable in quantity, does not exude to form a scab,
 but is absorbed, and the vesicle remains for a time entire,  forming
 what has been called variola siliquosa.
   About the seventh or eighth day of the disease, when the pustules
 are numerous, the face swells;  but about the  tenth or eleventh, it
 subsides, and then the hands and feet swell.   It is also common,
 about  the  sixth or seventh day, for the throat to  become  sore,
 with sneezing, and some degree of hoarseness or cough;  and, in
 unfavourable cases, the secretion about the throat becomes tough
 and thick.
  When the pustules  are  numerous, a return of the fever  may be
 expected  about the eleventh day.  This is called the secondary
 fever; but in mild cases it is very trifling, and does not last long.
  Such is a general history of the distinct small-pox :  but the dis-
 ease may also appear under a different form, known under the
 name of the confluent small-pox.   In this case, the eruptive  fever
 is more severe, attended with greater pain in the loins, and  often
 with coma.   It differs also from  the former, which is of the in-
 flammatory kind, in being of the typhoid type, so that sometimes
 petechiae appear.  The eruption comes out earlier, generally on
 the morning of the third day, and is sometimes preceded by ery-
 thematic inflammation of the face or neck.   The eruption is co-
pious, and at first, more  like measles than small-pox, so that some
practitioners have, at this stage, mistaken the  one disease for the
other.   The pustules, which are not so much elevated as  the va-
riola discreta, become  confluent, especially  on the face;  and
though they may be confluent only on the face, yet those on the
body are not of a good kind.  They form matter earlier,  do not
retain the circular  form, and, instead of having the interstices  of
the  skin, where they do not coalesce, of a red colour, as in  mild 
                              92

 small-pox, these spaces are pale and flaccid.   The coalescence is
 most remarkable on the face, which often seems as if covered with
 one extensive vesicle.   The matter which these pustules form is
 not thick and yellow, like good pus, but either of a whitish brown,
 or black colour.  Scabs generally form about the eleventh day of
 the disease, but these do not fall off for a length of time, and leave
 deep pits.   The swelling of the face is greater and  more perma-
 nent  than  in the  former species, and  the  eruptive  fever  does
 not go off when the eruption is completed;  it only  diminishes  a
 little, till the sixth  or seventh day, when it  increases, and often
 proves fatal on the eleventh.
  The treatment of the distinct  is different from that of the  con-
 fluent small-pox.   During the eruptive fever, the antiphlogistic re-
 gimen must be carefully enjoined, the  diet must be light and spar-
 ing, the surface kept cool and clean, and the bowels loose.   Emet-
 ics, at an early stage of the fever, are  often serviceable, and  it is
 generally proper to give laxatives.  Eclamptic fits are  relieved by
 opiates and cool air.  When the  eruption is  coming out, the cool
 regimen  should still be persisted in, and the bowels kept open.
 After the pustules  have appeared, the fever generally abates ;  and
 then, although  heat should  be avoided, the  cooling and  purging
 plan need not be carried so  far as formerly.   But if the fever still
 continue, these means should  be also  continued.   The diet must
 be sparing, and plenty of ripe fruit should be  given.  If secondary
 fever supervene, it is to be removed, chiefly by laxatives and cool
 air : or if there be oppression at the stomach, a gentle emetic may
 be given.
  In  the confluent kind, during the eruptive fever,  the cold plan
 should be  diligently  employed,  and  cathartics are  of essential
 benefit.   When the eruption appears,  the cooling regimen should
 still be persisted in, and both vegetable and mineral acids ought to
 be given freely.  Bark is also proper,  provided that it is not pro-
 ductive  of sickness or vomiting.   When the  fever is aggravated,
 at the height of the disease, emetics have been  sometimes given
with advantage; but in general they are  not necessary, and more
benefit is derived from laxatives and clysters.   Opiates are useful,
 for abating irritation;  and wine, with  nourishing diet, should be 
93
prudently given, to support the strength, which is apt to be com-
pletely exhausted under the constant fever  and irritation.   On
this account also,  it is necessary to restrain  diarrhoea, when  it is
frequent,  and adds to the weakness.  Blisters have been advised
as stimulants, but they are only useful when deep seated inflamma-
tion exists.  Sometimes the brain seems to be affected, the  head
being pained, the eyes impatient of light, and the patient delirious.
In this case, leeches may be applied to  the temples, and  a blister
put on the head.  When the lungs are affected, blisters on the
sides or breast  do good.   When the stomach is very irritable, if
saline draughts and opiates do not give relief, a small blister should
be applied over the the stomach.  If the swelling of the face sub-
side quickly, and be not  followed by tumefaction of the  feet and
hands, blisters have been applied to the  wrists, but  sinapisms are
better, though  it is not decided, that  either are of great utility.
When  the throat is much affected, and filled with viscid  phlegm,
gargles are  of  use, and sometimes a very  gentle  emetic gives
relief.
   If the eruption suddenly subsides, cordials tend to bring back a
salutary inflammation; or if it altogether recede, the tepid  bath,
with ammonia, and other internal stimulants, will be proper.  The
boils and inflamed pustules, succeeding variola, are very trouble-
some, and sometimes prove fatal.  When large, suppuration should
be  hastened with a poultice;  when  small, unguentum resinosum
may be applied;  or if they be indolent, gentle friction, with  cam-
phorated liniment, and bathing with laudanum, is of benefit.  The
strength must be  supported, and, as soon as possible, sea-bathing
should be resorted to.
  The violence of the variolous disease is generally lessened by
inoculation,* which was  first introduced into this country in the
year 1721.  The operation itself is very simple, consisting merely
in abrading the  skin on the arm or leg with the point of a lancet, and
then applying on  the small scratch  a little of the variolous matter,

  * Inoculation, even after exposure to infection, is capable of producing a mild
disease. 
94
   which should be taken early, as when it is delayed until the pustules
   are collapsing or scabbing, it sometimes produces a spurious inflam-
   mation.   By the third day,  we are sure of success, by observing
   a slight redness on the arm at the incision.  On the third or fourth
   day, the part is hard to the  touch.   The  redness gradually in-
   creases for the two succeeding days, and then a small vesicle may
   be  perceived.   By the  eighth, or  at  farthest  the  tenth  day, the
   pustule has completely the variolous character.  It forms a circu-
   lar  elevation, surrounded with circumscribed redness, and the vesi-
  cle  is a  little flatted  on the  top.  The constitution, at this time
  becomes affected ;  and the earlier that the eruptive fever appears,
  the  milder in general is the  disease.   The  character of  the suc-
  ceeding disease may,  it is supposed, be foreseen, even  before the
  eruption take place, or be completed, by examining the arm; but
  this  is doubtful.
    The safety of the practice  of inoculation is  greatly  increased,
  by having the system as free as possible from every diseased state;
  and, therefore, children  are  not  inoculated  during dentition, at
  least if they cut their  teeth with any trouble.  Very young chil-
  dren are not considered as favourable subjects, Dr. Fordyce ob-
  serving that two-thirds of those who died from  inoculated small-
 pox  were under nine months.  If we  have our choice, the best
 age is said to be from two to four years, but it is dangerous to wait
 so long, lest the child  should take  the casual small-pox ; and  Dr.
 Adams informs us, that of three thousand children inoculated at
 the hospital  in  one year, two thousand five hundred were under
 two  years of age, yet  only two out of that number died.  Full
 plethoric children should be frequently purged, and fed sparingly,
 before the operation.   Some particular modes of preparation have
 been  often employed,  such as giving calomel or antimony, but
 these have very little effect.(i)  The  attention  ought chiefly to
 be directed to bring the body into a state of good health, if pre-
 viously delicate, or diseased :  and, on the other hand, if requisite,

  CO In so far as they operate as laxatives, their effects occasionally must be
beneficial, and children are more easily induced to take them, as they are not so
nauseous as some other cathartics. 
65
 diminishing plethora and inflammatory disposition by the obvious
 means.  After the inoculation, the bowels must be kept open, and
 all stimulants avoided; and when the eruptive fever commences,
 the antiphlogistic regimen is to be strictly practised, and often has
 so good an effect, that few or no pustules come out; or if they do,
 they do not maturate, and  we have no secondary fever.  In gene-
 ral, the arm heals kindly ; but when it forms a sore, it should be
 exposed to the air, or dusted  with  chalk; or if it  threaten gan-
 grene, it should be bathed  with camphorated spirits, or tincture of
 myrrh.

                        § 33. COW-POX.

   As a preventive of the small-pox, the vaccine inoculation is now
 universally practised.   This is productive, in general, of a very
 mild and safe disease,  consisting of a single vesicle,  forming on the
 place where the inoculation was performed.   On the third day, the
 scratch is slightly red, and, if pressed with the finger, feels  hard.
 Next day, the red point is a little increased, and somewhat radiat-
 ed.  On the fifth day, a small vesicle appears, but it is still  more
 easily seen on the sixth.  This gradually increases, until  it acquire
 the size of a split  pea.  The  colour of the vesicle is dull white,
 like a pearl.   Its shape is circular, or slightly oval, when the inocu-
 lation  has been made with a lengthened scratch, acquiring about
 the tenth day a diameter equal to about the third or fourth part of
 an inch.  Till the  end of  the  eighth day, the surface is uneven,
 being depressed  in the centre; but  on the ninth day it  becomes
 flat, or sometimes rather higher at the middle than at the edges.
 The margins are turgid and rounded, projecting a little over at the
 base of the vesicle. The  vesicle is not simple, but cellular, and
 contains a clear limpid fluid, like the purest water.  On the eighth
 or ninth day, the vesicle is surrounded with an areola of an intense
 red colour, which is hard and tumid.   About this time, an erythe-
matic  efflorescence sometimes takes place near the areola, and
spreads gradually to a considerable part of the body.  It consists
of patches, slightly elevated, and is attended with febrile symptoms.
On the eleventh or twelfth day, as the areola decreases, the surface 
96
 of the vesicle becomes brown at the centre, and is  not so clear at
 the margin; the cuticle gives way, and there is formed a glossy
 hard scab, of a reddish brown colour, which is not detached, in gene-
 ral, till  the  twentieth day.  When  it falls off,  we find  a cicatrix,
 about half an inch in diamater, and with as many pits as there were
 cells  in the  vesicle.   During the progress of the vesicle, there is
 often  some disorder of the constitution; and occasionally, a papu-
 lous eruption, like strophulus,  appears near the vesicle.
  As  security against the small-pox is  not  procured by spurious
vaccine vesicles, it becomes necessary to  study carefully the cha-
racter of the genuine disease, which I have briefly described.  A
very frequent species of spurious cow-pox, is rather a pustule than
a vesicle.   It increases rapidly, instead of  gradually.  From the
second to the fifth or sixth day, it is raised toward the centre, and
is placed on a hard inflamed base, surrounded with diffused red-
ness.  It contains opaque fluid, and is usually broken by the end
of the sixth day, when an irregular yellowish  brown scab  is formed.
If the  vesicle be regular in its progress, and have pretty much of
the  general aspect of the vaccine vesicle,  but contains, on  or be-
fore the ninth day, a turbid  or purulent matter, it  cannot be de-
pended  on;  and  the  security will be still less, if die scab be soft.
Besides these, Dr. Willan has characterized three  spurious  vesi-
cles.  First, A single pearl-coloured vesicle, less than the genuine
kind ; the top is flattened, but  the  margins  are not rounded  nor
prominent.  It  is set on a hard red  base, slightly elevated, with an
areola of  a  dark rose colour.   The second  is cellular, like the
genuine vesicle, but somewhat smaller, and with a sharp angulated
edge.   The areola is sometimes of a  pale  red colour,  and very
extensive.   It appears on the seventh or eighth day after inocula-
tion, and  continues  more or  less  vivid for three  days;  during
which, the scab is completely formed.  This is less regular than
the  genuine scab, and  falls off sooner.   The third is a  vesicle
without an areola.  These forms of the disease do not give secu-
rity against  the  small-pox;  and it  would appear that  a vesicle,
which is even regular at  first, or which runs through  the whole
course  with regularity, may  fail to secure the constitution;  for
there  are well authenticated cases,  where the small-pox has thus 
                                 97

 succeeded the cow-pox.   Professed writers  on this subject, have
 enumerated  three causes of  failure.   1st. From  matter  having
 been taken from a spurious vesicle,  or from  a genuine vesicle at
 too late a period.   The  best  time for taking  matter is about  the
 eighth day ;  and after the  twelfth,(k) or when it becomes puru-
 lent, it cannot be depended on;  or  the same effect will  be pro-
 duced by any cause which can disturb the progress  of the vesicle.
 2d. From  the patient  being  seized, soon after vaccination, with
 some contagious  fever, such  as measles, scarlatina, influenza, or
 typhus.  3d. From his being affected, at the time of  inoculation,
 with some chronic  cutaneous disease, such  as tinea,  lepra, czc.
 The precise circumstances under  which  these causes produce
 their effect, or the degree to which they  must be present in order


  (~kj It has  been satisfactorily determined by  the experience of the physi-
 cians of this city, that the genuine Vaccine scab, after the usual process of sepa-
 ration from the arm, will, when properly used, communicate  the real Vaccine
 disease.
  This valuable fact was first brought before  the medical  public in the year
 1802, by James Bryce, of Edinburgh, surgeon to the Vaccine Institution of  that
 place.  The student is also referred to a paper on this subject, with directions
 for the proper  mode of using the scab, or crust, by Dr. Samuel Powel Griffitts,
 Eclectic Repertory, Vol. I. p. 362.  Dr. G. has used with success, a scab, which
 he had possessed for eleven months.  As it appeais to be a matter of importance
to the young practitioner to understand  this subject well, we shall take  the
liberty of subjoining from the paper above alluded to, the most essential circum-
stances to be observed in the use of  the scab in vaccinating.
  " The most perfect vesicles which go on to the state  of crust, or scab, without
any deviation from the proper character, and which when they fall off are some-
what transparent, smooth, of a mahogany colour, and  rather brittle than tena-
cious in their texture, are to be chosen to propagate the infection.  It should be
the first scab that falls off; this  should be wrapped up in a piece of white paper,
and kept in a cool dry  place.  When used, the margin, which is of a  lighter
colour, should be removed  with a knife, and a portion of the remaining dark,
hard internal part is to be shaved off, reduced to powder on a piece of glass, and
moistened with a small quantity of cold water, mixing it well together, and then
introducing it in the arm .on the point of a lancet,  leaving also a small portion of
the scab on the scratched part.  No more of the scab must be  moistened at  one
time, than what is used, and no greater portion should be shaved off from the
scab, than what is wanted for the present occasion, as it appears to retain its
strength better by continuing in the undetached state.  It  is believed that the
livid vesicle, and especially the unopened one, i«  most powerful."
  Vol. II.                       13 
98
to operate, have not  yet been determined with certainly.  It has
also been supposed, that puncturing the vesicle in order to  take
matter from it, may, by disordering the  process, sometimes  pre-
vent its efficacy.
   Even where none of these causes exist, and when the vesicle
runs its course with distinctness, it does, though very seldom, hap-
pen that the constitution is not rendered  insusceptible of the  vari-
olous action.   It were much to be wished, that some test could be
discovered, by which the security could be determined.  The con-
stitution is often manifestly disordered during some part of the vac-
cine progress, and such children  are most probably  secure ; but
sometimes the disorder is too slight to  be discovered, and there-
fore this sign is not to be relied on.  We are also assured, that even
when no constitutional disorder has taken place, the child is secur-
ed.  Other means, then, have been resorted to, in order to  dis-
cover if the system be affected, so as to have a complete change
induced by the inoculation.   These are two in number: 1st, If  a
second inoculation be performed on the fifth or sixth day after the
first, a vesicle  will arise as usual, but it will be surrounded with an
areola nearly as early as the first one.   2d, If a second inoculation
be performed any time after the twelfth day after the first inocula-
tion, some degree of inflammation will be induced ; but  if the sys-
tem have been affected,  no regular vesicle will be produced.   But
the most satisfactory method is, to inoculate  with small-pox  mat-
ter, which produces a small  pustule,  generally totally unattended
with constitutional affection; but  sometimes,  even  although the
constitution have been changed by the vaccine  inoculation, a  slight
febrile affection may be excited, either without  any secondary
pustules, or attended by an efflorescence on the skin, or  an erup-
tion of small hard pustules, which disappear  in about  three  days.
It unfortunately happens, however, that parents in  general do not
think it necessary to adopt any of these means ; and inoculators,
perhaps, trust too much to their own  power  of discrimination, in
determining how far a vesicle is capable of producing  the desired
effect.  Some test is the more requisite, as vaccination is  often
performed in a very careless manner,  and by  people ignorant of
the character of the disease. 
99
   It has been said, that if a child, properly vaccinated, should af-
 terwards take the small-pox, the pustules are papulous, or tubercu-
 lated, and do not suppurate, but end in desquamation.  I have, how-
 ever, known very distinct cases of suppurating small-pox,  in those
 who, some years before, had gone through the vaccine process  in
 the most satisfactory manner.   Few facts, I believe, are now bet-
 ter ascertained in our " ars conjecturalis" than that small-pox may
 take place after vaccination ; and I believe that the proportion will
 increase as we recede from  the date  of vaccination, and augment
 the activity of the infection.   Many  will  escape, who are  merely
 exposed to the casual company of those who have small-pox, who
 would take the disease if inoculated with virus.  This much,  at
 least, I know, that a great majority of those  whom 1 have inocu-
 lated, have taken a mild  small-pox.   The eruption has been more
 papular than if vaccination had not preceded, and has only vesi-
 cated and dried like chicken-pox.  In other cases,  the principal
 part of the eruption has been  efflorescent like  measles.   But all
 who were formerly conversant with small-pox, know, that children
 inoculated and properly treated, often had scarcely  any eruption,
 and  that  not coming to suppuration.  Those,  again, who take
 small-pox from exposure to contagion, have  the disease more se-
 verely ; the pustules maturate, and leave  for a time distinct blanes.
 Variola occurring after vaccination is contagious, and produces the
 same disease in those who are not vaccinated, as any other small-
 pox  would have done.  Some seem to think, that by changing the
 name they can change also the disease, and  have called this, not
 variola, but a varioloid disease.  It must either be small-pox, or it
 must be something else.  If it be  not then  small-pox, virus can
 produce a new disease.   We are told it does so, and long  ago  it
 was maintained, that chicken-pox  was merely  a modification of
 variola !   The substitution of the term varioloid, is indeed  a very
good way of getting rid of the fact, that small-pox may occur after
vaccination;  but it is not an original  idea, for Falstaff fell  on the
same expedient with regard  to stealing, " call it  conveying Hal."
I do  not,  from these remarks, mean  to depreciate the  cow-pox;
on the contrary, it is only by  ascertaining the precise power of 
100
 vaccination, that its full benefit can be derived to mankind :  and
 although the warmest friends of this discovery must admit, that  it
 is not always successful, yet  it has hitherto failed  in so small a pro-
 portion of cases, that  we must consider it as justifiable to rely upon
 it,  and adopt it, in preference to the variolous inoculation.(I)  Ex-
 periments have been  made to ascertain  the effects of inoculation
 with a mixture of variolous and vaccine matter;  and the result has
 been, that sometimes the  cow-pox, sometimes the small-pox  has
 been thus produced.  When a person is inoculated with variolous
 and vaccine matter at the same time,  the incisions being very near
 each other, the vesicles enlarging, join into one ;  and matter, taken
 from the  one side,  will  produce cow-pox, from the other small-
 pox.  When a person is inoculated with  the  two kinds of matter
 at the same time,  or within a week of  each  other, both diseases
 Will be communicated to the patient, whether the incisions be near
 or remote, and small-pox  pustules will be  produced on the body;
 but  they  seldom maturate,  and the  disease is  generally  mild.
 When, however, the variolous inoculation  is performed more than
 a week, as, for instance, nine days before vaccination, the vaccine
pustule becomes purulent, and sometimes communicates the small-
 pox even in a very bad form.  When,  on the other hand, variolous
 matter  is  introduced nine  days after vaccination,  its action is alto-
 gether prevented.  From  these observations, it follows, as an im-
portant conclusion, that when a child has been exposed to  small-
 pox contagion, vaccination, though it  may not prevent,  will  yet
 generally  mitigate the subsequent disease.

  (~IJ Numerous cases have of late years  been undeniably  adduced, of the va-
riolous virus producing its full effects twice in the same system, so that a similar
objection will apply to variolous inoculation as to vaccination, as it regards the
after security of the patient.  It might perhaps be considered as superfluous to
refer to particular instances in proof of this position; but  the  curious reader
may find a very interesting case of this kind, related by E. Withers, surgeon,
in the Memoirs of the Medical Society of London,  Vol.  IV.   The patient's face
was severely pitted with  the first attack, and he died nearly 50 years after-
wards in consequence of the second.  See also a case of secondary small-pox,
with references to some cases of a similar nature, by T. Bateman, M. D. F. L. S.
Physician to the public  Dispensary, and to the  Fever Institution.   Medico
Qtururgical Transactions, Vol. II. p, 31. and seq. 
101
   It only remains to take notice of two objections to vaccination.
The first is, that it is apt to be followed by a very sore arm.  This,
however, applies in a greater degree to small-pox; and in general,
the vaccine sore heals, by being dusted with chalk or hair powder;
and even  when tedious,  seldom  requires any other application.
The second is, that it is followed by cutaneous diseases.  But these
occur seldomer, than when the  variolous inoculation was perform-
ed; for' then inflamed pustules  and boils, with leprous and impeti-
ginous  eruptions,  frequently succeeded the disease.  Doubtless,
children, after vaccination, may have crusta lactea, lepra, &c. but
it does  not  thence follow, that these are the  consequences of ino-
culation ; and it is not unworthy of remark, that no new cutaneous
disease has been produced  by the introduction of the cow-pox.fmj


                       § 34. CHICKEN-POX.

   The  chicken-pox is a disease  sometimes mistaken for small-pox;
and at one  time,  and by some authors, described  along with  it.
It  is preceded by  eruptive  fever, which continues for three days,

  CmJ The following note is extracted from the Eclectic Repertory for July
1813.  The interesting nature of the information it contains, it is presumed, pre-
cludes the necessity of apologizing for introducing it here.
  " The  following important statement, from the annual official Reports of the
Board of Health of Philadelphia, with the  accounts of persons vaccinated by the
society for promoting vaccination, must be peculiarly interesting and conclusive
in respect to the benefits of this  invaluable discovery.  By the Reports of the
Board of Health, it appears, that there have died of inoculated and natural small-
pox, in the city of Philadelphia and its neighbourhood,
             In 1807                  32 persons
                1808                 145
                1809                 101
                1810                 140
                1811                 117
                1812                 None
             In 1809               1102 ^    Persons were successfully
                1810                955  J   vaccinated by the Physicians
                1811               1277  (  of the Society for promoting
                1812               1255  f  vaccination  in the city and
                                  ----  I   neighbourhood of  Philadel-
                          Total    4589 J  phia. 
102
 and is marked by langour, loss of appetite, thirst, furred tongue,
 pain in the head, back,  and limbs, sometimes pain in the epigas-
 tric region,  with nausea and vomiting.   The pulse is quick, the
 face occasionally flushed, and cough and hoarseness  may attend
 the disease.  Convulsions also,  in some  cases, occur during the
 fever,  or the child has tremours when asleep, accompanied with
 terrifying dreams, or he is slightly delirious.  The eruptive  fever
 does not always go off when the  eruption appears, but may conti-
 nue even till the third day of the eruption.  In general, however,
 the symptoms are mild,  and sometimes exceedingly trifling.   The
 eruption commences on the back, or breast, and next appears on
 the face and head, which is not  the order observed by the vario-
 lous eruption.   Last of all, it appears on the extremities.   The
 pustules very soon contain lymph, and by the fifth day are cover-
 ed  with scabs or  crusts, which is  earlier than  happens in the
 variolar.  These drop off sooner than in  small-pox, and very sel-
 dom leave any cicatrix.   The eruption is attended with very con-
 siderable itching, in consequence of  which the pustules are soon
 broken.  The pustules  are seldom  or never confluent, and Dr.
 Heberden never could count more than twelve upon the face, but
 we sometimes meet with many more.
  In  varicella,  almost every vesicle, on  the first  day, has a hard
 inflamed margin.   On the second or third, they are full of serum
 at the top; and those which are fullest of the yellow liquor, resem-
 ble small-pox pustules of  the fifth or sixth day.   On the third or
 fourth day, the shrivelled and wrinkled state of the vesicles which
 remain entire, give a different appearance from the variolae ; and
on the fifth day, the presence of  scab assists the  diagnosis.   It is
 proper, however, to add, that in some cases, 1 have found the pus-
tules longer than usual of running their course, and the disease al-
 together so like small-pox, that  I would have been  at  a loss to
decide on the nature of the disease, had not the rest of the children
in the family had the chicken-pox at the same time  in the usual
 form.
  Such is the general description of this disease ; but it consists of
some  varieties, which have very properly  been separately describ-
 ed by Dr.  Willan, whose distinctions I shall retain.  1st, The len- 
103
ticular.  The eruption consists, on the first day, of small red protu-
berances,  not exactly circular,  with  a flat shining surface, in the
middle of which, a minute vesicle is  soon formed  These, on the
second day, resemble miliary vesicles, are about the tenth part of
an inch in diameter, and  are filled  with whitish lymph.   On the
third day, the extent is the same, but the fluid is straw-coloured.
Next day, many of the vesicles are broken; and those which are
not, have1 shrunk, and are puckered at their margin.  Few are entire
on the fifth day.  On the sixth day, small thin brown scabs appear
universally,  in place of the vesicle.   On the seventh and eighth
days these turn yellow and dry,  from the circumference toward the
centre;  and on the ninth or tenth day, drop off, leaving red marks
without pitting.  2d, The conoidal.  The vesicles rise suddenly,
and have a hard inflamed border.   On the first day, they  are acu-
minated, and contain a bright transparent lymph.  Next day, they
are more turgid, the lymph is  straw-coloured, and they  are sur-
rounded  with more extensive  inflammation.  On the third  day,
the vesicles  have shrivelled, have inflammation round them;  if
entire, contain purulent matter,  if they have burst, they are cover-
ed with slight gummy scabs.   The scabs fall off in from four to
five days, and often leave durable pits.   A fresh crop  of  pustules
come out on the second or third day, and runs the same course with
the first; so that the eruptive stage in this species is six days, and
the last formed scabs are not separated till the eleventh or twelfth
day.  3d, The  swine  or bleb-pox.  The vesicles are large  and
globated, but the base is not exactly circular.   They are surround-
ed with  inflammation, and contain transparent lymph, which  on
the second day resembles whey.   On the third day, they subside
and  shrivel,  and appear yellowish, the fluid being mixed with a
little pus.  Before the end of the fourth day, they are  covered
with thin blackish scabs, which fall off in four or five days.
  The chicken-pox is a very mild disease, and requires  no other
management than keeping the bowels open, and the surface mode-
rately cool.   The  skin may be spunged with cold water, which
diminishes the heat, and lessens the number of pustules, if  done
during the eruptive fever; at a  later period it abates  the itching.
I have, especially in  scrofulous children, observed,  that if the 
104
bowels were neglected by the parents, and the  diet was full and
heavy, the pustules became much inflamed, and ended in sloughs,
which left large and  permanent cicatrices ; and  in  some cases,
boils  and abscesses have occurred from the same cause.

                       § 35. URTICARIA.

  Urticaria, or nettle rash, may appear either as an acute or chro-
nic disease.*  The first is most frequent with infants and children.
It is preceded by languor, sickness, and fever, on the third day of
which, but sometimes earlier, an itchy eruption appears,  bearing a
very exact rejsmbl .nee to that produced by the stinging of net-
tles.  It  consists of irregular  patches, slightly elevated above  the
surface.   These are of a dull white colour at the centre, and  red
towards the margins, which are sometimes hard and well defined.
The size and  shape of the patches  are very various.   Generally
they are  about the size of a penny-piece, but sometimes form pret-
ty long stripes.  This  eruption is,  in  some  cases, attended by a
slight turgescence  of the skin, but especially of the face  and  eye-
lids.  The patches do not remain constantly out, but appear  and
disappear irregularly during the disease, which  lasts for  seven or
eight  days, including the period of the eruptive fever.  When the
eruption  declines, the languor, stomachic symptoms, and feverish-
ness go off.  The disease terminates by slight exfoliation of the
skin.   In infancy and childhood, it is'often dependent on dentition.
or affections of the bowels ;  and from the itching which attends it,
great  distress is produced.   The febrile urticaria is not infectious,
but in certain seasons  it is  very  prevalent; and the same holds
true with regard to the chronic species.  Chronic urticaria is more
rare in infancy.   It differs from the former, chiefly in being  des-
titute of fever, and vexing the patient at intervals for a  length of
time ; sometimes  even for years.  The patches seldom  continue
out, however, for above a few hours  at a time.   They  are,  like
the former, reproduced readily by exposure to cold, and are also
particularly troublesome after undressing to go to bed.  A tempo-
  * Dr. Willan notices five different species of this disease j but for the present
purpose, this simple division is sufficient. 
105
 vary eruption of this kind, without fever, is often consequent to eat-
 ing particular kinds of fish, or substances which disagree with  the
 storhach.  An eruption  somewhat resembling urticaria, is describ-
 ed by Dr. Willan, under the name of roseola annulata;  it differs
 in size, and some other circumstances, whilst it agrees in others.
 It consists of circular patches, about half an inch in diameter,  the
 margins rose-coloured, the centre of the usual colour of the skin.
 These cover the body, and produce, especially  at night,  a sensa-
 tion of heat and itching.   When unattended with fever, the erup-
 tion fades in the morning, and becomes round and elevated at night.
 The use of acids and sea-bathing will  be of service.
   A gentle emetic, followed by one or two  purges, gives  relief in
 acute urticaria.  The  child  should, if possible, be  kept from
 scratching, so as to tear the skin ; and this will be the easier done,
 if he be  preserved  in a uniform temperature.  The  tepid bath
 sometimes gives relief.   The chronic species is more obstinate,
 and in consequence of  the  abrasion  of the skin,  from  frequent
 scratching, it has sometimes been treated as itch, but without ad-
 vantage.  The bowels are to be kept open by cream of tartar, and
 some  tonic medicine  should be administered. -Tne  tepid bath
 daily will also be proper, but sometimes, sea-bathing continued  for
 some months succeeds better.   Mercurials  have been  tried with
 very little good  effect.

                      § 36. SCARLATINA.

   Scarlatina may appear under two  different forms.  In the first,
 it  is  accompanied with inflammatory fever, and is generally mild,
 in the second, it is connected with a typhoid fever, and is very
 malignant.  The first species admits of a farther subdivision, ac-
 cording to the  degree of  mildness; one  variety being attended
with slough or ulceration of the throat; another, still milder, with
little or no affection of the fauces.   This has by some been called
scarlatina simplex, to distinguish it from the first, or scarlatina an-
ginosa.
   The scarlatina simplex  begins with a  febrile attack, attended
with considerable debility, chilliness, nausea, and pain in the belly
     Vol. II.                  14 
106
 and about the loins and extremities.  It generally attacks very sud-
 denly in the afternoon or evening, the patient having been, not an
 hour before, lively, and apparently in good health.  The pulse is
 extremely rapid, being often 140  in the minute;  the trunk is very
 warm, and the feet cold; the respiration frequent, irregular and
 sometimes sonorous; the eye dull,  and  the eye-lids turgid and
 red on the inside.   Sometimes, but  not  often, convulsions occur
 early, and  are to be  considered  as  unfavourable.  On the next
 day, if not earlier, an .ruption appears, first on the face  and neck,
 and very soon, always within twenty-four hours, it is diffused over
 the whole body.  It consists of numerous minute specks, so close-
 ly set together, that the skin appears altogether of a red colour,
 like  a boiled  lobster,  and it feels rough.  Broad patches also ap-
 pear on those  parts which are most  exposed to heat or pressure.
 The inside of the  eye-lids, nostrils,  cheeks, and fauces, are of a
 deep red colour,  and the tongue participates in the appearance.
 The eruption is most vivid at night, and especially on the evening
 of the third or fourth day.   On  the fifth day it declines, and is
 wholly  gone by  the  seventh,  when desquamation takes place.
 During the eruptive stage, the patient is  generally either restless,
 or very drowsy, often slightly delirious, and both during this stage,
 and the process of desquamation, complains much of  itchiness.
 Whilst the fever lasts, the skin is. extremely hot.   The contagion,
 in general, operates on the third or fourth day after the person has
 been exposed  to it.
   The scarlatina anginosa is attended with more severe symptoms.
 It commences with the usual symptoms  of fever;  and in general,
whenever these appear, or even before the  fever commence, the
 throat will be found, on inspection, to be  affected;  but sometimes
the cynanche does not take place till  the eruption come out, which
is nearly about the  same period as in  the former species.   Dr.
Sims says, that the  first marks of disease are paleness and dejec-
tion  of coutenance,  and that at this time the fauces will be found
to be red.  I am  very much inclined to  adopt the same opinion.
From the first, there is a sensation of stiffness about the muscles
 of the jaw and neck;  and very soon,  generally on the second day,
the throat feels as  if straitened, the  voice becoming hoarse, and 
107
sometimes a crbupy cough takes place.   In this case, the breath-
ing often becomes  sonorous, or even so obstructed that the child
is suffocated, as in  cynanche trachealis.   In very many  cases, de-
glutition is performed with difficulty, and sometimes the drink re-
turns by the nose.   On examining the mouth we find at the first,
that the tongue has a very red colour, and its papillae are evidently
elongated.   In the progress of the disease, it is often covered with
a fur.  The tonsils are early observed to be of a deep red colour,
and very soon whitish streaks may be  discovered.   Superficial
ulceration is  frequent on  the second or third days, and the parts
bocome covered with a white or ash-coloured substance, or slough,
whilst the rest of the tonsil becomes of a dark red colour.   The
sloughs are sometimes not removed for. a week or more, but often
are detached on the fifth or sixth  day, when the cuticular  erup-
tion declines.  The inside .of the nostrils is inflamed, and  some-
times ulcerated.  The lips, likewise, become tender and  itchy,
and owing to the child picking at them, they, as well  as the  gums,
are apt .to be covered with black patches, chiefly from effusion of
blood.  The eruption, in this  variety, is  the same  in appearance
and duration  as in the former.  When it is slight, or disappears
suddenly, it has been said that the event is hazardous, but this
is not  always the case.   The  fever is attended often with  great
nausea, bilious vomiting, restlessness, headach,  and delirium.
The heat is excessive, the pulse feeble, and sometimes  fluttering,
always very rapid.   The languor and inquietude are great, espe-
cially when the sloughs are  forming.   About a week or ten days
after the eruption fades, anasarcous swelling of the legs may take
place,  ana continue even for two  or  three weeks.  Sometimes
other parts of the body swell,  or the patient has ascites.
   Scarlatina is sometimes succeeded by pain in the ear, followed
by  temporary deafness, and the discharge of foetid  serous fluid.
This often  abates,  upon syringing the ear with decoction of camo-
mile for a few days; but it may be more obstinate, and the child
remain permanendy deaf.   The  tonsils  occasionally  suppurate,
after the external disease abates.  Swelling of the parotid gland is
not uncommon; and it is said by various authors,  when it  is late
of  appearing, to protract or renew the  symptoms,  even the erup- 
108
tlon itself; but this I have not witnessed.   Sometimes the glands
of the neck swell  and suppurate, or the bones of the nose, after
obstinate ulceration, become carious.   I have seen some unfortu-
nate cases, where  the lips have sloughed  completely  away, and
these  ended fatally.  Even after the patient has, to all appearance,
recovered from scarlatina, there sometimes unexpectedly  super-
vene languor, debility, and pain of the bowels, frequent pulse, and
loss of appetite, which symptoms terminate in dropsy.   Bronchitis
or pneumonic affections  may also be produced.  In some cases
the patient  becomes  languid without fever or dropsy, but these
generally  do well.
   In  the second species, or scarlatina maligna, the pulse is very
small  and feeble, sometimes indistinct.  The debility is very great,
the patient fainting  on making  the  smallest  exertion, and very
generajly he is unable to  sit up in bed..  In the scarlatina benigna,
the tongue is red,  the eyes and eyelids red, the throat at firsi red,
and the skin like a boiled lobster; but in this species,  the tongue
is livid, tender, and soon covered, together with the  teeth and lips,
with a brown or black crust, the eyes are dull, and the insice of
the eyelids dark-coloured, the cheeks are livid, the throat of a dark
red colour, with brown or blackish  sloughs;  there is  very foetid
breath,  with much acrid  discharge from the nostrils.  The inside
of the labia pudendi of girls, and of the prepuce  of boys,  has in
scarlatina the same colour with the inside of  the cheeks and lips :
in the scarlatina maligna, the vulva and lips are of a dark colour,
and sometimes mortify.   The eruption is sometimes faint, in other
cases very dark and purple-coloured, and often appears and disap-
pears irregularly. In the progress of this disease, delirium, great fret-
fulness, or coma may come on.   The breathing is rattling, the neck.
seems to be full, and  of  a livid colour, and the head is bent back.
This  disease sometimes  proves fatal in a few hours.  It is  not,
however,  always alike mortal, for there are several smaller degrees
of malignity, forming a  gradation  betwixt this and the scarlatina
anginosa.
   The first species, when properly managed, is not very dangerous,
but the last is attended with great hazard.   The prognosis must be
made, by attending to the symptoms  of debility, the progress of 
109
the affection of the throat,  the  tendency to imflammation of the
trachea, and the general character of the epidemic.
   Drs. Withering, Adams,  and  Willan, believe, that the scarlatina
does not attack the same person twice, though the throat may be
to a certain degree repeatedly affected.  Although I have  had
many opportunities of attending to this disease, I cannot form a
decided opinion on this important point; but I am inclined to adopt
the same conclusion.  Aphthous affections of the throat, and exu-
dation of lymph from inflammation, are often considered as belong-
ing to scarlet fever, though  the eruption be absent, but the conclu-
sion is incorrect.  Those  who are exposed to the contagion of
scarlatina, may have sloughs in the throat, attended with consider-
able debility, but a regular repetition of the scarlet fever is certainly
not a frequent occurrence.  Sometimes other eruptive diseases,
such as roseola infantilis have been taken for it.
   The scarlatina simplex and anginosa, are often so mild diseases,
as to require little medicine, but still great attention is necessary.
When there is a considerable appearance of inflammation, vene-
section has been recommended ; but this is very seldom necessary,
often hurtful, and  may almost uniformly be superseded by other
means.  In adults or children, however, who have a determination
to the head, marked by  severe headach, or feeling of weight, ac-
companied with much fever, the instant use  of the lancet has been
attended with  immediate  and  permanent relief.   Emetics, given
early, are sometimes attended with advantage, and supposed to ren-
der the subsequent disease  milder.  But of the truth of this opinion,
I have  not been able to satisfy myself.   Laxatives  are still more
useful, and in  mild cases are the only medicines which are requir-
ed.   In some epidemics, the bowels are moved with greater diffi-
culty than  in  others, and in  those  cases  the laxative must be
stronger.  Even when there is a tendency to diarrhoea, if the stools
be foetid and unnatural in their appearance, purgatives are equally
necessary as in the opposite state.  »The best medicine to be given
at first, is calomel in a brisk dose, which often, even at the com-
mencement of the disease,  brings away foetid stools. This medicine
cannot be used too early; and if an emetic have been given, calomel
ought rapidly to succeed it.  After  the operation of the first  dose 
110
 of calomel the bowels must be kept open, or eveu rather loose, hy
 the daily use of infusion of senna with an aromatic.   This is bet-
 ter than repeated small doses of calomel, which often affect the
 mouth considerably.  But if the stools be very foetid, the patient
 oppressed, and  the belly full,  a brisk  purgative may be  given
 oftener than once in the course of the disease.   Another  remedy
 of great importance,  is affusion with cold water.   From careful
 observation, and repeated trials, I can with confidence recommend
 this remedy, which by no means prevents the exhibition of purga-
 tives at the same time.  It is of consequence to use this early, and
 whenever the patient feels steadily hot, the shivering  having gone
 off, and the skin feels very warm to the hand of another person, it
 is time to put him into an empty tub, and dash over him a large
 pail-full of cold water.  By this I have known the disease arrested
 at once, the eruption never becoming vivid, and the  strength and
 appetite in a few hours returning.  Even where it is not arrested,
 it is pleasant to observe the change it produces.  The patient, from
 being dull, languid, and listless, feels brisk, and disposed to talk or
 laugh ;  the skin becomes for  a time colder, and refreshing sleep is
 frequently procured.  The repetition must depend on the degree
 of heat: one  application  is sometimes sufficient,  but it often is
 necessary the first day to use it three times, and next day once in
 the morning, and again in the  evening.  It is seldom requisite after-
 wards ; for although the  disease may  continue, it is mild, and laxa-
 tives complete the cure.   If the affusion be not employed, we ought
 to have the surface cooled frequently with a sponge dipped in cold
 water.   Even an advanced state of  the disease, if the bath have
not been previously employed and the skin is hot, does not pre-
clude its use, though at this period, it is generally better to  employ
the sponge.   On the contrary, it revives  the patient.   The use of
 cold is generally beneficial when it is not succeeded by chilliness
or langour; in such cases it must be abandoned.  These two reme-
 dies do  not only mitigate the  disease, but lessen the risk of  drop-
sical swelling taking place afterwards.*   Gargles are often useful,

  * Dr.  Hieglitz recommends  in scarlatina, first an emetic of ipecacuanha,
and then so much Epsom salts as shall procure four stools.  In bad cases he gives 
Ill
  when they  can be employed.   Water, acidulated pretty sharply
  with muriatic acid, or mixed with capsicum vinegar, forms a very
  good gargle.  Acid fruits are  proper.   The diet  should  be  light
  and nourishing.  In mild cases, it is not necessary to  give wine ;
  but  if the debility be considerable, small doses of wine may, to-
  ward the end of the disease, be administered.  Should anasarca
  take place,  laxatives and diuretics, such as digitalis, are proper.
    The scarlatina maligna is much more dangerous, and requires
  the most vigorous practice.  The early use of cold water is highly
  proper, and often gives a  favourable turn to the future  disease
  Laxatives are likewise necessary, and so far from weakening  the
  patient, if prudently administered, seem to increase his strength
  Wine should be given, in such  doses as do not flush the patient, or
  make  him  hotter.   Ammonia is  sometimes  of benefit.   Two
 drachms should be dissolved in six ounces of water, and the  solu-
 tion  sweetened with sugar.   To infants, two tea-spoonfuls, and to
 elder children, from a desert to a table-spoonful of this solution,
 may be given every two hours,  or oftener if possible.   An infusion
 of Capsicum  in vinegar is also employed with advantage ; so much
 of it is to be added to a given quantity of water, as renders it pun-
 gent.   This mixture may be given in the same doses as the solu-
 tion of ammonia, and it both acts as a general stimulant and  as a
 local application to the throat.   Bark has certainly, in many cases
 been of service; but in general, children do not take  it in  such
 doses as to do much good ; or they loath it, or reject it by vomit-
 ing.   Even when taken freely, it is not a medicine that can be de-
 pended on, in the cynanche maligna of children, but  at present I
 know of nothing better to propose.  When it is prescribed, it may
 be combined with ammonia or  capsicum.   But in general  it is
 better to  give it in clysters  made of beef tea  without salt.  Myrrh "
 has also been given, combined with vinegar ; but of the effect  of
this, I cannot speak from my own observation.  Oxygenated  mu-
riatic acid, in doses of twelve drops to children, has been employ-
ed ;  but I question if it produce  better effects than water acidulat-
four grains of calomel daily, or rubs in gss of ung. hyd. Whenever the salivary
glands become affected, the disease, he says, takes a turn. 
                               112

   ed with sulphuric acid, which, if the ammonia  be not employed,
   makes a very proper drink.  If the patient, at an advanced period,
   be restless, and the skin dry and rough, ablution with tepid  water
   will be  useful.  As gargles, capsicum vinegar with water, or mu-
   riatic or nitrous acid with honey and water, may be  employed;
   but as children often cannot,  or  will not use gargles, their utility
   must be limited.  They might be thrown  on  the tonsils with a
   syringe, but are apt to  go into the wind-pipe if they get so far back
   as the fauces.   It is also proper to touch the sloughs  and tonsils
   frequently, with a pencil dipped in the tincture of myrrh or cam-
   phorated spirit of wine.  Fumigations, made by pouring sulphuric
   acid on  nitre, placed in a vessel in the bed-room, have also a good
  effect on the throat.  When the sloughs are large,  or the  child
  breathes with  difficulty, or has a croupy cough, gentle  emetics
  have been proposed.  On this subject, I must refer to what I have
  said already,  (sect.  28,) respecting laryngeal disease, occurring
  in putrid  sore throat.   Blisters  have also  been applied to the
  throat, but I really cannot say decidedly, that they do  good, and
  they add greatly to the irritation of the child.  In bad cases, there
  is risk of their being followed by mortification of the part.  Some-
  times, in the course of this disease, apoplexy succeeded by hemi-
  phlegia,  and inability to articulate  distinctly, takes place.  Blisters
  should be applied to the head,  and if the patient survive, the para-
  lytic symptoms go off in a few weeks.
    During the course of the disease, the strength must be supported
  by nourishment, or if that cannot be swallowed,  by nutritive  clys*
  ters.
    When a disease of this kind appears in a family, the children
  who are  unaffected, ought, if possible to be sent away, and should
"  not return for a month.   In the mean time, the clothes  should be
  washed,  and the apartment well ventilated, and fumigated with the
  vapour of oxygenated muriatic acid.   This fumigation may be em-
  ployed, even during this disease, for the destruction of the conta-
  gion, and of the smelling matter in the room. 
113
                        § 37. MEASLES.

   Measles commence with a distinct eruptive fever; on the first
 and second days of which, the patient complains of irregular shiv-
 erings, alternating with heat, general debility, languor, loss of ap-
 petite ; has white tongue, thirst, pain in the back and limbs, slight
 sore throat, hoarseness, with dry cough and sneezing, weight and pain
 across the forehead, giddiness, drowsiness, sometimes convulsions,
 frequent and irregular pulse, costiveness, and high-coloured urine.
 On the third or fourth day, the symptoms become more severe ;
the eyes are tender, watery, and appear as if inflamed, the eye-lids
 are often swelled, the nostrils discharge thin serum, and the patient
 sneezes  more frequently.   There  is  now often some  degree of
 dyspnoea, and sometimes pain and tightness in the chest.  These
 febrile symptoms usually come on distinctly, about twelve or four-
 teen days after exposure to infection ;  but I have known children
seized more gradually, being teazed with hard cough, and render-
ed more irritable and  fretful for many days before  the  eruptive
fever commenced.  The eruption appears betwixt  the  third and
 sixth day of the fever, but  most frequently on  the  fourth, and it
remains for about three days.  It is first visible  on the forehead,
then on the throat, then on the face.   Next day it appears on  the
breast, and by the evening  it  covers the  trunk and  extremities.
The eruption consists at first of small red spots, apparently a little
raised, like papulae, but without vesicular  tops.   Then  the spots
extend so far as  to form an oval or irregular figure, slightly elevat-
ed, but flat, resembling a flea-bite.  Very soon large  patches  ap-
pear, intermixed with the distinct spots.   These are  irregular in
shape, but tend to the semilunar figure ; they are made up of clus-
ters of distinct spots.   In some cases, the  eruption,  though vivid,
is not considerable; and in this case, it consists almost equally of
patches and circular and  irregular spots, and the  intervening skin
is of the natural appearance.  When the eruption is more copious,
the patches are most numerous and extensive.   In children under
a year old, the eruption is not so thick and confluent as in  older
subjects, and in many places has a papulous appearance, especially
     Vol.  II                  l* 
114
 oh the face and hands.  In some cases, the eruption,  though of
 the  usual  configuration,  is pale and indistinct;  but in  general,
 whether vivid or not, when the finger is passed over the  surface,
 the skin feels unequal, from the elevation of the spots and patches.
 The colour is most vivid  after  the eruption has been out for a day.
 Sometimes the eruption  suddenly  and prematurely recedes, or
 never comes fully out.  Both  of these cases are unfavourable, the
 fever is high, and the oppression great.   In the regular course of
 things, the eruption on the face fades a little on the sixth  day, and
 next day that on the body becomes also paler.*  From this to the
 ninth day, the eruption is going off, and then the former situation of
 the rash is only marked by a slight discoloration.   The  departure
 of the efflorescence is attended with  desquamation, during which
 the patient complains  much of itchiness.  The fauces in this  dis-
 ease, about the fourth  day,  are covered with  small red  patches,
 which next day have a scattered or streaked appearance.   The in-
 flammation of the eyes, sneezing, and hoarseness, generally  de-
cline with the eruption, and towards the end, epistaxis  sometimes
takes place.  The fever  continues during the eruption,  but the
sickness and nausea abate when the eruption comes out, and about
the sixth day  the heat and restlessness go off.   A spontaneous
diarrhoea often terminates the  jfever,  and then the appetite returns
pretty  keenly.   Sometimes, especially if  the  disease have been
severe, the measles are followed  either by an eruption of inflamed
pustulesf over the body, wJiich may ulcerate,  and prove  trouble-
some, but  more frequejj^  they  fade, or by a vesicular herpetic-
looking eruption about the  mouth, or  sometimes  by gangrenous
affections of the lips or vulva,} or by enlargement of the glands of

  * Sometimes, instead of this, the eruption becomes very dark-coloured, or pu»
pie, with increase of the languor  and fever.  Mineral acids in this state are use
ful, and most children recover. The danger is greater when petechia: appear
among the patches, for this marks great debility.
  f These are sometimes taken for a kind of small-pox.   They are occasionally
succeeded by a scabby disease of the skin.  The skin is inflamed and covered
with rough loose yellow scabs.
  $ The measles,  about fifteen years ago, were more prevalent than  any  prac-
titioner I have met with remembers them to  have ever been before.  They be. 
115
 the neck, or dropsy, or a cough, somewhat  resembling  that in
 hooping-cough, or by hectic fever, continuing for many weeks.
   Sometimes the sickness and oppression are great and perma-
 nent.  The child never looks up, but breathes heavily, and, owing
 to stuffing of the nostrils, loudly.   He coughs  often, has frequent
 pulse and hot skin.   He can scarcely be roused up,  even  to take
 a drink.   This state arises more from the brain than the lungs.
   In measles, the membranes are very apt to be affected.   Gene-
 rally, the membranes of the wind-pipe, bronchiae, fauces, nostrils,
 and eyelids,  are chiefly affected,  but sometimes that of the sto-
 mach or bowels principally suffers, producing sickness, vomiting,
 or purging.  At other times that of the brain is affected, producing
 coma.
   Rubeola, in general, is not a fatal disease, -when stimulants are
 avoided.   When it proves  fatal, it is most frequently in  conse-
 quence of the pulmonic affection, sometimes of coma, or fever,
 and oppression, with symptoms of effusion in the brain connected
 with recession, or imperfect appearance of the eruption.
   The treatment is  extremely  simple,  and may be briefly ex-
 plained.   During the eruptive fever, the use of mild diaphoretics,
 and the tepid bath* will be of advantage.   The bowels should be
 kept open, but the child should not be much purged after the first
 day.   If there be a considerable diarrhoea from extraneous causes,
 as dentition, or directly connected with the fever, it is often found
 that the eruption is late of appearing, and a late eruption is gene-
 rally attended with some troublesome symptoms, as it indicates  a
 tendency to  affection of some  internal  membrane.   A little rhu-
 barb, given early, often moderates this.
  If the eruption do not come freely out, or recede prematurely,
 and the child  be sick, oppressed, and breathe  high, we  must at-
 tend first of all to the bowels.  If diarrhoea exist, and the child be
not plethoric, a little rhubarb should  be given, and  then spiritus
ammonia? aromaticus with laudanum, and  the child  should  be put

gan about the middle of winter, and continued during the summer and autumn.
I had occasion, during that epidemic, to see different instances of the gangre-
nous affection I have mentioned.  The children all belonged to the poor, and
'ivrd in confined houses. 
116
in a warm bath, having a little mustard diffused in  it; afterwards
a sinapism, followed by a warm plaster,  should  be applied over
the stomach, and  we determine to the  surface by giving a saline
julap.  If in this state  the  child be costive,  a  gentle  purgative
should be  given, for the  bowels may be either  too torpid or too
irritable.
   I have not advised the liberal use of purgative medicines, though
these are found beneficial in scarlatina, because we often find that
diarrhoea interferes with the eruption.  But the bowels are upon
a general principle to be kept regular, or  rather open ; and if the
stools be foetid or ill-coloured, then, even although diarrhoea exist,
small doses of calomel  should be given, and afterwards, if neces-
sary,  the  purging is to be moderated by anodyne clysters.   So
far as I have observed, the continuance of the  diarrhoea, in this
case,  does not mitigate the symptoms ; and if the child recover,
it  is either by the use of medicines bringing the bowels into a bet-
ter action, or it is independent of the mere evacuation produced
by the diarrhoea.
   If the pneumonic symptoms be considerable, marked by cough,
oppressed breathing, flushed cheeks, and  pain in  the chest, which,
in young children, may  be discovered  by the  effect of  coughing,
and if a slight motion excite coughing,  a blister should be applied
to the breast, and if the symptoms are urgent,  either  the  lancet
must be early used, or leeches may be applied  at the top of the
sternum, according  to  the age and constitution  of the child, and
moderate doses of  calomel given to keep the  bowels  open.  If
the cough be frequent, without inflammatory symptoms, opiates
give great relief.  If the symptoms of inflammation be such as to
require bleeding, or to render the propriety  of using  laudanum
doubtful, then small doses of solution of tartarite of antimony may
be given every two hours, but not to  such extent as to produce
sickness or vomiting.  Diarrhoea should not be checked,  unless
severe, and it increase debility, or produce hurtful effects.  Ano-
dyne clysters are then the best remedies.
   Coma or drowsiness very frequently attends  the measles, and
the child may  perhaps  scarcely look up  for some  days.   When
the nostrils are stuffed with mucus, the breathing, in this case, has 
117
an alarming appearance of stertor.   Most  children  recover from
this state ; but as some die evidently from this  cause, and as we
have no means of ascertaining the security of any individual,  I
hold it expedient to use means for the removal of the coma, par-
ticularly by giving a purge, if the child have not a looseness, and
shaving  the  head, and afterwards applying either a sinapism or a
blister.   When the child is plethoric, it may also be proper to ap-
ply leeches to the forehead.
  The  cough which remains after  measles, is generally relieved
by opiates.  Hectic  fever is  often removed, by keeping the bow-
els open, giving an anodyne at bed-time, carrying the child to the
country, and adhering to a light diet.   Other symptoms are to be
treated  on general principles.
  When the measles are  epidemic, it is not uncommon to find
those who had formerly the  disease, affected sometimes with ca-
tarrh* without any eruption, sometimes with an eruption preceded
by little or no fever, and without any catarrh.  This has been very
distinctly observed, during every season when the  measles were
prevalent.  Whether the eruption be of the nature of measles,  is
not easily  determined,  but certainly the external resemblance is
very great, in so much that this eruption has been called rubeola
sine catarrho.   It requires no particular treatment, and is  only
noticed because it is sometimes mistaken for measles, but does not
prevent the patient from a second attack.f

  * During the epidemic, some years ago, ophthalmia was extremely prevalent
 amongst young and old.
  f Of all the eruptive diseases the measles are undoubtedly the most inflam-
matory.  They therefore require  to be treated by depletion.   Bleeding, even
pretty copiously, can rarely be dispensed with.  I speak now of the disease as
it appears in this country.  To this remedy may also be added occasionally purg-
ing with the neutral salts, and the  antimonial preparations with a view not less
of diminishing  arterial  action than overcoming the structure on the surface
of the body. The whole antiphlogistic plan is indeed to be pursued. If there
be much local affection either in the lungs or headfc blisters should be employed.
Change of air, especially by removal to the country will be found most speedily
and certainly to subdue those distressing effects which too often follow the dis
case, such as diarrhoea, cough, &c. C. 
118
                         § 38. ROSEOLA.

   Sometimes an eruption, termed by Dr. Willan roseola,* is mis-
 taken for measles, f  The first species, roseola aestiva, has no small
 resemblance to rubeola.  It is often preceded by chilliness, alter-
 nating with  flushes of  heat, languor, faintness, restlessness, occa-
 sionally with severe headach, delirium, or convulsions.  At some
 period, betwixt the third and seventh day from the commencement
 of these symptoms, the rash appears, generally  first on  the face
 and neck, and afterwards in a day or two over all the body.  The
 patches are  larger and more irregular than those of the measles,!
 m which the eruption consists of spots like flea-bites, and patches
 made up of  these spots arranged sometimes  in a crescentic form,
 and of a colour  seldom deeper than bright scarlet, often much
 paler.  In this  disease, however, the eruption is at  first  red, but
 in general it soon assumes a deep roseate hue, from  which Dr.
 Willan gives its  name.  The fauces are  tinged with the same
 colour, and the patient feels a slight roughness in the throat. The
 eruption appears first at night, and  continues vivid next day, with
 considerable  itching.   On  the  third  or fourth  day,  only slight
 specks of a dark red colour are observable, which next day disap-
 pear, and together with these the internal disorder.   In some in-
 stances,  the skin on many parts becomes of  a dusky colour, with
 an appearance of slight vesication or desquamation.   The drow-
 siness, sneezing, watery eyes, and  running  at the nose, so com-
 mon in measles, are wanting in roseola, and  there is no pulmonic
 complaint, whilst at the same time, the patches are  larger, and
 occasionally  intermixed on the body with an appearance of net-

  * This he defines to be rose-coloured rash, without scales or papulae, variously
figured, and not contagious.  By some  former writers, this term is applied to a
disease resembling nettle-rash. Vide  Lory, 398.—The appearance of roseola
aestive is extremely well expressed by Dr. Willan in his plate.
  f Lichen simplex is also apt to be at first mistaken for measles. From  its
itchiness, and the effects produced by rubbing or scratching the extremities, it
has also been mistaken for itch.
  $ Sometimes  young infants have an efflorescence  of numerous coalescir
patches, of a strong red colour, rounded, and of the size of a sixpence.  T}
terminate in desquamation in less than a week. 
119
tie-rash.  Sometimes the rash is only partial, appearing in patches,
slightly raised  above the surface, with a  dark red flush of  the
cheek.  This form lasts  about  a week, the rash appearing and
disappearing occasionally; and  usually  the disappearing  of  the
rash is attended with nausea, faintness, &c.   In some cases, no
fever is observable, or the progress and duration of the eruption is
more  irregular  than  I have described; and  sometimes on  the
breast  or trunk, the eruption has a resemblance to urticaria, whilst
on the arm the appearance is like roseola.  This disease decidedly
is infectious.  For, in particular seasons, 1 have observed it to be
unusually frequent, and to affect all the children, and many of the
adults  in  a family.  In such cases  the  eruption has lasted from
two  to four  days,  but has been attended with  very little fever.
The only treatment which is necessary  consists in giving gentle
laxatives, the use of acids, and light diet.   If the eruption be sud-
denly  repelled, the warm  bath is  proper.   Should there be  a
marked determination to the head, brisk purgatives are proper.
  Another  species, called  roseola autumnalis, affects children
generally in the harvest, and  consists of distinct patches, of an oval
or circular shape, which  increase  to  nearly about the size of a
shilling; they are not elevated, but are of a very dark colour,  ap-
pearing at a distance, as  if a black cherry or brambleberry  had
been pressed on the  skin,  so as  to leave the impression.  The
patches are  not attended with fever, are  usually diffused over the
arms,  and disappear  in about a week.  Acids may be taken in-
ternally.
  The roseola  infantilis appears during dentition, or in a disor-
dered  state  of the bowels.  It  consists of a red efflorescence,
usually very closely set, so that  the surface is almost entirely of a
red  colour,  as  in  scarlatina; but there is  more appearance of
patches than in that disease, and the other  symptoms are wanting.
The eruption generally goes off  in a day, but it sometimes appears
and  disappears for several days, with symptoms of great irritation.
No  particular treatment is necessary except what is required on
account of concomitant circumstances.  It is sometimes preceded
or attended  by vomiting or  convulsions, with  pale face and lan-
guor.  In such cases  a gentle emetic, the warm bath, and cordial-
are proper. 
120
                         CHAP.  V.

               Of Cerebral and Spinal Irritation.*

   The action of the brain and spinal marrow, may be affected in
 different ways.   Certain  parts of the animal system sympathise
 With  each other  in a manner which cannot always be accounted
 for on the  principle of communication of nerves.  This sympathy
 manifests itself variously; but three of the most important modes
 are, First, Where  one part becomes associated with  another in
 action, the former  having its action  increased or  altered by the
 latter.  This sympathy of association may exist between remote
 parts which come to act similarly,  but not always exactly in the
 same degree or proportion.  Second^ Where action spreads with-
 out interruption, from a part to the neighbourhood,  or, perhaps, to
 a great extent.   This 1 would call communication of action ; and
 it may be  salutary, or the contrary, according to  circumstances.
 Third, When one part has its action diminished in consequence of
 another having an increase, and  vice versa.  This I have called
 the sympathy of equilibrium.   In all of these ways the brain and
 its appendages may be influenced; but these are not the only modes,
 and  some  others seem also  to assist those.  For instance, the
 brain considered as the sensorium commune, or origin of  the ner-
 vous system,  may undergo certain changes peculiar to it in that
 view.  A sudden failure in its power or action, by whatever cause
 or in  whatever  way  it may  be produced,  must occasion instant
 debility, or even  death  itself.   A slighter degree,  gradually pro-
 duced, is followed by less striking, but  not always less  serious
 changes.   A similar degree, suddenly produced, occasions not only
 debility at the instant, but important secondary effects afterwards.
These, which have been  attributed to re-action, as it has been
called, proceed  from the communication of action, already men-
tioned, whereby the part which is weakened, is not  allowed to act

 * This Chapter is new, and not to be found in the former editions of this Work. 
121
 in that degree which is proportioned to its vigour; but  has more
 excited in it than  it can properly  perform ; and the same conse-
 quence is  produced as if a positive  and  direct stimulus had been
 applied to it.   This is illustrated by  bruises and the effects of cold,.
 inflammation attacking frost-bitten parts, not only from the impro-
 per application of heat, but also from the communication of action
 from their vicinity.  Hence one object, in such cases, is to pre-
 vent communication of action, by endeavouring to moderate that
 of the neighbourhood, or even of the system, at the same time that
 we avoid the operation of stimuli on the part itself.   It is also illus-
 trated by concussion of the brain, where, in the stage of re-action,
 as it has been called,  venesection is required to cure the disease
 which is excited.   A  similar state  is  produced in those who,
 having been long exposed to hunger and cold, have heat suddenly
 applied to the body, and warm soup speedily given,  or cordials
 administered.  Such excitement of the brain thereby is produced
 as requires depletion and great care.
   Another mode of affecting the action of the brain is, by the direct
 operation of stimuli, both mental and corporeal, on it.   In the lat-
 ter case, it is similar to  any other viscus.   The heat of the sun,
 especially  if the person be stooping, a current of cold air blowing
 on the head, &c, may thus excite disorder.
  Injurious effects may also be produced by irritating the extre-
 mities of important nerves, whereby  the origins of these  nerves are
 not only affected, but also the parts in the vicinity of these origins,
 and the nerves which come off there are  irritated,  or the whole
 encephalon may, more or less, and in varying degrees, be affected.
 This is exemplified by the effects of irritation of the  nerves of the
jaw in dentition, or of the intescostal and par vagum  in abdominal
 affections.  These are two of the most important nerves  of the
 body, and are intimately connected with the basis  of  the brain,
 and spinal marrow, and also with one another, both anatomically
 and in function.  The 8th pair of nerves, so important to the sto-
 mach and thoracic viscera, arises from the  very base of the brain,
 from  the  medulla oblongata, and corpora olivaria.   It  communi-
 cates with the intercostal  and cervical nerves, and its recurrent,  as
 well as the laryngeal nerve it gives off above, have a most impor-
     Vol. II.                  16 
122
   tant influence on the larynx.  Near its origin we have the 5th, 6th,
   7th, and 9th pair of nerves, given off.   The intercostal does not
   arise itself from any particular part of the brain, although so impor-
   tant as to be called the great sympathetic nerve.  It originates from
   filaments from the 5th and  6th pair, and in its progress forms gan-
  glia, and communicates, by means  of twigs, with the 8th, and 9th,
  and cervical nerves.  At each intercostal space, it receives  addi-
  tion from the dorsal nerves.   Whilst it is important to the thoracic
  viscera, and, along with the 8th pair, supplies the  stomach, it also
  goes on to all the intestines  and abdominal viscera, so that they
  cannot be affected without influencing this nerve.
    The effects produced on the brain,  or its appendages, by  these
  causes, may, perhaps, be referred to the following heads.  1st, A
  moderate degree of excitement,  or  irritation, producing a febrile
  state, with or without spasmodic affections, or distant pain, or un-
  easy sensations.   2d, Pain referred to the head,  or spasms and
  pain m other parts, without fever, or extreme sensibility of some
 organ  of sense, with susceptibility of mental emotion.  3d,  A
 higher  degree of irritation, inducing  inflammation.  4th, A loss of
 vigour  or action in part of the brain, or its appendages, producing
 a corresponding injury  in  the parts  dependent thereon, such as
 weakness, anesthesia, palsy, &c.   This has too often been attribut-
 ed to pressure;  but pressure only produces this state, which may
 exist without it, as we see in simple concussion, or some diseases
 to be soon noticed.   5th, Apoplexy.   6th, As  secondary conse-
 quences of some of these  states, we  may have suppuration, serous
 effusion, torpor, or extreme susceptibility,  change of structure, oc-
 casioning, in its turn, new symptoms.
   The  visible consequences of cerebral  or spinal  irritation are so
 various, that  it is not only impossible to class them,  but also diffi-
 cult to believe that they arise from the same source.  They vary
 not only in kind,  but likewise in intensity and danger.  All that I
 can propose here, then, is only to give a short sketch of some of
 the effects produced, without attempting methodical arrangement.
 We are very  much in the dark, with regard to the effect of intes-
tinal action and irritation.  Some suffer nothing, others almost con-
 tinually, from this cause.  It appears that there is a kind of sym- 
123
pathy of equilibrium, between the stomach and intestines, the ac-
tion gradually descending along different portions, so that when the
duodenum is active, the stomach is less so.  Few, therefore, can
cat constantly, and digest what they eat, unless the nerves be in a
particular state, as we see in some patients who have certain varie-
ties of insanity.  In some cases, the different portions of the canal
act irregularly, or inordinately, or become torpid, in consequence
of which,  the functions of the stomach and  liver are disordered :
and, on a  former occasion, I  have said,  that in many  instances
where the stomach was supposed to be primarily, it is only secon-
darily affected.   Improper action of the stomach or bowels,  may
not only operate on the extremities of the nerves of the portion in
fault, but also, by sympathy, on other parts of the canal, and  their
nerves ; a very frequent, though seldom a dangerous effect of this,
is headach, which varies in its  seat, sensation and severity, accord-
ing to the part of the bowels affected.   Intense  thinking, anxiety,
or reading long, give  headach,  and in that case the stomach is af-
fected, the food, if recently taken,  becoming acid.  Abstinence,
for a longer period than usual, also  causes  headach ; acid in the
stomach does not uniformly occasion, but always aggravates it; so
does bile.  The most frequent cause of headach, accompanied
with anorexia, or sickness, is irritation of the  intestines, by  acid,
undigested food, inefficient doses of laxatives, or  whatever can
produce partial or slowly  progressive excitement, or irritation of
the bowels.   An opposite state, or degree of torpor in part of the
canal, may do the same.  The upper  portions of the small intes-
tines, but  especially the duodenum, are the most important in the
present  view.  They have more action to perform than the lower
parts, and the duodenum, in particular, is  to  be considered  as a
second stomach, and not only intimately connected with the first in
function, but also in nerves which communicate directly with the
brain, and not through the medium  of ganglia.   When affections
of the inferior tract produce headach, I believe it is by sympathetic
action on  the duodenum and stomach.  If the colon be briskly ex-
cited by glysters or medicines, it often happens, that by sympathy
the stomach, or duodenum in its vicinity, are affected, and the per-
son is sick or vomits,  when he  is going to have a stool; or in in- 
124
 fants, a convulsive fit often takes place at the time.  Severe grip-
 ing in the lower part of the ileum has the same sympathetic effect
 whilst it produces faintness.   A moderate degree of griping gener-
 ally relieves sickness and headach.   Laxatives rather add  to  the
 evil, till they get low, and produce this effect; relief is then  ob-
 tained, if the irritation have not been too  great.   Griping is  also
 salutary when it is moderate,  and affects the colon, particularly at
 its sigmoid flexure.*   It is not always  there,  however,  when  re-
 lief is obtained by the discharge of flatus, for this may produce a
 sympathetic effect on the ileum, and give relief.  Griping is quite
 different from spasmodic  pain, which in children  often  produces
 eclampsia, probably through the medium of the stomach or duo-
 denum.  In female adults, again, spasm of the duodenum often af-
 fects the brain, and in its turn is perhaps renewed by such affec-
 tion.    Severe pain  referred to the stomach,  often  alternates with
 insensibility, intense headach, spasmodic affection of the throat, or
 eclampsia.   This is peculiarly apt to happen  at, or immediately
 after the menstrual period.  It is relieved by  blood-letting, glys-
 ters, and laxatives, followed by an opiate, combined with asafoetida.
 If coma or carus  occur, a blister to the back of the head,  and
 leeches to the temples, are to be superadded.
   The eclampsia of infants might very properly  be noticed here,
 but I shall  refer its consideration for a separate  chapter.   The
 same is the case with spasmodic croup,f and chorea.
   Cough is another affection of a spasmodic nature which cannot
 be noticed here.   In some cases, in  young females, I have known
 almost incessant cough continue for weeks during the day, and  re-
 sist both laxatives, antispasmodics, and opiates.  When there is no
  * Griping is attended with relief, not only as it arises from excitement of the
 bowels, but from the mere sensation.  Many are relieved, for a time, from both
 headach and sickness, by transient and shifting pain in the side, bowels, arms, &c.
 When affections of the stomach, or duodenum, produce a sensation  of stricture
 or pain across the chest, there may be flatulence, but rarely either headach or
 sickness.
  f  The disease termed spasmodic asthma, is of this nature; the accumulation
 of phlegm, the flatulence, the frequent pulse, and difficult respiration, all coming
 on rapidly, and going off as speedily, the respiration remaining unaffected, in
 the  intervals, depend on an affection chiefly of the eighth pair of nerves; and
whatever irritates or disorders the stomach, is sure to bring on an attack. 
125
other apparent cause, it may be suspected to arise from  some af-
fection of the cervical portion of the  spinal marrow.   If pressure
be made on the different vertebrae, cough is excited by pressing
on one of them.  In that case leeches, and afterwards  blistering
the part, and keeping up, a discharge,  cures the disease.  At the
same time, the bowels are to be kept open.  If this disease be ne-
glected, especially at or after the time of puberty, the trachea and
lungs become affected, and phthisis takes place.
   The remarks I have made on cerebral, are applicable to spinal
irritation ;  and this cough is an example of the effects which wilj
be farther seen in an obstinate  disease I am soon to mention.
More irremediable or even fatal consequences, may arise from in-
flammation of part of the spinal marrow, or effusion of  blood, or
serum.  Local pain, with paralysis or spasmodic affection,  or pain
of the organs supplied below, are the symptoms,  and death suc-
ceeds either a general spasm or stupor.   If any thing can be done
in these cases, it is by free topical bleeding, and the application of
caustic.  The cases  which end best,  are  those where  there has
only been torpor of the part, succeeding  possibly to previous ex-
citement.  These may be tedious and alarming, but are curable.
   Some affections of the abdominal nerves produce headach, at-
tended with much feeling of fulness.   Now, in many cases, this
fulness is the most prominent part of the disease, and is more ob-
stinate than headach.   It may even go the length of apoplexy ; but
this I cannot consider here, nor is it necessary to  do more than
mention  it.  There is, however, in females, both at an early and
mature period of life, a very distressing  disease, which must be at-
tended to here.  It may succeed  to exposure to the sun in  sum-
mer, or stooping; but it may also come  on suddenly, entirely from
visceral affections.  The patient, in slighter degrees of it,  merely
feels, suddenly, heaviness of the eyes, weight in the head,  some
pain at the upper part, but this is not constant, vertigo, and a sense
of fulness in the  throat.  If standing, she is obliged to  sit down,
partly from giddiness, partly from weakness of the limbs.  The
latter Symptoms  abate, and she  feels relieved,  but not  well, and
suffers many aggravations of the complaint.  In the more  severe
cases, she. feels as if the blood were  rushing violently to the head, 
126
 and has so much vertigo, that she cannot stand, hardly can sit, and
 requires to have her head held.  If no active means be pursued,
 the complaint becomes very protracted, and for months she cannot
 walk, and even  sits with difficulty.   These are  merely different
 degrees of the same complaint.   The best remedy is venesection,
 to  an  extent proportioned  to  the  violence of  the  symptoms.
 Leeches are useful, but in a very inferior degree.   Cupping at the
 upper part of the  neck is highly advantageous.  The  head ought,
 in severe cases, to be shaved  and blistered.   In all, the bowels
 are to be freely opened.   In  protracted cases, asafoetida with aloes
 appear  to be useful, and  an issue in the  neck o.- on the head is re-
 quisite.   Some  prolonged cases have speedily been  removed by
 erysipelas, followed by sloughing and copious suppuration, taking
 place about the  issue.
   Another modification of this disease appears under  a variety of
 symptoms, and  too often is considered merely as  hysteria.   I do
 not object to this, if thereby  the proper treatment be not omitted.
 I shall describe some of the  varieties, as they appear  in females,
 generally, but not always, at an early period  of life.  One frequent
 form is  spasmodic croup, or  acute difficulty of breathing, accom-
 panied  with hoarse cough and wheezing, rapid pulse,  and heat of
 the skin.  This  yields speedily to bleeding, but is apt to return,
 and therefore requires purgatives to  remove the   primary  cause.
 It often  occurs for many nights in succession.  Emetics are dan-
 gerous,  without  the previous use of the lancet; and, in severe
cases, the patient cannot wait their operation.  Arsenic and foetids,
 in the intervals, are useful;  but purgatives and strict  diet are in-
dispensable.  In some cases, the pulse is excessively rapid,  the
face flushed,  the eye suffused, and the head confused.   The sen-
sibility is morbidly increased, so that a very little light is offensive,
and the  smallest  noise  excites either spasmodic croup, or general
muscular agitation; and there is at an early, but particularly at a
more advanced period, a propensity to laugh or cry without any
evident  cause.  There is thirst, and no appetite.  The head either
is not pained, or the patient  does not attend to it.  The eye-lids
are heavy, and soon cannot be raised.   Presently the fits of spas-
modic breathing become less frequent, but the head cannot be 
127
supported from weakness of its muscles ; and soon the whole body
becomes more or less paralytic.   The arms cannot be moved; a
weight, like a bar of iron, is felt on the chest; the pulse becomes
slow, and soon beats only perhaps thirty times in a minute.  What
the result might be, if relief were not artificially obtained, I do not
know;  but the probability is, that death would  take place.  Even
active means, if not promptly employed, do not prevent a very te-
dious and varying disease.   The  treatment I have found most use-
ful, is the instant and free use of the lancet, detraction of blood top-
ically,  full  purging, and shaving and blistering  the  head.   These
means are soon productive of relief, but it is necessary afterwards
to keep up the action of the bowels, and occasionally to take away
blood by cupping between the  shoulders.   This is also of excel-
lent effect,  in that variety of puerperal delirium,  which I have
described as analogous to this. If the first symptoms be not instantly
attacked with the lancet, and paralysis have come on, nothing gives
so speedy relief as,caustic applied to the neck;  or any very strong
and rapid stimulus, as hot water, might have the same effect. Befoi e
the pain of the caustic has been long felt, I have known the patient
able to  move her arms, and open  her eyes, but the slowness of the
pulse usually continues  long.  Anomalous  and protracted  symp-
toms may succeed  to this partial cure, or may  follow where  less
active treatment has allowed the disease to remain in more force.
The power of walking, for instance, may be slowly though  not
perfectly restored, but slightly convulsive agitation of the muscles,
with insensibility, may take place at uncertain periods; or every
night, or every second day, for  a time, the  patient  may complain
for a few minutes of headach, or vertigo, or  is observed to be dull,
and then sinks down in  a state  of coma; there is no flushing, no
stertor,  and little affection of the pulse.   From this she partially
awakes, or is roused by  convulsive motions of the  arms, or mus-
cles of the trunk; the eye turns spasmodically, and the jaw is open-
ed to its utmost extent, and fixed for a time.*   Then the  spasm

  * These strong and apparently convulsive contractions  of the muscles, are
greatly, and in some instances, altogether i lepcndant on transient paralysis of their
Antagonist* 
                             128

relaxes, and if the patient have been supported, she sinks down, as
if quite exhausted, and in a state of syncope ; but the pulse is not
weak, though sometimes frequent.  Soon, in general, another  at-
tack comes on, and then she is relieved.   It is usual, during some
part of the paroxysms, for ttie stomach and bowels to seem prodi-
giously inflated, and feel very hard ; but in an instant, and without
any evident discharge of flatus, the inflation vanishes.   This tume-
faction, however, is often apparently increased by the spine being
bent back, and the abdomen protruded.   The paroxysm does not
go off by much eructation, but often by ineffective efforts to vomit.
It is usually accompanied with distressing feeling of stuffing, par-
ticularly after eating.   Sometimes paralysis of particular members
or organs suddenly takes place, and as suddenly goes off; one side
may be affected, or the sphincter of the bladder, or tongue, or pha-
rynx, may be paralytic, and continue so  for many hours.  The
patient cannot  speak,  and  although  tormented by thirst,  cannot
swallow, but spontaneously these symptoms go off for a time;
anaesthesia generally exists as long as the disease lasts, and particu-
larly in  the lower extremities.   At last, after many months,  all
these affections subside; and although they may be replaced  by
others, connected with a  different set of nerves, yet in general, the
health is slowly restored.  It may, however, be a year or two be-
fore it is perfected, if ever.  To prevent this tedious and uncertain
issue, it is evidently important to attack the disease at the first, in
the most vigorous  way by depletion, and the means proposed.  At
this second stage, the  plan  must be general,  such as  the adminis-
tration of laxatives, the regulation of the diet,  the use of arsenic,
foetids, &ic, and gentle exercise in the country.   But I confess, in
most cases, 1 have not known decided advantage from  any medi-
cine, beyond what was required for symptoms as they arise, time
appearing to be the chief remedy.  Another variety of this, is at-
tended with violent pains  in the head,  and extreme weight  or
throbbing, alternating with palpitation, incessant cough, pain in the
side, or excessive griping.  The occasional wheezing, the convul-
sive aftection of the members, and the partial paralysis, and fits of
stupor, or insensibility, are similar to the former variety.  Mercury
and  arsenic, purgatives, tonics,  and antispasmodics, have been 
129
 tried in this case, with little apparent benefit.   Venesection for the
 more severe affection of the larynx, or pain in the side, leeches or
 blisters for the feeling of fulness in the head, large doses of lauda-
 num for the relief of pain in the head or  bowels, blisters on the
 head, issues in the neck,  and friction  for the paralytic  affection,
 have seemed to do good;  but, as in the former case, time has been
 the grand restorer; and it is satisfactory to  know, that most deplo-
 rable and protracted cases have thus been  relieved.   In  the wane
 of the disease, the recovery may be accelerated by redoubling the
 attention to the bowels, giving almost daily  some purgative potion,
 and at night extract of hellebore.  When there is a renewal of the
 sensation of fulness in the  head, or any suffusion of the eye, cup-
 ping is useful.  This, or the use of leeches  is also proper, when
 the patient sits weeping.   In other cases, the symptoms have been
 at first, at least, and sometimes altogether  more concentrated to-
 ward one organ.  In some, for instance, there has been from the
 invasion, pain in the head, gradually increasing to the greatest de-
 gree, at least, if the plaints of the patient be  admitted as a criterion
 of severity.   The pulse has  been frequent, and then slow or irre-
 gular, and the same gaping, coma, and inflation of the bowels, at-
 tending on  a former variety, appear  here.   In  others, there is
 chiefly  throbbing in the head and neck, with much vertigo, so that
 she cannot sit.   Some, again,  refer the sensation to the  stomach,
 complaining of much feeling of sinking there, on sitting up, which
 is soon followed by frequency of pulse and  headach.   In many of
 these patients, if great attention be not paid  to the limbs, the knees
 become bent, and the thighs  raised to the  belly, so that it is long
 before the contraction of the  muscles  can be overcome ;  but this
 is generally at  length effected by friction,  and efforts to stretch
 the limbs, or walk.
  There is  one feature of this disease still to be  noticed, which
 fortunately is not invariable, but nevertheless is very commonly an
 attendant, I  mean temporary mental  aberration.*  A very early

  * This is to be distinguished from a common attack of insanity, which may af-
fect young girls, as well as others, both by the previous symptoms, and by the
 periods it observes.  Insanity may be preceded by cephalic symptoms, and at-
     Vol. IT.                 17 
130
 manifestation of this consists in  obstinate deceit.   In some cases,
 the patient pretends to be asleep, in others to be blind, and this 1
 have known persisted in  for  months,  with  great  pertinacity.
 Others will not eat, although pinched with hunger, or will only eat
 in a whimsical way.  Then, the  mind suffers  more, the patient
 being as if in a waking dream,  or sometimes  melancholy, some-
 times in high spirits.  She forgets the names of persons and things,
 as well  as their relation to her, and forms new opinions concerning
 them.   This state  sometimes continues, without  interruption, for
 many weeks; in other cases,  it comes on  at  regular intervals;
 so many days, for  instance, at the end  of  a  fortnight,  or  perhaps
 even every second  or third day; and it is  observable that often
 the appetite is  voracious, during  those days.*   Like the bodily
 distemper, this yields rather to time than to  management; never-
 theless, prudent exercise of the  mind, and, in a state of convales-
 cence, vigilant efforts  to prevent a  relapse  into any former bad
 habit, along  with strict attention to the diet, and the alvine dis-
 charge, will be useful.   The best prophylactic of those distressing
 diseases, is  to avoid whatever can irritate the  brain, particularly
 costiveness; and those who have the  charge  of  young  females
 cannot be too careful in this respect.
  It is a circumstance  deserving attention, that  in these diseases,
 although different parts become suddenly  paralytic, and although
the stomach itself  is  much  affected,  and perhaps may even,  as
well as  the  bowels, partake of the torpor, if not of the paralysis,
for a time, as we see  in the  sudden inflation, yet the heart and
lungs never lose entirely their power.   The heart may beat slowly,
and the lungs may act with difficulty, but life goes on.   In another
affection, however,  death  suddenly takes  place, either from the
heart and lungs ceasing at once to act, or from the brain losing  its

tended with frequent pulse, inflation of the bowels, more or less, at different
times, and even involuntary discharge of urine;  but the mental affection is con-
tinued, and the prominent corporeal symptoms mentioned above are absent#
Early venesection, followed by purgatives and tepid  bathing, and mild diapho-
retics, constitute the practice, and generally in a few weeks the attack goes off.
  * In many of the modifications of this disease, whether the mind be affected or
not, every exacerbation is attended with increased appetite. 
131
 activity.  The patient merely says he is not very well, and is not
 disposed to rise, and then  suddenly expires, without a groan or
 struggle.  In a few cases, a kind of general uneasiness or languor
 has preceded this for a day or two.  Dissection discovers nothing
 unusual in any of the cavities, or in the spine.
   With children the case is a little different; for in general they
 complain for some days, perhaps for a week or two, of slight and
 varying fever.   The pulse is frequent, there is some headach, the
 nights are restless, there are thirst and anorexia.  In the  evening
 the cheeks are a little flushed, and the fever  increases, but abates
 toward morning.  The water is not much  altered, but sometimes
 it is thick and white.  The bowels are costive.  Then,  all at once,
 without any material increase of the complaint,  nay even when
 the patient has seemed to be better, and appeared to have a return
 of appetite, he  has been seized with a convulsion, aild suddenly
 expired; or repeated fits, with rapid motion of the eye-lids, and
 extreme gaping  have taken place, and in a few hours he has died.
 In some cases, a little fulness of the veins in the head has  been
 observed, or 1 have detected a very little water at the base of the
 skull, or in the spinal canal; but in other instances, nothing could
 be discovered by dissection.  More than one child in the same
 family has died thus.   The treatment consists  in lessening the
 cerebral irritation, by venesection or leeches, in the regular ex-
' hibition of laxatives, and in determining gently to the surface  by
 mild diaphoretics.  If the symptoms do not yield  soon,  a blister
 to the back part of the head is useful.  This fever bears  a strong
 affinity, or rather is only a modification of that, improperly called
 the infantile remittent fever, which may very properly  be  con-
 sidered at this time, as it really proceeds from cerebral irritation,
 in whatever way that may be excited.  It will be useful to divide
 it into that variety which occurs in early infancy, and  thSt which
 takes place in childhood.  The first is  very similar to the early
 stage of hydrocephalus, but the remissions are more distinct in the
 morning, and the exacerbations  greater in the  evening.   There
 cannot, however, be much difference, for in both we have much
 cerebral irritation, and the difference is more in the result, than in 
132
the early condition.  The pulse is extremely quick,* the skin hot,
the mouth  warmer than usual.  The child is at first fretful, rest-
less, costive, and inclined to vomit;  then he becomes more op-
pressed, and in some cases has  slight cough, with increased secre-
tion of phlegm  in the trachea;  perhaps, he does not for hours lift
his eyes, till the remission comes, when he looks up, and attends to
the objects presented to him for a short time.   He sucks in gene-
ral freely,  and sometimes bites the nipple,  and  very often aphthae
appear in the mouth.   The bowels are irregular, but whether the
stools be  frequent or seldom, they are generally green or brown,
and offensive.  The urine is usually high-coloured and scanty, and
sometimes the feet swell a little, and very often become cold.  If
the disease prove fatal, it is generally attended, in  the end,  with
symptoms of effusion into the ventricles of the brain, or the infant
is exhausted gradually by the continuance  of the  fever, or more
quickly by  the  accession  of obstinate diarrhoea.  A favourable
change takes place, sometimes about the fifth day, sometimes later,
the child looking up for a longer  space of time  than formerly, and
seeming more free from sickness.  After this, the symptoms sub-
side, and the strength  is gradually restored.  It is  very common
to find,  that at this time one  or more teeth have made their ap-
pearance.   In many cases, the  fever may proceed from affections
of the bowels ; but frequently it is caused by dentition, the irrita-
tion in  the jaw  operating  either alone,  or in  connexion  with  a
morbid  state of the bowels.   In this kind of fever,  the  gums
should be carefully inspected, and, if necessary, cut.   Small doses
of calomel should be given morning and evening, mixed with mag-
nesia, to prevent costiveness, or evacuate irritating faeces.  A few
drops of tincture of hyoscyamus,  with a saline julap, may be given
occasionally  to abate irritation.   The tepid bath should be em-
ployed  tmce a-day, when  the  exacerbation takes place, and the
strength supported by the breast milk or beef tea.   If the child
be plethoric, a leech should be  early applied on  the forehead;

  * In the early stage of hydrocephalus, the pulse is more irregular, and often
beats alternately quick and slow, for two or three pulsations. 
133
 and if a favourable crisis do not soon take place, the head ought
 to be blistered.   In  some cases, although the acute symptoms go
 off,  the child does not recover, but remains  fretful,  languid, and
 emaciated.   The eyes  are  suffused, the feet swell, and the stools
 are not regular  nor  natural.  In some instances, tumour of the
 mesenteric glands seems to  be excited.
   The remittent fever of older children, is met with from  the age
 of two to ten or twelve years, and is generally found to be produc-
 ed, either speedily, after eating some improper substances, which
 have not been immediately removed from  the stomach or  bowels,
 or gradually, by the  induction of a costive state, or the accumula-
 tion of irritating faeces in the bowels.   In the first case,  the fever
 attacks suddenly, sometimes through the day, but generally at night,
 and  the child is sick, pale, very restless, extremely hot,  disturbed
 in the  sleep,  and thirsty.  Sometimes he vomits, or complains  of
 headach, or pain in the belly.  The tongue is at this time tolerably
 clean,  but next day it becomes furred, and the fits of vomiting or
 sickness are  pretty frequent.   They are generally preceded by
 headach, which goes off or abates after throwing up.   If this dis-
 ease be attacked immediately with an emetic, followed  in the morn-
 ing with a smart  purge, the health is  soon restored ; but if the
 remedies be delayed till the  next day, I have generally found, that
 although the  emetic, with purging, mitigate the disease, it does not
 arrest it speedily, and notwithstanding the regular use  of laxatives
 with diaphoretics, it continues for several days.  Emetics and pur-
 gatives, in this disease, generally bring off some half digested sub-
 stance, such as almonds, orange  peel, &c.   It  is astonishing how
 torpid the bowels sometimes are, large  doses of^medicine, either
 producing no effect, or, lying for some time inactive in the stomach,
they are then vomited.   In such cases, strong clysters  are  proper
 to assist the physic.  In this fever, if the symptoms be acute, and
there be much headach, advantage may be derived from the use
of the lancet.   Experience convinces me, that this is safer and bet-
ter than the application of leeches, which in cerebral  diseases of
the febrile kind,  may weaken, but seldom do good, unless in the
slightest cases.   Where the constitution, however, is rather feeble, 
134
the lancet must be used with caution, and  here  leeches  may be
admissible, or in infants they may be applied.
  In the second case,* the attack is often more gradual, the child
being for several days somewhat feverish and unwell.  The pulse
is frequent, and, in the course of the day, he has several attacks of
feverishness, during which he is dull, and disposed to sleep or lie
down; but these do not last very long, and in the interval he seems
tolerably well, but is easily put out of temper, and complains when
lifted  or touched,  though he be not hurt.  The  appetite  is not
steady, he has little thirst, and the tongue is clean.  The  bowels
are sometimes very open, but oftener bound.  These symptoms
appear more or less distinctly for about a week, though sometimes
not so long.   Then an acute paroxysm of fever takes place, pre-
ceded by shivering, and  attended generally by  vomiting.  The
pulse becomes much more frequent, sometimes 140  in a  minute.
The cheeks are flushed, and the patient is very drowsy, but com-
plains of little pain in the head,, or indeed any where, except oc-
casionally in the belly, which may at times be very severely pain-
ed ; or if he complain of headach, it is evidently from his stomach,
for it is  followed by sickness or vomiting.  There are, however,
cases where the  headach  is both violent and permanent.  The
fever does not continue alike severe during the whole of the day;
it remits a little, but not at very regular hours.   The exacerbation,
which usually occurs in  the afternoon, is generally  accompanied
with drowsiness.  Very soon after the attack of fever, the  tongue
becomes covered with a white or brown coat, and  both the stomach
and the bowels seem to  be extremely torpid.   The appetite,  in-
deed, is soon alrnost totally lost, or the food which, is taken is not
digested.  The bowels are generally, but not always, costive ;  and
the stools are foetid, dark-coloured, sometimes like pitch,  or  thin
and olive-coloured, or green and curdy-looking, or clay-coloured,
indicating a deficiency of bile.  This  last state sometimes alter-
nates with too copious secretion of bile.  There  is a great desire
to pick the nose and lips ; and if the child be not watched, some-

  * This is commonly called a worm fever, although worms are not necessarily
passed in this disease. 
135
 times an ulcer is thus produced upon  the  lips or angle of the
 mouth.
   The face is  flushed during the exacerbation ;  but except at this
 time it is pale.  The eyes are  dull and white ; though sometimes,
 in the course of the disease, they are unusually clear.   Generally
 delirium occurs in the advanced stage of the disease, and in some
 cases it is difficult to keep the child in bed.  From this state, how-
 ever, he can usually be recalled for a few minutes,  and  will  then
 answer questions distinctly.   If the debility be  considerable, the
 countenance becomes  vacant, the child picks  at the  bed-clothes,
 and though he  does not speak much, makes a constant inarticulate
 noise.  In some instances convulsions have taken place ;  but these
 are rare, and are chiefly met with  in young children.  Sometimes
 the stools are passed in bed, without  any intimation being given.
 In  severe cases the patient becomes  paralytic on  one  side, and
 perhaps convulsed on the other, moans much, has fits of scream-
 ing, and almost maniacal yelling, strabismus, loss of memory and
 of sight, or that extreme degree of gaping I have noticed  above.
 This disease runs on for a week or two, or even for several weeks
 and may at last destroy the patient by universal debility, or ex-
 haustion, or diminution of the cerebral function ;  events which will
 take place earlier, if the proper remedies are not employed,  than
 if they be, even although  they  may ultimately fail.  In general,
 success attends their use.   Tumefaction  of  the  belly, with great
 and constant fever, are very unfavourable, and the symptoms usual-
 ly supposed to  indicate pressure on the brain, or paralysis, &c. are
 still  more so ; nevertheless these are not absolutely mortal, for they
 by no means certainly indicate effusion.  Even in  cases of effu-
 sion, or pressure, these symptoms proceed from the impaired func-
 tions of the brain and nerves, consequent to pressure, and  any other
 causes, capable of producing a similar diminution of function, will
 have precisely  the same effect.  We see this exemplified by the
 effects of concussion of the brain; by that  instantaneous loss of
power producing universal palsy and  death;  and those  diseases
 producing sudden palsy of particular sets of muscles, that I have
 already described.  It is also exemplified in  the effect  of  burns
 and surgical injuries, where stupor or paralysis take place,  and often 
136
prove fatal.  All these cases show, that pressure is only one cause
of these symptoms, and merely  an exciting, not the  proximate
cause.  This fact, and a recurrence to some of the  cases  noticed
above, afford strong evidence that we have no diagnostic mark of
structural and irremovable injury of the brain, in these diseases ;
and, therefore, we are encouraged to  proceed in an attempt at a
cure, in  circumstances  where we would otherwise abandon  all
hope.
  In  mild, but protracted cases of this fever, the patient perhaps
is  confined to bed only part of the day, and becomes cheerful in
the afternoon.   The stools for a day  or two improve, and then
become very offensive; the appetite returns soon,  but the  fever,
emaciation, tumour of the belly,  and other symptoms,  may conti-
nue for several weeks.
  This bears a strong resemblance to  hydrocephalus, and it can-
not be otherwise, for in  both,  in many cases, the cause and  the
effect are exactly the same.  The chief assistance, perhaps,  in the
diagnosis, is derived from the intensity of the symptom, but this is
not a certain rule to  go by.  In hydrocephalus there is a  more
frequent vomiting, and as often a tossing of the  hands above  the
head, as picking  of the nose, or lips.  There is generally constant
pain of the head, which in this fever is sometimes altogether want-
ing, or is slight, or, if severe, comes in paroxysms connected with
sickness, or affection of the stomach.  There is screaming and
strabismus, and  often a more constant  delirium,  from which  the
patient cannot be  roused, after it has continued for some time;
and convulsions are accompanied with great injury of the mental
faculties. There is in general, in this fever, more complete remis-
sion of the symptoms at  some time of the day, than in water  in
the head, the pulse not only being slower, but the child more  lively
and easier.  The stools are more foetid and  darker than in hydro-
cephalus, in which they are often thin  and bilious, and sometimes
glossy.  The pulse in hydrocephalus is more irregular, and, in the
second stage, usually becomes slow and intermittent.  It  must,
however, be repeated, that, in many instances, it is very difficult to
make the diagnosis, especially if we have not attended the child
from the first.  I have had the happiness  of seeing children  reco- 
137
 vered from situations apparently desperate, when there was every
 reason to fear that there was water in the  head, though the result
 proved the contrary.  Fortunately, in all such ambiguous cases,
 the exact diagnosis would be of more consequence in determining
 the prognosis than the treatment.  For, in these circumstances, the
 application of blisters to the head, the use of laxatives, and support-
 ing the strength,  are the means to be chiefly resorted to in both
 .diseases.
   This disease  very generally, but by no means invariably, pro-
 ceeds from disorder of the bowels, irritating the brain.  Derange-
 ment of the functions of the stomach and intestines, or liver, &sc.
 unquestionably re-acts on the origin of the nerves, and produces,
 as has already been stated, various effects.  We are not yet ena-
 bled to say, what particular mode of  irritation  gives rise  to the
 different modifications of phenomena;  or  why, in one case, the
 same apparent exciting cause should produce spasmodic,  and in
 another febrile  affection.  The  fact,  however, is  incontestible,
 that in some cases, unripe fruit, or much  pastry, or costiveness,
 shall sometimes cause  a fever, sometimes chorea, &c.   In  the
 present disease,  the cause is generally resident in the bowels; but
 assuredly other  exciting causes may affect the brain, in a  similar
 way; and, therefore,  the  modern view, that the disease is  seated
 in the bowels, and that the remedy is purging, is too simple.  But
 whatever may excite the cerebral irritation, there can be no doubt
 that it again re-acts on  the abdominal viscera, and  these on one
 another, so as to induce soon a complicated, and often both  a pro-
 tracted and dangerous disease.   This state of the brain is not in-
 flammation, but  inflammation  may supervene on it.  It does not
 seem to affect the  whole brain equally and universally, but  may
 be confined to the basis and the upper part of the spinal marrow c
and farther, it is  evident, that  this state of  irritation  may be  suc-
 ceeded by  torpor of the parts so affected; or one part of the brain
 may become torpid, whilst anodier is still  in a state of irritation,
or excitement.   This view,  I  apprehend, explains why  some
 parts of the body are  excited to over-action, and others, in course
 of time, become almost or altogether paralytic.   In the treatment
 of this fever, our objects are to remove  the farther operation ef the
     Vol.  IL                  18 
138
 exTciting cause, to lessen cerebral irritation, and to obviate parties
 lar symptoms.   In  the  very commencement of the disease, more
 especially if there be still some degree of chilliness, and especially
 if there be reason  to suspect that any indigestible aliment  have
 been taken, an emetic is of the greatest service, and ought seldom
 to  be omitted.  As soon  afterwards as the stomach will retain it,
 an efficient purgative is to be administered, so as  to operate co-
 piously.  It is  also  proper to attend to the existence of other irri-
 tations, whether in the  gums  or elsewhere,  which we  endeavour
 to detect by accurate and close investigation ; and when we are
 at a loss, we may often be assisted by manual  examination of dif-
 ferent parts of the  body, and of the spinal region.   Means are to
 Be taken for removing any cause that can  be discovered.  All this
 may be done in a few hours, and if early resorted to, the disease.
 is at once checked.   If, however, it be not,  or we have not  seen
the patient in the first few hours, then it  comes to  be considered,
how far the detraction of blood  is likely to lessen the cerebral ex-
 citement.  If there be  headach, heavy eye, flushed face, ardent
 heat, and frequent throbbing pulse, I am decided both  as to the
safety and utility of venesection.  I know  there  is a prejudice
against  it, from the hazard of debility; but it  is  not ascertained,
that a patient who has been bled, but not cured thereby, is weaker
at the end of a fortnight of fever, than one  at the same period, who
has not been bled;  whilst, on the other hand, it is  proved, that the
disease  is often rendered milder, and occasionally at once removed,
by this  remedy.  So soon as the cold stage has began to pass off,
and the heat is increased, bleeding may be resorted to.   Leeches
are of no great avail in this view.  They  may relieve locally, but
they do not check the fever, unless in  very young subjects.  Vene-
section, on the  other hand, particularly if it  produce sickness or
faintness, often brings down the pulse, instantly  to  the natural
standard.   It rarely,  however,  continues at this, but  soon rises,
yet not  to the same  degree as before;  and in  favourable cases, the
disease  passes off perhaps within three days from  its invasion.  I
am not, from these  remarks, to be supposed to sanction indiscri-
minate and injudicious venesection, nor this evacuation at all, if it
have been postponed beyond the  commencement of the disease 
139
Those who are weak, are either not to be bled at all, or sparingly*,-
and when we find that, during the flow, the pulse becomes smaller,
feebler, and more frequent, the evacuation is not safe, and is im-
mediately to be checked.  It is impossible to lay down a rule, as
to the quantity to be abstracted at different ages;  for much de-
pends on the constitution, the size of the orifice, and modification
as  well  as  period of the disease.   In general, five  ounces are
enough, and not too much,  from a patient six  or eight years old.
After bleeding, or in cases  where it  has not  been  expedient to
practice it, if the skin be steadily hot, advantage is derived  from
sponging the surface frequently with cold water.   If  the  disease
be  not checked, our object is to mitigate and shorten  it as much
as possible ; and this may be greatly assisted, by examining  daily
into the irritation which exists, or the sympathies which have  been
excited, that suitable remedies may be  applied,  such as  local
bleeding, blistering, friction, sinapisms, or internal medicine.  If
there be no prominent symptom, our attention is chiefly directed to
the bowels, which are never to be neglected, and to the secretion
from the  skin.   The surface is to be  kept in  a soft and slightly
moist state by saline  julap alone,  or containing a little  antimony.
The bowels are to be kept in a  state of due action by  purgatives.
We cannot, a priori, say what quantity may be necessary to  pro-
cure stools.  Usually, it is great  beyond  what any one  who has
not seen much of this disease would expect.   Senna tea answers
the purpose very well; jalap or castor oil  may  also be  employed;
or,  if the child can swallow pills, the aloetic pills stay well  on the
stomach, and, if given in sufficient number, act excellently  on the
bowels.   A moderate dose of calomel may be  premised or given
along with any of these purgatives.  Clysters are of great benefit*
It is useful to purge  the bowels freely at first;  but after this, it is
not proper to give so much medicine as  will operate strongly/
Drastic purges, particularly  large doses of calomel, must  not Be
employed  at this time,  for  they induce  subsequent weakness or

  *  Dr. Pemberton judiciously remarks, that if strong purges are given, the in-
testines are apt to become distended with air, and the patient is destroyed with
tympanites.  Practical Treatise, &c. p. 165. It is worthy of remark, that dissec-
r'ton often discovers nothing but great inflation of the intestines. 
140
torpor of the bowels.  It  is requisite, however, to give regularly
such doses as shall keep the bowels open, and support.their action.
When the stools are loose, purgatives are still proper, in prudent
doses, to evacuate them;  for they are not natural in their appear-
ance, and injure the action of the intestines.   The exhibition of
one blue pill for one or two days, alone or with a little rhubarb, is
useful in the view of improving the action and secretion  of the
bowels.   Whether  this disease have  been originally excited by
disorder of the bowels, or by some other cause acting on the brain,
and the bowels have thereby become affected in a secondary way,
still purgatives will be found useful on very obvious principles.
   Opiates, in the wane of the disease,  frequently allay irritation
and accelerate recovery, by procuring  sleep.  Anodyne clysters
are useful in this respect, and, especially if conjoined with fomen-
tations,  also for abating griping or  abdominal pain.   Pain  in the
side, if not removed by rubefacients or anodyne balsam, requires
a small  blister.   The tepid bath sometimes allays general irritation.
When there is continued pain in the head, or uneasiness of any de-
scription there, it is proper, at  an early stage,  to apply leeches*
and at a more advanced period,  to shave the head and bathe it
with cold vinegar.  Blisters, particularly on the back part of it, are
also proper, especially when there is delirium.  If symptoms of
torpor, or loss of vigour in one part, and undue excitement in an-
other part of the brain appear, blisters, either to the head or  nape
of the neck, are requisite; at the same time  that the bowels are
diligently, yet prudently to be stimulated by purgatives.  In  such
cases, it is useful also to employ mercurials, such as the blue pill,
combined with  aloes, so as both to excite the bowels, and produce
what is  called an alterative effect on the system ; taking care not
to push  the remedy too far. Occasionally small doses  of antimo-
nium calcareo-phosphoratum may be conjoined.  By these means
most unexpected recoveries have  taken place,  where the symp-
toms were such as to lead to strong apprehension that water  had
been effused in the head.
   In the course of the disease, the liver is apt to have its function
impaired, and even more  chronic diseases  may be  excited in it.
Mercurials and purges are useful in  this case, and doubtless, if 
HI
these or other means were  not  early employed, for exciting a
healthy action of the bowels, this hepatic affection would be more
frequent and more dangerous.  If the region of the liver be tender
on pressure, then, besides the other means, we should  either ap-
ply leeches, or a blister to the part, or both, according to the acute-
ness of the symptoms.
  The diet should be light, but it is not  proper to force  the pa-
tient to eat.  In the progress of  the disease,  infusion of  bark or
other tonics are sometimes beneficial, and ought always to be tried.
Wine may also be given in small doses, when there is much debili-
ty.   If it  do not produce flushing, headach, and  exacerbation of
the fever, but rather promote sleep, it will do good.   When the
disease is protracted, it is often of advantage to intermit the use of
purgatives, and employ only clysters, and at the same time begin
the use of steel.  Under this plan, the bowels, though formerly not
moved by strong medicine, act more regularly, and recovery goes
on fast.  As  this happens in the  progress of protracted cases, it is
probable that sometimes the purgative  and mercurial medicines
are pushed too far, and  keep up  an undue  irritation.  Great at-
tention should be paid to cleanliness  and  ventilation, and, when
convalescent, a removal to the country is highly  useful.
                         CHAP. VI.

                      Of Hydrocephalus.

  Hydrocephalus is one of the most dangerous and insidious
diseases to which children are subject.  It  sometimes makes its
attack suddenly, cutting the patient off in a few days; sometimes
more gradually, and is protracted for many weeks or months.   It
has,  therefore, been divided into the acute and chronic; and as it
may either appear as an idiopathic  disease, or come on in  the 
142
eourse of other diseases, at first quite different, it may likewise be
distinguished into the primary and secondary.
  Acute hydrocephalus begins very  like a  common fever,  but
there is more frequent vomiting, and greater pain in the head, es-
pecially on one side.  After the febrile symptoms have continued
for some time, marks of oppressed or debilitated brain appear,  and
the patient dies comatose, or convulsed.  Such is  the outline of
the  disease, which, however,  it will  be necessary to describe  a
little more  minutely.  Very often the patient, for some time previ-
ous to the  attack, is languid, peevish, and uncomfortable, without
any particular complaint.  The appetite is impaired, he has  fre-
quent sick  fits, or vomits bile, and the bowels are generally very
costive, though sometimes he purges foetid, dark-coloured, or green
feces, and he complains occasionally of his head.  Towards even-
ing, the face is a little flushed,  and  the skin is hot,  and very soon
the disease becomes formed.  In other instances, however, and
these by no means unfrequent, the disease invades more suddenly,
or with scarcely any previous indisposition.  The patient feels
chilly, whilst his skin is hot; he generally complains greatly of
his head, especially at the forehead, causing  him to frown, or at
one side, sometimes very much of his  neck; but, in a few cases,
I have found the patient denying that he had much or even  any
pain in the head.  Convulsions sometimes  appear as one  of  the
first symptoms, but, more  frequently, they do not come on  till an
advanced stage.   From the commencement,  the  patient can  sel-
dom keep out of bed, his eyes are usually very sensible to the light,
and when examined, the pupils are contracted, perhaps irregularly,
and the eye in some cases is troubled, in others as  clear as usual.
I must, however, observe,  that sometimes there is not the smallest
increase  of sensibility  to  light.  Spasmodic cough and pains in
distant parts occasionally supervene.   The head-ach is constant,
and produces moaning, or the  patient lies silent and  unwilling to
speak a word, or often even to take a drink.  The stomach is
very early affected, and for some days he vomits bile, and what-
ever he swallows; he has  no appetite ; the thirst is variable; the
tongue white,  the bowels  generally costive, but sometimes loose,, 
143
 and the stools in that case green and  foetid;  pain  is felt in the
 belly, and occasionally in other parts of the body.   The sleep is
 broken, and frequently interrupted, as if the patient had a frightful
 dream; he starts, grinds his  teeth, and  picks his  nose, which
 makes the disease sometimes pass for the consequence of  worms.
 The pulse, in a  few cases, is  not very frequent; but in general,
 especially if the  disease be rapid, it  is at first very  quick, being
 about 120 in  the minute, but subject  to  pretty  rapid  and  con-
 siderable variation within a short time, in point of frequency.   In
 about eight or ten days, the pupils  are somewhat dilated, and the
 patient squints a little.  In some cases, the vomiting is  renewed,
 but  more frequently it is not.   The pulse at this time often be-
 comes slow, beating only 60 in  the minute, and  being  generally
 irregular.   The  pupil  is more dilated, and the  eye  less sensible
 than formerly to light.  The headach is often diminished, but the
 patient frequently cries out, or even screams.   In some cases, de-
 lirium comes on ; in others, the patient continues sensible and in-
 telligent, until the stupor supervene.  More food is often taken in
 this  stage, than formerly.  In the  course  of either two or three
 days, the pulse becomes  again  quicker, the  pupil more dilated;
 but still the patient may continue to see, and complain of the light,
 and  often answers distinctly every question.  Presently,  however,
 the  symptoms of oppressed brain  become greater,  the pulse is
 Weak, and gradually increases to 160 in  the minute.   The eye
 squints, vision is  at last lost,  the  urine is either retained, or,  with
 the faeces, passed involuntarily. The breathing becomes stertorous,
 and  the patient dies; or he may sink from weakness, and remain
sensible till the last,  or  having been delirious, or even comatose,
 he may recover his intellect and sensibility, for a short time before
 death.  Even the power of vision and hearing have been thus re-
 covered.   In the course of this malady, the cheeks are alternately
 flushed and pallid; and after the  second stage, one side is more or
less paralytic, whilst the other in many cases is convulsed; indeed
convulsions may  come on at any period of the disease, even in its
commencement.   The symptoms are generally aggravated during
the night.   When the patient sleeps, the eye-lids are often only 
144
half closed, and the eyes turned up.   He complains much, or be-
comes giddy, when the head is raised.
   Hydrocephalus has been divided into three stages, characterized
by the state of the pulse and of the sensibility.   In the first, the
pulse is frequent, and  the sensibility  great.   In the second, the
pulse becomes slow, with  marks of oppressed brain.  In the third,
it is again rapid, there is great debility and cerebral  irritation.
But it is to be recollected, that these stages are not always well de-
fined, sometimes the pulse never becomes slow, and the division
cannot be relied on.
   This disease runs on generally till the twenty-first  day, if the
patient be above two years old ;  but if the child be  younger, it of-
ten terminates more speedily, sometimes so early as the fourth or
fifth*
   From this account, it appears, that the symptoms, when the pa-
tient can describe them, are in the first stage much  the same  with
those of the fever of the adult, or the  remittent  cerebral fever of
children,  and  that upon these supervene those of oppressed brain.
In some cases, however, water has been found  in  the  ventricles,
when no symptoms indicated it during life,f or when many of the
usual symptoms were absent.J
   Infants cannot give an account of their sensations, and therefore
we are more uncertain, until the symptoms of oppressed brain ap-
pear.  We may, however, dread the nature of the  disease, when
the infant has a high fever, vomiting, with costiveness or diarrhoea,
  • It is not at all uncommon in hydrocephalus at the  expiration of eight or ten
days, especially  if its progress  has been rapid, for the more violent symptoms
to subside so as to  induce a very sanguine expectation of a speedy recovery.
This is often a most treacherous and fatal calm, as it results from an effusion in
the ventricles of the brain.  The vessels in this way become relieved, and the
disease is suspended.  After a short time, however, the extraneous fluid acts as
a re-exciting cause, and the disease returns with redoubled force.  Under such
circumstances, it is perhaps incurable.   Effusions in other cavities of the body
may be taken up, but as far as we know, the ventricles are destitute of absor-
bents, or if they exist, they act incompletely in these cases.  C.
  f Vide Quin's Treatise, p. 43.
  $ Dr. Rush mentions cases where there  was no pain in the head, os where it
began like a catarrh, or wanted the strabismus, dilated pupil,  sickness, and loss
of apptrtite.  Med. Inq. Vol. II. p. 210. 
Ub
 lies oppressed, and apparently sick, with the eyes obstinately shirt,
 •iisfikes the light, puts the hand frequently up to the temples, as if
 going to rub something off the head, has starting and spasms^ and
 awakes suddenly as if terrified, and sucks or drinks at first  with
 great rapidity.   The diagnosis, it must however be confessed, is
 very difficult; for in disorders  of the  bowels,  from dentition and
 other causes, spasms, starting, drowsiness,  and strabismus,  may
 take place.*  Dark green stools forming  a  gelatinous  mass, not
 possessed of a foetid smell, have been  considered as peculiar to the
 disease, by one very respectable writer, whilst others assert, that
 this appearance depends on the use of calomel.  This state of the
 stools is not to be disregarded, but it cannot be  depended on  as
 pathognomonic; much less can the micacious deposition from the
 urine noticed by Dr. Coindet.  Rapid and frequent variations in
 the frequency of the pulse, connected  with other symptoms,  are
 very suspicious.   It is prudent, whenever  there is much ferer
 with any ambiguous symptoms,'to proceed as if the patient were
 threatened with hydrocephalus; more especially, as the  early use
 of the remedies thus indicated,  will generally be serviceable in the
 complaints with which this disease may be confounded; and if we
 delay till the late stage, to obtain  a more certain  diagnosis,  we
 have scarcely any hope of doing good.  When children can give
 an account of their sensations, we may with great justice fear this
 disease when they complain much of the head, have vomiting, and
 quick pulse.  It is not however possible always  to  determine  at
 once, whether the disease be that fever already described, or  hy-
 drocephalus, nor is it so essential as may be supposed, for prudence
dictates, even in the mildest disease  of the two, the prompt use of
vigorous remedies.
   Dissection shows that the vessels of the brain are full of blood,
some of them  very turgid, the membranes and brain in some
places seem inflamed, and covered with coagulable lymph ;  whilst

  • A very interesting case, where strong symptoms of hydrocephalus were pro*
«luced by accumulation of the faeces, and a speedy cure obtained by purging with
senna, is related by the late Mr. Benj. Bell.—Hamilton on Purgatives, p. 217.
Other cases  might be pointed out where strabismus,  double vision, paralysis,
screaming, headach, 8cc. all yielded to the same means,
     Vol,  II.                  19 
                             146

betwixt the dura mater and the brain,* but still more frequently in
the ventricles of the brain, there is  an accumulation  of water,
sometjmes to the extent of several ounces, and it is generally of a
very pure and transparent quality.  Small tubercular granulations
are described by  Laennec, and  other late  dissectors, as  being
dispersed through the brain; but these assuredly  are not essential
to the  disease.  The spinal marrow, or its  covering, sometimes
participates in the  affection, and water may  be formed  there, or
pass from the basis of the  skull.  This appears sometimes to  be
productive, in the early stage,  of pain and rigidity of the neck, or
peculiar sensations  about the larynx, or slight irritation there, as if
a small filament were tickling it.   The intestines occasionally have
an inflamed appearance, or portions are constricted, or intussuscep-
tio is met with.   The liver also may be somewhat enlarged.
   Hydrocephalus is more  readily excited in some children than
in others, and this predisposition  is very remarkable in particular
families.  Those who are  of  a scrofulous habit  are liable  to  it;
but it also attacks  children  who  have no other  manifestation of
that constitution, and none, not even the most healthy, are alto-
gether exempted from it. In infancy, both sexes are alike affected;
but it is certain, that about the period of puberty, or a little  before
it, females are more frequently attacked.  Coindet has  stated the
proportion at the age of twelve years to be as eight to one.
   Exciting causes, acting evidently and directly on the  brain, can
sometimes  be detected, as blows, or other  injuries, exposure to
cold, violent exertion, passions of the mind, the sudden removal of
a continued irritation, or discharge from the scalp, or neighbour-
hood,  &c.  In other instances, it is  excited  by previous  diseases
acting  in a secondary way  on the brain, such as hooping-cough,
scarlatina, &tc.  Any long continued fever, by keeping up  a con-
stant overaction in the vessels of the brain, which contain so large
a proportion of blood, has  been viewed as a cause, and doubtless
where  there is strong predisposition, it will so  act.   Transition
                                               «
   * In this case the disease is called hyd. externus, to distinguish it from the
species in which the water is in the ventricles, which  is called hyd. internus.
By the former term, some of the ancient writers merely understood oedema of
the scalp. 
                              147

 of action, it is also probable, is a cause.   The continued irritation
 of important or  very sensible  nerves, is perhaps one of the  most
 frequent causes;  hence it may follow  dentition,  and very  often
 arises from a bad state of the chylopoetic viscera.   Having noticed
 this pathological fact in the last chapter, I have little to add  here.
 It is an important inquiry, however, why in one set of cases,  mere
 fever is excited, often simulating, no doubt, hydrocephalus, but
 rarely ending in it, whilst in another, this disease is speedily in-
 duced, in its  most formidable characters.  This would lead to a
 belief, that either, in many cases supposed to arise from the state
 of the bowels,  the original disease has been seated in the brain,
 and the apparent disease  in the bowels, has been  only an  early
 symptomatic affection; or, that the  nature of the irritation, com-
 municated to the brain, is different, essentially in the one case and
 in the other:  perhaps  both suppositions may at times be true, and
 much also depends on predisposition.
   The next inquiry is, what is the state occasioning hydrocepha-
 lus ?  Is it inflammation, and  is the  effusion analogous to hydro-
 thorax succeeding pleurisy ? An acute and considerable degree of
 inflammation  ends in  suppuration, and  this is the termination of
 many cases of phrenitis.   A  more  moderate degree,  capable  of
 greater prolongation, ends in serous effusion.  Even a state of ac-
 tion inferior to inflammation, produces this;  and it is this sub-in-
 flammation, which I believe most frequently exists  in hydrocepha-
lus.   During this state of  irritation, amounting at most  to what
 may be termed  sub-inflammation, the pulse is frequent, and the
 fever generally acute.  It ends in. a state of exhaustion, weakness,
or torpor, in which the cerebral functions  are impeded, or dimin-
 ished, in their performance.  Symptoms, supposed to arise from
compressed brain, take place at this period ;  but they do not arise
from that source, but from the condition of the brain just described.
They  take place before effusion  in all  probability exists ;  they
are similar to those  produced by concussion of the  brain, or any
cause capable of interrupting or interfering with the performance
of its functions.   The train of symptoms are various and uncer-
tain, in as much as one part may fall into torpor, whilst  another
remains still in a state of evacuation.  Where effusion has taken 
148
jsbce, 3iie pans are often thereby irritated, and ike ireu>eacy **
the pulse renewed, whilst usually the stupor augments.  In a few
instances, the nature  ©f which we cannot yet ascertain, this pres-
sure seems to excite rather to temporary advantage, for there have
been instances of the intellect returning, and the patient being bet-
sex, a short time before  death,  it is probable, then, that these
symptoms, attending what has been called the second stage, and
supposed to indicate (effusion, menely  evince the commencement
of that exhausted or (enfeebled (condition^ which  leads lo effu-
sion, and that it is not too late, even at this time, to -entertain faint
hopes of recovery-  After effusion takes place, in acute hydroce-
phalus, I hold recovery to he next to impossible- the few instan-
ces that have not ended hi death have terminated in fatuity, accom-
panied with enlarged head.  The term hydrocephalus, is therefore
perhaps improper, as it is applicable  only to the ;ultimate and in-
cmahle stage of .this disorder j hul^ as it is amiveisally accepted, A
■would he wrong lo change it.
  In considering the hest mode of treatment, k is evident that we
must, in the .first stagey or that of inflammatory irritation, u&e the
ttoosl prompt and vigorous means for  allaying  action ;  and in the
seconrl, or stage of diminished functions, use such remedies as may
safely excite to more healthy :and vigorous action, 'without stimu-
lating to inflammation.   In the stage of effusion, we may lay down
the almost hopeless  indication of promoting ahsorption,  or artifi-
cially m*ocuring the evacuation of the  .fluid.
   In ithe first stage, much may be done 'by vigorous treatment, and
many Ev.es ane saved thus, which would otherwise haye been lost;
»or, in different terms, many .axe prevented from having the disease
car stage properly called hydrocephalus, who  otherwise would fall
victims lo .effusion.  The most efficacious means consist in the de-
traction of .blood by venesection, or leeches, or both, according to
like aige of the patient, and the severity of the disease-  In no in-
stance ought leeches to be neglected, and they cannot too early bt.
^applied.  Evacuations of this kind, carried as far as prudence dic-
tates, ought instantly to he ibllowed by the administration of smart
fpturgativesi; and 1 wish it could .he impressed sufficiently on  .the
 «nmds both of parents and practitioners, that the loss of one day 
\m
 'a"(this active treatment, may be the loss of the  patient  I am *:rt
 from advising debilitating depletion., or late evacuations/but earJy
 venesection, or leeching, or both, if not carried the length of great
 exhaustion, will do good, or at least prove safe.  At the same time
 that these means are adopted, the head ought to be shaved,  aod
 bathed frequently with cold water; and in a few hours thereafter,
 m blister ought to he applied to the back pari of it   When I adrise
 cold water,  I wish it to be understood, that this is to be applied
 efficiently, not hy wetting cloths once or .twice, but by keeping the
 3calp con stantfy cool, or even cold, by the diligent repetition  of wet
 cloths.  The affusion  of cold water on the head, I  have some
 doubt of, as it is often followed by alarming collapse; but if it is to
 be practised* it must he very early, and when there is much heat,
 and immediately  after,  but never antecedent, to the evacuation.
 Blisters, I am confident, are useful; although some,, whose judg-
 ment I respect, place little reliance on them.
   Hoping that these means have given a check to the disease, our
 next object is to  prevent  a nelapse or keep up  and improve  our
 gramnd, and this  is done ,by strict attention to the  bowels.   The
 purging system ought theBefore  to  be maintained,  and dpi even
 although the child have a diarrhoea, if  the stools he green,  foetid,
 ®r contain Jumps.  The best remedy* I believe^  is .calomel, in
 small doses, or such doses as excite or keep up the action of the
 bowels without purging ,too much.  This,, however, must not be
 ■often given., as it weakens the bowels; but soon we must substitute
 me .blue pill, dissolved in a little warm water, and having the addi-
 tion of some other laxative.  Two pills, for instance, may he given
 for a dose, to a child of eighteen months old, with the  addition of
six grains of jalap, or  a little iufusion of senna.   Small blisters
tought also to be applied successively to  the scalp, and all stimulate
 ing diet is to be,avoided.
   In the .next stage, when symptoms of inaction or loss of energy in
 one part ofthe .brain occur, perhaps with a continuance of excite-
 ment in another, remedies have little effect; but still, as they some-
 i.Hies succeed, they ought invariably to  be tried as sedulously as if
 .•-.e expected certain success. They consist ina continuation.of blis-
 ters, the u«e of purgatives,  and the exhibition of  mercury, by fric- 
150
 lion or internally, so as to affect the system, or act  on the brain.
 Antimonials have been used, in conjunction with mercury, but  I
 do not know with advantage.
   Paracentesis has been  chiefly resorted to in the chronic species.
 In acute hydrocephalus, the fontanelle is often  so prominent and
 elastic, as to give rise to a belief, that  water is really lodged  in
 contact with it.  A puncture cautiously made has shown  the  mis-
 take ; and whilst it has not been attended with any injury, it has as
 certainly failed to do good.   Opiates are hurtful at first, but in the
 conclusion they may sometimes render the scene less distressing,
 by abating the convulsions.   These are  also sometimes relieved
 by sprinkling the face with cold water, or  administering a  large
 clyster.
   When hydrocephalus is known to be a family disease, it will be
 proper to use every means to strengthen the constitution, such as
 the cold  bath, light nourishing food,  and strict attention to the
 bowels.  If the child be plethoric, or have momentary fits of in-
 sensibility, or the slightest and most transient paralytic affections or
 eclampsia, the bowels should be kept loose, and a small issue must
 be kept open on the head; from this I have observed great advan-
 tage.   We should be particularly careful not to  heal too suddenly
 any eruption, especially about the head.  The  first symptoms of
 disease must be watched; and we had better be blamed for using
 remedies too early, than have to regret  that we employed them
 loo late.
   The chronic hydrocephalus makes its attack  more slowly,  and
 runs its course with much less speed.  It seems sometimes to be
 gradually approaching from birth, the child  being  dull,  languid,
subject to frequent fits of stupor or drowsiness, and  the head en-
larging faster than it ought to do ; or it may even begin in utero,
In other cases, the child is at first tolerably healthy, and it is many
vears before symptoms of the disease appear.  First of all, we ob-
serve him to be duller than usual, with a slight degree of fever, at-
tended with pain in the head, sometimes constant  but moderate.
sometimes  attacking like paroxysms  of headach,  attended  with
sickness and vomiting.  He is amused for a  short  time with the
entertainments of his age, but is soon tired, and generally is found; 
151
after a little play, lying on a chair.   The appetite is gradually im-
paired, and his food  is apt to sicken him,  or  to  be  rejected by
vomiting.  The headach becomes more constant,  and sometimes
severe, often attended with giddiness, and pain or  stiffness in the
neck.  The skin is rather hot, the  pulse  at first is frequent and
irregular, although in  some instances it very  early becomes un-
usually slow, and continues so for a  long time.  The bowels are
constipated, the urine sometimes passed with pain and difficulty.
The eye is dull and languid, and at times the patient  sees  double
or indistinctly.   After these symptoms have continued some time,
the bones of the head enlarge greatly, if the sutures have not unit-
ed, and the veins on the scalp become  very distinct.   The body
wastes, and the muscular powers are more or  less impaired.   In
this state the patient may live many months ;  or occasionally the
disease seems to recieve a check, and the patient  lives for years
with an enlarged cranium, and sometimes in a state  of idiotism.
In general, however, in a few weeks, or at most a few months, the
symptoms of compressed brain become more distinct; and it has
been  supposed, but  not  always correctly, that these take place,
whenever the head ceases to enlarge, and not sooner.  The pupils
are dilated, the patient squints, the limbs are  paralytic and con-
vulsed, the urine is suppressed, so that the catheter is required, the
pulse full and slow, but presently it becomes weak and  fluttering,
and the patient dies comatose, with  stertorous  breathing.  When
the patient can  give an account of his sensations, we may early be
led to suspect some disease in the head, but ininfancy we can re-
ceive no  account of the sensatiops.  We may  discover it, how-
ever,  by  the unhealthy look of the child, the frequent application
of the hand to  the head, which often is  greater,  and feels heavier
than usual, even before water be formed ; drowsy  fits, and some-
times convulsions; vomiting, and awaking terrified from sleep ;  at
the same time that there seems to be  no tendency  to  dentition.
Afterwards the  size of the head, and other symptoms, indicate the
disease more decidedly.
   There is an  affection  which is liable to be confounded with
chronic hydrocephalus.   The patient complains of his head and
ner-k  for  a  length of time, has the pain increased by exercise, agi- 
l&Z
 tenon, or reading iong,  and sometimes he squints.   The pairv,
 however,  is rheumatic, follows the course of that disease, is i/ol
 constant,  and shifts its place.  The  squinting is either habitual,
 and consequently accidental, with regard to the disease, or it  is
 caused by a temporary affection of the muscles of the eye, and is
 increased  by looking long at any object   The patient is easily
 agitated, and at a more advanced age, would be said to be hysteri-
 cal*  Laxatives, bark, and sea-bathing are usefuL
   On opening the head, we generally find a great quantity of water
 in the ventricles, and some even on the surface of the brain. Some-
 times the ventricles are so much enlarged, that the cerebrum resem-
 bles two vesicles laying on the cerebellum.  The bones of the cra-
 nium are occasionally very thin and softened, sometimes very irregu-
 lar on their inner surface. In a girl who died, after having been ill for
 about five  months, I found the inside  of  the cranium, at the lower
 part, covered with sharp bony processes or spines.  There is sel-
 dom, if ever, any indication of previous inflammation.  This dis-
 ease, therefore, differs from acute hydrocephalus.
   The  practice consists  in the application of blisters to the head,
 or the formation of an issue on the scalp, by means of savine  oint-
 ment ; or a more general irritation may  be  kept up, by  rubbing
 with garlic ointment, or ointment with tartarite of antimony.  The
 bowels are to be kept open, or at least regular, by the use of  pur-
 gative medicines; and it will be proper to give a course of calomel
 or mercury, combined with digitalis, nearly  in the same doses we
 would use  for dropsy.  By this plan, some children are cured, and
 others have the head reduced in size for a time.*  These have had
 the urine considerably lessened in  quantity; and  when the medi-
 cines do good, they increase the flow of urine.  It has been  pro-
 posed, by bandages, and other means, to support the bones of the
 head, and  prevent distention, but of this I can say nothing from
 my own observation; and am persuaded it would be hurtful.
  It has been proposed to draw off the fluid by puncture; and this

  • In a case atteqjkd by my brother, he succeeded so far with the mercury and
digitalis, as to render the fontanelle slack, whereas, before, it was tense and pro-
minent. But whenever this Slackness was produced, convulsions came on, and
the patient died, 
153
has been done, and sometimes, it must be acknowledged, with
success.   One case of this kind is related by Rossi, and another
more lately by Dr. Vose, who cured a child by puncturing three
times with a couching needle.*
  The secondary hydrocephalus is a very insidious disease.  In
one respect, perhaps,  the majority of cases of acute hydrocepha-
lus  may be called secondary, in as much as they are excited by
other irritations, in the bowels or gums, &e.  But by this term, I
wish particularly to  understand the attack which succeeds to soma
previously well formed and prolonged disease, such as scarlatina,
booping-cough, &c.  It too often happens,  that in the progress or
sequel of such diseases, hydrocephalic symptoms supervene, and
the child is cut off.   That this should take place is not wonderful,
when we consider the remarkable sympathy existing betwixt the
brain and other organs, and the  great vascularity of the brain, as
well as its delicacy in children.  But however the fact is  to be ex-
plained, its existence is undoubted.  It is highly necessary, in all
diseases of children, to watch the safety of the head; and when-
ever symptoms  appear,  indicating  an affection  of that organ, to
have recourse to the application of leeches, blisters, and other
means, which have  been pointed out. Indeed, in all the protracted
diseases of children, especially if attended with considerable fever,
it will be prudent to shave the head, and apply a small blister upon
it   Calomel purges are of great utility.
                         CHAP. VII.

                Of Convulsions and Eclampsia.

  Convulsions  proceed from various  causes during infancy.
They very frequently arise from irritation in the bowels, from den-

               • Medico Chir. Trans. Vol. IX. Part 2d,
     Vol. II.                 20 
154
tion, or in the course of eruptive fevers.   Sometimes they  pro-
ceed from immediate affections of the brain itself, and very often
they occur in  hydrocephalus.   They may be distinguished into
those proceeding from a primary affection of the brain, and those
occasioned by sympathy, with some other organ in  a  state  of irri-
tation.  It is not, however, easy to make the diagnosis in.every
instance; and when convulsions continue long, whatever may have
been their origin, the brain ultimately  suffers; and if the disease
be protracted, the patient  becomes emaciated, and perhaps para-
lytic, or even hydrocephalus may very early  be excited.
  We may be assisted in our judgment, by examining the gums,
especially if the child be about the time of life .when teeth appear;
by inquiring into the state of the bowels, whether they be loose or
bound, or the child be troubled with worms; by  learning if an
eruption have  suddenly  disappeared;  or if the child have been
frightened, or had heavy food, or too much food, or been sucking
a woman whose mind had  been recently agitated;  or if none of
these causes be discovered, we  should inquire if the child have al-
ready had those febrile eruptive diseases, which are often preced-
ed by convulsions, especially small-pox. In at least  nine cases out
of ten,  convulsions proceed  from  irritation  of the bowels;  the
stools being generally unnatural, or the digestive functions impaired.
This observation is of much importance in  practice, as it  points
out both the means of prevention and of cure.
  Very young infants are subject to a  slight degree  of spasms,
called inward fits, in which the  mouth is, during sleep, drawn into
a smile; the eyelids are not quite closed, and the eyes are  turned
about,  so  as at times to discover  the white ;  the breathing seems
occasionally to flutter, and the child is very easily startled.  These
fits appear to be occasioned by wind in the stomach  or bowels, for
they are relieved by a discharge of wind, and  require some  carmi-
native, such as oil of anise,  with a gentle laxative. They generally
go off in a short time, but sometimes they are succeeded by vomit-
ing or purging, or drowsiness, ending in convulsions.*

  * Dr. Armstrong was the first I believe who called the attention of physicians
to this complaint.  He has written very elaborately upon it, and deems  it mud 
155
    Some children, very early after birth, appear languid, moan, and
 pass dark-coloured faeces, different from meconium, and after it, in
 the usual course of things, ought to be removed.  Presently they
 fall into a state, rather resembling syncope than convulsions, and
 die perhaps in forty-eight hours after they are born.   The early
 use of calomel, in small doses,  conjoined with some gentle aroma-
 tic, is proper.*
    Others, soon after birth, are seized with a violent fit of crying,
 and they become more or less  distinctly convulsed, and the mus-
 cular irritation may repeatedly recur.   This is relieved  by the
 warm bath, gentle  laxatives, and rubbing the belly with a  little
 laudanum.  1  have sometimes thought that this state was induced
 by tying the cord too near the belly,  by  which an  irritation was
 communicated to the abdominal viscera.   Infants of a  month old,
 who are subject to severe fits of crying from colic, which is often
 induced by bad nursing, may be suddenly carried off by a convul-
 sion after a violent and continued paroxysm of screaming.  This
 state requires great attention to the bowels and to diet.
   Regular convulsions may occur at a very early period of infancy,
 and in this case attack those  children  who, from the  time of
 birth, have been subject to heavy  sleep, or to whine and moan, or
 to violent screaming, or to start suddenly from their sleep, and who
 have twisting of the extremities while awake.
   Convulsions  vary  much in their  degree and duration.   Gene-

 more formidable than it is commonly represented to be. Where it is neglected,
 he says,  " it will degenerate into an almost constant drowsiness, which is sue*
 ceeded by a fever and thrush, or else it terminates in vomitings, sour curdled or
 green stools, the watery gripes, and convulsions."  The antimonial wine given
 as an emetic is the chief remedy which he has suggested.
  Notwithstanding the preceding frightful picture, I cannot help considering
 " inwards fits" as a very trifling sort of complaint, too trifling, indeed, to get a
 place among the diseases of infants. That very young children often exhibit the
 symptoms described by Mr. Burns is undoubtedly true.  These, however, will
 be found to proceed from uneasiness, the consequence of an overloaded and die*
 tended stomach.  The mild carminatives will generally give relief.   But if they
fail, the stomach must be emptied by a puke or purge.  It is better however to
 prevent this complaint altogether by a proper regulation of the child's diet. C.
  * At this very early stage of life, I would prefer purging with castor oil to
calomel.                                                      C. 
156
 rally the child is seized quickly with a spasm of the muscles of
 the  arms and legs,  which are agitated to and fro,  the  fists  are
 clenched, the body bent back, the features distorted, the eyelids
 open, the pupils dilated, and the eyes either fixed in the socket or
 rolled about.  The face is either pale or livid.  These convulsions
 may prove very suddenly fatal; but sometimes after the  fit  has
 lasted a minute or two, it goes off and does not return.   In other
 cases, it returns very frequently for several days, or at uncertain
 intervals for many weeks.  In general, the longer the fits, and the
 shorter the interval, the  greater is the danger.  The occurrence
 of paralytic symptoms or emaciation, in those cases  where fits are
 frequently repeated, adds greatly to the danger, and generally in-
 dicates hydrocephalus.  When the child  is very much stretched,
 or bent back,  some call the disease tetanus, and give the appella-
 tion  of eclampsia to the other cases.   In many instances, the first
 symptoms are a kind of wheezing or croupy breathing,  immedi-
 ately succeeded by a general convulsion.
  When a child is seized  with  convulsions, a  very great alarm
 prevails ; and it is expected, that if the practitioner  arrive  before
 the child is carried off, or has recovered from the fit, very prompt
 and  active means must be employed.   The first thing to be done,
 is to order a warm bath and clyster to be got ready immediately ;
 and  while these are preparing, we enquire into the circumstances
 of the case, and examine the gums.  If the child be at the time
 of teething, and no other cause be discovered, it will be proper to
 cut the gum freely over that part where the teeth ought, according
 to the usual order  of dentition, to  appear, even although no swel-
 ling  be discovered.  Then the child is to  be put into the warm
 bath, the face alone being kept above the water, and he is to be
 retained there for a few minutes, if the fit  do not  pass off sooner.
 If the bath do  not give speedy  relief,  I have seldom found
 much advantage in resorting to it again, if the  fits should be  re-
peated.   In some  instances  the addition of a little hartshorn or
 mustard to the bath is useful.  When the  child is taken out of the
bath, a cloth is to be applied over the. stomach, or great part of the
 abdomen, wet with  strong spirits, and lightly sprinkled with pep-
 per.  A clyster is at the same time to be thrown up, so as to opera* 
157
 speedily ; and this is te be followed by a calomel purge, and the
 subsequent use of laxatives,  to keep the bowels open.  It may be
 proper, however, to state to the parents, that it is not unusual for
 the fit to  return, about the time of having a stool.   If the  child
 has diarrhoea, if the stools  be not natural in appearance, laxatives
 will still be proper, according to the directions given in considering
 diarrhoea.*  Emetics have  also been employed  during  the fits »
 but unless we have reason to suspect that some indigestible or im-
 proper substance has  been taken, they will not be so beneficial  as
 laxatives.  But when fits are only apprehended in dentition, from
 starting, feverishness, and circumstances ascertained by former ex-
 perience  to precede convulsions, a gentle emetic is often of service,
 and ought to be followed by the warm bath  and some antispasmo-
 dic, such as asafcetida,  conjoined with a  laxative  if necessary*
 Tincture  of asafcetida, with the  addition of oil of anise,  is a very
 useful remedy; or we may give tincture of hyoscyamus with oil
 of anise.  Camphor has been strongly advised, either by the mouth
 or in clysters, by Stork, but I do not know  that it is very useful.  I
 must say  the same of musk.   When it is deemed proper to  exhi-
 bit emetics during the fit, a few spoonfuls of a solution of sulphate
 of zinc may be given in quick  succession,  as  operating speedily
 and safely ; or ipecacuanha  may  be employed, and the fauces
 tickled with a feather, to hasten  its operation.
   If  the face be flushed, or the arteries of the neck beat strongly,
 it next will be proper to apply one or more leeches to the  fore-
 head, according  to the age and constitution of the child; or if
 possible to take blood with a lancet from the arm, and avoid  stim-
 ulants : but if the face be pale, a  few  drops of the aromatic spirit of
 ammonia may be given repeatedly.  Opium is hurtful when the face
 is flushed;  and even when it is  pale, is  only useful when  there
 seems to be considerable irritation about the bowels, or from the
gums.  Oil of  rue is strongly recommended by Dr. Underwood;
 and when the fits are repeated,  it will be proper to make use of

  • The propriety of giving purgatives in convulsions, when the bowels are
costive, or the stools unnatural, is confirmed by experience, and the effects of
this course  in chorea. 
158
this, or asafcetida,  musk,  or other antispasmodics.   The spine
should, in such cases, be repeatedly rubbed with some stimulant
embrocation; or oil of amber, and  a blister should be applied to
the head, after it has been bathed for a time with  cold water.   I
have also found advantage in  pouring cold water on the head ; at
the same time I must observe, that  it may, and often does produce
paleness, and appearance of alarming collapse, but from this the
child has recovered.  Smart aspersion of the  face, with cold wa-
ter also tends to shorten the fit.   When it is preceded  by  spasm
about the larynx, a  blister on the nape of  the  neck is a usefuf ad-
dition  to the free use of purgatives.  In all cases the diet must
be attended to, and it may even be  necessary to  change the nurse.
   When a child has repeated convulsions, and almost constant
moaning and bending back of the neck or spine, the disease is in-
curable, as it proceeds  from water in the head.   It may, however,
be protracted for several  weeks.  Repeated small  blisters  on  the
head, and the daily use of calomel,  may be tried in such chronic
cases,  but at last the only relief is obtained by opiates.
   Children disposed to hydrocephalus sometimes fall down for  a
few seconds in a state of insensibility, without  much or even any
jpasm. By purgatives and keeping an issue on the scalp the dan-
ger is averted.
   Trismus nascentium is  not  a very  frequent  complaint  in this
country, but it is not uncommon in  warm  climates.  It makes its
attack  within the first fortnight of life, very rarely before the sixth
day, and has been supposed by some to be connected with a cos-
tive state of the bowels, by others with the falling off of the navel
str'.ig and  the state of the umbilicus.*   In some instances,  the
Spasm  is confined to the jaw, which  is rigid and closed ; in  others
it extends to the neck or  trunk, which is stiff and bent  back.  The
disease is very fatal, notwithstanding that the warm and cold bath,
opiates, purgatives,  and blisters have been fully tried.   The state
of the navel should  be attended to, and proper dressings applied,
so as to avoid irritation.

  • Vide a Paper by Dr. Bartram, in Trans, of Coll. of Phys. at Philadelphia,
Vol. I- p. 227., and by Dr. Colles, Dub. Hos. Rep. Vol. I. p. 235. 
159
    After the period of infancy is past, and during the time when
 the second set of teeth are coming out, convulsions  are  generally
 of the eclamptic kind, attack suddenly, the patient screaming out
 as if terrified, and then  he  falls down convulsed.   When the fit
 goes off, he becomes nearly  quite well.   These  do not indicate
 that the patient shall be subject, after puberty, to epilepsy.  They
 are relieved by attending to  the state of the  gums,  removing de-
 cayed teeth, and cutting the gum over the grinder which is com-
 ing out, but especially by keeping the bowels open, which must be
 done  with perseverance in the most efficient way.  We  thus re-
 move a frequent exciting cause ; but we must not  confine our at-
 tention to the bowels alone,  but must inquire whether  any other
 source of irritation exist.  Near the time of puberty it may occur
 in either sex, from irritations which exist at that period, but it is
 particularly frequent  in the female.   Sedulous attention must be
 paid to the  bowels ; and, as in other cases, we must  call in the aid
 of remedies of a different description.  01. succini, valerian, sea-
 bathing, and tonic medicines, as zinc, have been found of service -
 asafcetida or camphor, given  by the mouth, or in clysters, have also
 been  useful.  When  there is much determination  to the  head,
 especially in the first  attack, either the lancet or leeches  ought to
 be used.  If these means are not successful, an issue ought to be
 established  in the neck.   But in obstinate and  protracted cases,
 organic alterations have generally taken place, and the patient be-
 comes fatuitous, a state sometimes preceded by morbid perversity
 of disposition.  This  condition of the brain is  more apt to take
 place,  if suitable evacuations have not been made  early.   Bleed-
 ing and purging, timeously employed, may be of the most signal
 service, in preventing organic changes.  Eclampsia  occurring at
 the menstrual period,  although partaking  much of the nature of
 hysteria, requires the  same treatment.  Convulsions  have some-
times been caused  by  impure air, and can only, in such cases, be
relieved by a removal to a purer atmosphere.  This is a fact which
 it may be of service to remember. 
160
                        CHAP. VIII.

                   Of Chorea and Paralysis.

  The convulsions called chorea sancti Viti, attack children most
frequently from the age of eight  years to that of puberty.   This
disease makes its approach with  languor, and dislike  to the enter-
tainments of the age; a variable  and sometimes  very keen appe-
tite ;  in general continued  costiveness,  attended usually with a
hardness and swelling of the abdomen, especially at the lower part,
though occasionally  the belly is  flabby,  and rather small, instead
of tumid.   Sometimes the  bowels are open, but the stools are not
of a natural appearance.   Presently convulsive twitches and mo-
tions of the muscles  of the  face take place, and are succeeded  by
more marked convulsive affections of the muscles of the extremi-
ties and trunk, so that the  patient cannot sit still, nor carry a cup
of tea safely to the mouth.   These are often almost constant; even
when the patient is  asleep, the limbs are in motion,  and the rest
is greatly disturbed.   He does not  walk steadily, and sometimes
seems to be palsied,  or  the motion may be very rapid, the  head
shaking like a rattle.  The patient is  sensible during the convul-
sive motion.  At a  more advanced period, the  countenance be-
comes vacant, the eyes  dull, the  speech  is affected, and, in  some
cases, the patient cannot even swallow without  difficulty.   Ema-
ciation takes place, and a febrile  state may be induced.
  A variety of remedies have been  tried in this disease, but none
with so much advantage as purgative medicines,  which have been
prescribed  with the  happiest  effect by Camper,* Sydenham, and

  • " Having described the nerves, I now come to the symptoms, which are ea-
u sily explained by their connexion. I will begin with tremour of the teet,
" which is common in hysterical cases.  But I ought in the first place to men-
** tion, that the dreadful hysterical symptoms, which we daily see either in indi-
'« vidual parts, or in the  whole body, are altogether dependent  upon the accu-
" mutation of acrid matter in the prims vise;  for the intolerable fetor, the 
161
Hamilton.   These, if given early, and before  the disease is fully
formed, will very effectually relieve the patient, and at  this time
they only require to be gentle, and repeated  as the state of the
bowels may require.  But when the disease is confirmed,  " pow-
" erful purgatives must," as  Dr. Hamilton observes,  " be given in
•* successive doses, in  such a manner that the latter doses may
rt support the effect of the former, till the movement and expulsion
" of the accumulated matter are effected, when symptoms of re-
* turning health appear."  Calomel and jalap are useful purgatives
in this disease, and Dr. Hamilton is in the habit of using aloetic
pills on the days when these are not employed, which is a useful
practice  when the  patient can swallow pills.   My own experience
reads me  decidedly to agree with  Dr. Hamilton in  the employ-
ment of  the aloetic pills, which must be given in sufficient num-
ber daily, to produce a full  effect  Dr.  Underwood recommends
aloetic and mercurial  purges.   By these  means, chorea  is per-
haps cured in a fortnight, or, in obstinate cases, within two months.
Boys are said to be more readily  cured than girls.  If no great
amendment take place soon, we must  not on  that account desist,
but continue the purging plan for several weeks, and  generally we
succeed at last  Tonic medicines are useful adjuvants, and in ob-
stinate cases,  we  must take  the  assistance  of copper, arsenic,
nitrate of silver, nux vomica, lactuca virosa, and the other remedies
which formerly were chiefly trusted to for the cure of convulsions.
The food should be  light and  nourishing, and  due  exercise taken
in the open air.*
   There is a variety  of chorea, in which the patient generally

u scantiness and unnatural appearance of the feces, always warn us of an ap-
<« proaching paroxysm of rigours and convulsions.
  " Ought not purgative medicines, and even the most drastic ones, to be exhi.
" bited ? They probably might cure  spurious epilepsy, chorea sancti viti, and
" other spasmodic.diseases, hitherto generally  deemed hopeless by  medical
" men." *                    Camper on the Pelvis, Chapter iii. section 7.
  * I can bear testimony to the decisive and superior efficacy of active and con.
tinued purging in chorea.  Two case's of the disease in boys, which had been
previously treated for several months by  stimulants and antispasmodics, without
the least advantage, were perfectly  cured by me in a very few weeks, by ad-
 ministering every two days, a powerful purge.                     C,
     Vol.  II.                 21 
162
a female, has paroxysms of starting, and convulsive contraction ol
the muscles, particularly after eating, sometimes accompanied with
pain in the region of the stomach.  When this state has continued
for some time, she is seized more acutely with an attack of severe
general spasms, in which the whole body feels as if it were cramp-
ed.  The face is flushed, the pulse frequent, and much weight is
felt in  the  head, but the patient does not become  insensible.   It
participates in its nature with an obstinate spasmodic disease, con-
sidered in  Chap. 6th, and may attack those who have recovered
for some time from  that.  The acute  paroxysm, which may be
mistaken for a common hysterical fit, demands the instant use  of
the lancet, and the application of a blister to the neck;  afterwards
the usual treatment of chorea is to be strictly adopted.  A gentle
mercurial course is  sometimes of service, and  the assistance  of
varied tonics is not to be neglected.  Fcetids are also occasionally
serviceable.
   When chorea  occurs in a child of a family prone to hydroce-
phalus, we ought, if it do not speedily yield to the usual remedies,
to establish a small issue on the scalp or neck, and redouble our
attention to the bowels.
   Some children are apt to awake during the night screaming vio-
lently, or in great agitation, as if in dreadful terror.  This proceeds
from a dream, but the  imaginary scene continues after awaking;
the child, for example,  insisting that snakes are crawling along the
curtains.   This is cured by a  smart purgative, given every two
days, for some time, and avoiding much supper.
   A weak, or even completely  paralytic state of one of the supe-
rior or inferior extremities may take place, in consequence of a bad
state of the bowels, in which case the stools are offensive, and the
belly tumid.  This  is cured by  purgatives and friction.   But it
may also proceed from some slight disease of the brain, or medulla
spinalis, though no mark of this can be discovered locally, unless
it be that often the head is rather larger than usual.   Sometimes
one arm appears  to be either powerless or weak for many days,
 and yet otherwise the child is  in health.   This yields to a purge
 and friction  with  oil of amber.  In other  cases, one leg is  long
 weak, and the child drags it slightly.  Whimsical practitioners 
163
have mistaken this for diseased hip-joint, though the bone wete
precisely the same with that on the other side. It goes off in course
of time, and only requires the cold bath and laxatives.
   When paralysis occurs, as a prominent symptom, in chorea, or
m the sequel of that disease, brisk purgatives are to be employed,
along with the hot bath, friction,  small blisters to the spine, nux
vomica, electricity, Sec.
   The violent and involuntary jumping, tossing, or dancing, de-
scribed by some authors,  are to be referred to the same cause as
chorea.   It is not easy to point out a cure, but the disease some-
times ceases suddenly, without any very evident reason.*
                        CHAP.  IX.

                          Of Croup.                   *

  The croup is divided by some writers into two species, the in-
flammatory and spasmodic; but there is perhaps no case of croup
in which muscular action is not concerned, only in some cases the
inflammatory symptoms are more prominent than in others.  The
croup begins with shivering and other symptoms of fever, which,
when the child is old enough, can be very well described by him;
but in infancy, we discover them  by thirst, restlessness,  starting,
hot skin, and a tendency to vomit   Along with these symptoms,
but sometimes even for a day or two preceding them, the child has
a dry  hoarse cough.   Often  however, the attack is very sudden,
the previous indisposition  being short and scarcely observable.
The local  disease manifests itself by a difficulty of breathing, at-
tended with  a wheezing noise; the voice is shrill, the cough is of a
very particular sound,  somewhat resembling the barking of a littla

  * A case which occurred in  tins city is described by Dr. Watt, Med. Chir.
Trans, v. 2., and another by Mr.  Wood. Ibid. vii. 337. 
164
 dog;  others describe it as resembling a cough sounding through a
 trumpet.   This barking hoarse  cough, however, is of much less
 importance than the symptom of difficulty in breathing.   It is not
 uncommon for vomiting to attend this cough in  the early stage.
 The pulse from the  first is frequent,  the patient is restless and
 anxious, and the face flushed, the eyes often watery and inflamed,
 and the mouth frequently filled with viscid saliva or phlegm.  Very
 soon, especially in those cases where the face is  much flushed, a
 great degree of drowsiness comes on, from which the child is fre-
 quently aroused by the cough, and fits of suffocation, and great agi-
 tation ; for this disease has exacerbations, during which the heavy
 sonorous  breathing is exchanged for a violent struggle, in  which
 the child  makes a crowing noise, and if old enough, starts up, and
 clings  instantly to the nearest object, and  stares most pitecusly.
 If the disease be more mild, the face in this remission is sometimes
 pale, otherwise it is flushed, and before death it assumes a blue or
 purple colour, whilst the lips become livid;  in the early stage they
 may be rather pale.   If it do not prove suddenly fatal, the face and
 lips become tumid in the progress of the disease.  Convulsions
 sometimes succeed the cough.
   The duration of  the  complaint is various; in some cases  it
 proves fatal in a few  hours, in others not for a week, but most fre-
 quently in a day or two.   Much depends, in this respect, on the
 degree of inflammation, the violence of the spasm, and the strength
 and constitution of the child.  Sometimes there is much more of
 spasm  than inflammation in the disease, in which case we have
 less  fever, less  permanent dyspncea,  and less frequent cough, but
 the attacks of suffocation are not  milder.  Those cases end  best,
 where  the breathing  is  least sonorous, the fever  most moderate,
 the cough early attended with  expectoration, and  the symptoms
 seem at times to become  so slight as to constitute intermission.
   Dissection has occasionally discovered, on the inside of the larynx,
 alymphatic incrustation, or layer of membranous-looking substance,
 which  is sometimes coughed up in considerable portions.   This,
though it adds greatly to the danger and distress of the patient, is
not to be considered  as the cause of the disease :  for it is merely
an effect of inflammation, which, together with spasm,  could pro- 
166
duce all the symptoms without its aid. If the disease do not prove
very rapidly  fatal,  the  lungs are found to be inflamed,  although
th ere was no pain felt in the chest*
  The most frequent cause is the application of cold  and damp.
Infants under six months are not often seized with  this complaint,
but from that  period to the age of puberty are obnoxious to it.f
They are peculiarly liable to it soon after being weaned.
  From the nature of the disease,  blood-letting evidently is the
appropriate remedy, and the most ample experience has  now con-
vinced me, that it is the only one on which, in such cases, depen-
dance can  be placed.  There are two facts, however, which I wish
earnestly to impress on the reader.   The  one is, that this remedy
is only  useful in the very commencement of the disease; for  if it
be  neglected until the  symptoms become  very severe, and  more
especially  till  they have  lasted for many hours, it only increases
the suffocation, and hastens death.  The other is, that  the blood
ought to be  taken at  once from the arm, by a lancet and not by
leeches.   I am not prepared to determine, that leeches applied to
the throat  itself, are of no avail; and, therefore, when a vein can-
not be opened, this is the practice to be adopted.   But I am quite
at liberty to  pronounce, that leeches applied to a distant part, as,
for instance, to the foot, are worse than useless ; and the practi-
tioner who advises or  acquiesces in  this application is guilty of a
great crime.    In a disease so formidable as croup,  it  is not to be
expected  that  any remedy shall  be uniformly  successful;  and,
therefore,  I am not surprised, that venesection may have fallen in-
to  discredit; but I would wish  to learn from the practical physi-
cian, what remedy has proved more  beneficial, or better deserving
ofconfidence.^

   * A pretty good epitome of the symptoms, causes, and treatment of this dis-
 erase, up till the year 1808, will be found in the tract of Schwilgue.
  f Croup sometimes occurs even among people of advanced age. Cases of
 this kind have been repeatedly noticed by different practitioners in this coun-
 try.  C.
   t During the growth of the body, the fluids, and especially the blood, in re-
 lation to the solids are larger in quantity, as is distinctly shown by a variety of
 circumstances.  This fulness of their vessels, and the greater excitability of their 
1(56
   Emetics have been greatly recommended by some, whilst others
have little faith in their utility.   I have sometimes  observed great
benefit from them, if employed very early; and would advise them
to be given in every instance.  Even in the advanced stage of the
disease, emetics do much service, appearing  mechanically to re-
move the lymphatic membrane.   Decoction of seneka, arid pre-
parations of squills,  have been used to assist the expectoration  of
the membrane, but they do not equal emetics for this purpose.
   Antispasmodics have  been  trusted to, almost exclusively, by
many ;  but I apprehend  that their exhibition ought to be confined
to a different disease, which I  shall immediately notice.


systems, render children peculiarly  liable to inflammatory affections.  Nearly
all their diseases partake in some degree of this character.  It follows, therefore,
that they require oftener to be bled. My own experience, confirmed by that
of other practitioners, has perfectly satisfied me, that blood-letting may be used
with as much safety, and decidedly with greater advantage in the complaints of
children, than in those of adults.  If too, they do not at the time bear the loss
of blood better, they undoubtedly recover much sooner from its effects.  The-
prejudice against  bleeding in children  seems to have arisen out of the too
prevalent opinion, that owing to an extreme delicacy and frailty of constitution,
they cannot bear any vigorous impression.  As a natural consequence of this
opinion, the  general practice in their complaints is extremely feeble, exactly,
indeed, of that kind which has been  facetiously described as observing a strict
neutrality between the patient and the  disease, neither declaring  for the one
nor the other.  By no narrow nor partial observation, I am thoroughly persuad-
ed that the very contrary of this opinion is true.  Children, I have remarked,
display  an  uncommon tenacity of life,  and strength  of constitution.   They
often survive under circumstances which destroy adults. They have been found
living at the breasts of their mothers who had perished by exposure to cold.
They resist contagion better than adults, and when attacked, more certainly  re-
cover not only from contagious diseases, but from all others, if properly treated.
They also sustain better  the  operation of the most active remedies, namely, of
vomiting, purging, sweating,  and blistering; and, I may  repeat,  bleeding.
These superior vital energies give, moreover, to children  very extraordinary
recuperative powers.
   Children recover confessedly, more speedily from wounds and injuries, and
surgical operations.  They likewise  recruit more rapidly after being reduced
either by disease, or by  remedies.  While there is any indication or life, how-
ever discouraging the appearances may be, I never consider the case of a child
in an acute disease as altogether desperate.  But still retaining  some hope, I
continue to administer to the restorative principle of the constitution.  C. 
167
  Blisters applied to the throat are useful remedies, and should not
be neglected.   The warm bath is also of service.
  Calomel would appear to be a powerful remedy in this disease
and, if given early, it will frequently save  the  child.  I do not,
however, recommend it to the exclusion of other  remedies, with
which it is by no means  incompatible.  The early detraction of
blood, followed by an emetic, and the subsequent use of calomel,
will  afford the greatest hope of removing the disease.  But I think
it my duty to state, that in some cases no alleviation was obtained
by any remedy  but the calomel; and in others it  was trusted to
alone, and with success.  To an infant of six months, a grain and
a half of calomel may be given every hour, until it purge freely;
to a  child a year old, two grains; and to one of two years, some-
times even four grains are given  every hour, until  the bowels are
acted on, and the child purges freely or vomits  repeatedly.   The
stools are generally  green in colour, and their discharge is usually
accompanied with an alleviation  of the symptoms.   When  this is
observed, the dose must be repeated less frequently, perhaps only
once in two hours for some time, then  still seldomer, and finally
abandoned.  Should the child be greatly weakened, either by the
disease or the medicine, the strength must be afterwards  carefully
supported by nourishment and  cordials.   It is astonishing how
great a quantity of calomel  is sometimes  taken in a short time,
without affecting the bowels, or purging violently afterwards.  Oc-
casionally above 100, and often 50 or 60  grains, are given in this
disease.   Salivation is not produced  in ch'ildven.(n)
  That excellent and experienced practitioner,  Dr. James Hamil-
ton,  jun. to wThom we are chiefly indebted for the  introduction of
the use of calomel in croup into this country, from the practice of
Dr.  Rush,* is extremely  unwilling to bleed children freely in their

  (~nj This assertion may be considered as generally correct, but notwithstand-
ing, instances have occurred of salivation being produced in children by mercu-
ry ; and when this is unfortunately the case, it is apt to be attended with the
most unpleasant symptoms, sometimes threatening gangrene, and requiring the
most assiduous care and attention of the practitioner.
  • Mr. Burns has erroneously ascribed to Dr.  Rush the credit of introducing
calomel in the treatment of croup.  As far as I have been able to ascertain, it was 
163
diseases, from its subsequent debilitating effects; and  in  croup,
begins at once with the calomel, after having used the warm bath.
He observes, that " in every case where it was employed previous
to the occurrence of lividness of tjie lips and other mortal  symp-
toms, (amounting now to above forty) it has completely succeeded,
both in curing the disease, and in  preventing  any shock  to  the
child's constitution."  He adds, that he has now  seen two cases,
where, although the croup was cured, the patient sunk from weak-
ness ;  and therefore  very  properly gives  a caution  to stop  the
calomel, whenever the symptoms begin to yield.  The alleviation,
in true croup, follows the discharge of dark green stools, like boil-
ed spinage ; in spasmodic croup, it takes place whenever  vomit-
ing has occurred. „ When much debility is  produced,  he, besides
using cordials, applies a blister to the breast.  I have  a  high  opi-
nion of the efficacy of calomel, but I cannot speak by any  means
so strongly as Dr. Hamilton ; for even when it was early, pointed-
ly, and exclusively employed, and brought away green stools, I have
known it fail; and deem it my duty most earnestly to caution the
reader against trusting to it exclusively: at the same timelmustadd,
that 1 have known it procure recovery from very desperate cases,
even without evacuation by stool;  and when, after a  great quan-
tity of calomel was given, and relief obtained, it was necessary to
open the bowels by clysters.   In those who are old enough to ex-
press their feelings, we generally find that  relief is not  obtained,
till the medicine gripe, as well  as  purge.   Whether   it  have  any
power in positively diminishing inflammation, or act  principally,
if not entirely, by relieving that part of the disease which is mus-
cular or spasmodic, is not determined;  but I am inclined  to  the
latter opinion, as it is not of much efficacy in the laryngitis of adults.
Calomel has been combined with ipecacuanha to produce  vomit-
ing, but I cannot satisfy myself that I have  ever  seen  this  combi-
nation do more good than either of the medicines would have done
singly.

first employed in this disease about forty years ago, by Dr. Kuhn of this city, to
whom the practice of physic is indebted for some of its most valuable contribu-
tions.  C. 
169
   In cases otherwise hopeless, it has been proposed to perform
the operation of bronchotomy, and it is justifiable on every prin-
ciple both of science  and prudence.  Assuredly  we  would  not
wish rashly, or too early, to have recourse to this operation, but it
is as improper  to delay too long.   If relief be not early obtained
by the  vigorous  means  I have  advised, and more  especially, if
these have not been employed, and the disease have run on with
little effectual check, we are too well warranted in saying that death
must be the result.   If this arise from the mere existence  of  in-
flammation of a sensible or vital part, acting by sympathy on  the
system, as that of the  lungs or stomach would do, then an opera-
tion, as it cannot remove that, would do no  good.  But if  it pro-
ceed not altogether from this source, but in a great measure from
the effect produced  on respiration, and the organs  concerned in
that function, rational hopes may be entertained, that if we can ob-
viate this  immediate and urgent effect of the disease, time may be
allowed for the subsidence of the complaint.  This  seems to be
the state of the case ; and, if it be  not early adopted,  the risk is
increased by the tendency which exists to the induction  of inflam-
mation of the lungs; and, independently of this, by the debility pro-
duced by the continuance of the disease.   Parents naturally recoil
from an operation, and practitioners too often  shrink from respon-
sibility.   Let such timid people bring forward the opinion of Dr.
Baillie,  and the conduct of eminent men in our profession, as a
shelter from  reproof, if they fail; and, above all, let them  solace
themselves  with  the gratifying  reflection, that if they have  not
succeeded, they at least have done  all that  skill could  suggest or
art accomplish.  One of the earliest successful cases of tracheoto-
my, in this disease,  is that of the boy,  five years of age, operated
on by Mr. Andree.*   Another boy, two years older, was operated
on by Mr. Chevalier, on the afternoon of the third day, when ven-
esection and other means had been tried in  vain.   His  breathing
was difficult,  his pulse  160, countenance livid, he  was covered
with cold  sweat, and although still sensible, was evidently sinking.
On dividing two rings of the trachea, one ounce and a half of frothy

                • Med. Chir. Trans. Vol. III. p. 335.
     Vol. II.                  22 
170
coloured mucus were discharged.   Next day his pulse fell to 144,
and in the same evening the breathing  became easy.  The  third
day he coughed up some tough mucus, and soon recovered.*  In
this case surely the operation was too  long delayed, if it were at
all in contemplation.  Far, indeed, be it from me to make this re-
mark with a view to blame the operator, who is  strongly  to be
praised for performing it at all, with so little encouragement before
him.  But I make it with the hope of others profiting by the case,
and being excited to a  still earlier operation, where  circumstan-
ces  indicate that  there is  no other probable alternative but that
of death.  There is no occasion  for employing a tube after this
operation.
  Spasmodic croup, or  acute asthma, is often, but not necessarily
connected with inflammatory croup.   There is, perhaps, no case
of  the latter disease unattended  with affection of  the  muscles
of the larynx, but there are many cases  of this affection with-
out inflammation; yet if it continue long, there is a great risk of
inflammation taking place, and of a  membrane being  formed.
The spasmodic croup attacks children chiefly, but  it may also af-
fect women, especially about the age of puberty, and harass them
occasionally for many years afterwards.  It makes its  attack very
suddenly, generally at night, and sometimes  for many nights in
succession, especially if the child be agitated, or the mind of the
young woman anxious respecting it.  The patient  breathes with
difficulty, and with a wheezing sound, has a  hard barking cough,
with paroxysms of suffocation,  as in inflammatory croup.   The
extremities become cold, the pulse, during the struggle, is frequent,
but in the remission it is slower ; and if the remission be great, it
becomes natural, unless kept up by agitation.  There is little or no
viscid phlegm in the mouth, some drowsiness, but more terror,
and  the  eye stares wildly during  the paroxysm.  The disease is
often suddenly relieved by sneezing,  vomiting, or eructation.  It
differs, then, from the inflammatory croup, in the  suddenness of
its attack, in there being little fever, but only quickness of pulse,
greatly abating when the child  does  not struggle for breath ; less
* Med. Chir. Trans. Vol. VI. p. 151. 
171
 drowsiness, and little phlegm about the mouth.  The cough is less
 shrill, and the fit often goes off  suddenly and  completely, either
 spontaneously, or by the use  of the  remedies acting quickly.
 Sometimes, however, even in adults, inflammation takes place, and
 this disease is, in infants, very readily converted into true croup.
   It is at times brought on by exposure  to cold, and in that case,
 it is occasionally preceded by slight sore throat, or hoarse cough ;
 but oftener the spasm comes on without any precursory symptoms,
 and seems to  arise sometimes perhaps from direct affections of the
 origin of the eighth pair of nerves, but much more frequently, al-
 most always, from irritation or injury dependant on abdominal dis-
 order.   The recurrent of the eighth pair seems to be often chiefly
 affected ; and when we call the disease  spasmodic,* we probably
 are often wrong;  its nature,  being, in  many  instances, rather a
 temporary paralytic state of that nerve,  or,  at least,  a condition
 unfitting it for its function, and the modus operandi of emetics may
 be to  excite  the nerve.  Bleeding, on  the other hand, relieves
 the cerebral affection, or state of the origin of the nerves.   I have,
 in a former chapter, noticed this symptom, in a particular and very
 obstinate affection dependent on abdominal disorder; and am inclin-
 ed to think, that a great majority of cases of  croup, in infants, are
 of  this description at first, and that inflammation is only an  effect.
 The drowsiness  which often attends  this complaint,  is owing to
 the affection of the base of the brain, which is thereby produced,
 and which might prove fatal independently  either of laryngeal
 spasm or of the inflammation.   Sometimes  this disease is exci-
 ted by dentition, or, if the  patient  be older, by passions  of the
 mind.   Not unfrequently a  renewal of the disease  is excited, in
 those who are subject to it, by eating a full meal in the evening.

  * 1 retain the name of spasmodic croup, both because it is generally received,
and as it is probable that spasm may in certain cases be the cause.  There, how-
ever, is  often a mistake made, by considering the  contraction of one set of mus-
cles produced by torpor or paralysis of the antagonists, for spasm : and it is this
kind of contraction which often takes place in croup, and produces doubtless
the same feeling and effects as spasm. Inaction  of both sets of muscles about the
glottis, would have the same effect-  Where the  recurrent is cut, the rima clo.
3«s, and the animal dies. 
172
   With regard to the treatment, I shall  briefly state the result of
 my observation.   In young girls, venesection has uniformly given
 relief, the spasm suddenly abating, and very soon  going  entirely
 off, after a certain quantity of blood has flowed.   Topical blood-
 letting has not the same effect, and  indeed is nearly useless.  But
 if the paroxysm should be repeated for many nights, venesection
 cannot be employed on every attack, as it debilitates and predis-
 poses to the disease.  Emetics, such as sulphate of zinc, or ipe-
 cacuanha, have the effect of abating, and occasionally of remov-
 ing the paroxysm, but not of stopping it so soon, and so suddenly
 and entirely as blood-letting.  They debilitate less, however, and
 may be oftener repeated.   In this species, and in the commence-
 ment of inflammatory croup, they act probably through the eighth
 pair of nerves, or the recurrent, which is much affected; but some-
 times the fit, though impeded during their operation, returns, and
 in such cases has yielded  to venesection.  When the emetic has
 been very long of operating, the stomach not being easily acted on,
 blood-letting has produced speedy vomiting and immediate relief.
 Opiates, and antispasmodics, such as ether, given  in large doses,
 have, if exhibited in the very commencement of the attack, some-
 times checked it, but have not always that effect, and, if not given
 soon, are longer of procuring relief.  Calomel, in  croup  affecting
 girls and women, is out of the question ;  for the paroxysm is so
 severe, that we cannot and must not trust alone to its operation.
  A relapse is to be prevented by giving purgatives, and avoiding
 exposure to cold damp air.  When the paroxysms return every
 night, or every second night, there is strong ground to suspect that
 the bowels are in fault.  Aloes, combined with a little calomel, or
 with the mass of  the blue  pill, ought to be given so as to operate
 freely and effectually, and we are not to relinquish this plan, be-
 cause it  does not immediately cure  the  disease.  In yoimg  girls,
 a course  of tonic medicines alone, or combined with asafcetida or
valerian, will be useful; and when the attacks have been kept off
for some time, sea-bathing will be proper.
  With infants we generally succeed, by giving instantly an eme-
tic, and afterwards calomel in considerable  doses, so as to produce
sickness and vomiting, or free purging.   But if the emetic do not 
173
 decidedly and immediately mitigate the disease, then, in place of
 trusting solely to the calomel, we premise venesection. Asafcetida*
 has been strongly recommended in this disease, and has sometimes
 a very  good effect.   The  warm  bath is also useful.   If the child
 be  about the period of dentition, the gum  should be examined,
 and cut if tumid.  If the disease  do not soon yield to these reme-
 dies, there is ground to  suppose that it  will be converted into  the
other species of croup ;  but this  affects the prognosis rather than
 the treatment.f


   *  Dr. Miller  has given an ounce of this gum to a child of eighteen months
 old in forty-eight hours, and almost as much at the same time in form of clyster.
 His formula is as follows : K. G. asafoetids, Jii, Spt. Mindereri, ^i, Ap. puleg. 5;iii
 M. s. a.  A table spoonful  of this is to be given every half hour.  Vide Obser-
 vations on Asthma, p. 43.
   |  The practice recommended by Mr. Burns is nearly the same as that which
 prevails in this country.  Though the distinction of inflammatory and spasmodic
 croup is undoubtedly well founded, yet 1 am not aware, that it leads to any prac-
 tical difference.  My mode of treating this disease is as follows. 1 begin by endea-
 vouring to puke the child very freely, and for this purpose I commonly employ
 the tartarized antimony, given at short intervals, as  being one of the most certain
 and powerful of the emetics.  At the same time I direct the child to be put  into
 the warm bath for ten or fifteen minutes.   This is a useful remedy.  It rarely  fails
to promote the  operation of the emetic, and will, indeed, alone, sometimes cure
the disease.  If, however, the emetic does not operate, or if after its operation,
the anticipated effect be not realized, 1 then bleed copiously, and repeat the bath
and the emetic.   The attack must be extremely obstinate if it do not now yield.
Nevertheless, it will occasionally continue with little or no abatement.  Under
these circumstances, I resort to topical bleeding, either by leeches or by cups,
and afterwards, if necessary, apply a blister, or sinapism of mustard to the throat;
extending from  ear to ear.   If the preceding remedies fail, or the symptoms be
so alarmingly violent as to demand immediate relief, 1  bleed ad deliquium animL
When pushed to this extent, 1 may almost say that blood-letting in these cases is
invariably successful. I learnt this practice from two  of the most distinguished
physicians of our country, who seem to have employed it nearly about the same
time.  I allude to Dr. Belville of Trenton, and Dr.  Dick, of Alexandria.  After
the force of the disease is broken, which is shown by the alleviation of the hoarse-
ness, and of the  difficult respiration, and above all by the restoration of the natu-
ral susceptibility of the system to the action of medicine, 1 administer calomel,
not in small and repeated doses as is more generally advised, but in the largest pos-
sible dose, in order that it may speedily and most actively purge.  In this parti_
rular stage of the disease, a thorough opening of the bowels carries off the  lin- 
174
   Some children are subject to slight wheezing, continuing for a
 day or  two, with intermissions, and accompanied with  a hoarse
 cough, but without fever.   Emetics, laxatives, and a large burgun-
 dy pitch plaster,  applied to the back, remove the disease.
   Infants during  dentition are subject  to sudden attacks of spasm
 about the windpipe, producing a  temporary feeling of suffocation
 with a crowing sound, but there  is no hoarse cough.  It is apt to
 take place suddenly  at night, or when  crying.   It is  relieved by
 giving a combination of tincture of asafcetida, and of hyoscyamus,
 and using laxatives.   The warm  bath is also useful.   The gum
 should be cut.
   I have, in the seventh chapter, noticed the spasmodic breathing,
 which is complicated with convulsions.  Some children, very nearly
 from the time of their birth, have a constant wheezing or sonorous
 breathing, subject to  exacerbation.  This  does not indicate the
 existence of an organic affection, for I have known it  removed by
 change of air.
   Besides these affections, ending acutely,  there are others which
 produce more slow  effects.  The parts about the larynx inflame,
 and this may doubtless cause speedy death, by suffocation;  but in
 other instances, necrosis of the cartilages, or abscess, or ulceration
 take place, and the patient is thrown into the disease called laryn-
 geal phthisis.  This is to be prevented in the outset,  by vigorous


 gcring symptoms, obviates a relapse, and confirms  the convalescence.  But if
 cough, or hoarseness, with tightness of the chest and deficient expectoration re-
 main, I employ the decoction of the polygala senega as an expectorant.  It is in
 extinguishing the remains of croup that it displays, 1 think, its best properties-
 Doubtless, however,  it may be used at an earlier period of the disease with ad-
 vantage as an emetic.  But still I prefer the emetic tartar. I have recently heard
 that croup has been very successfully treated by a watery solution of corrosive
 sublimate, by large quantities of melted lard or olive oil given internally, and by
 common mustard in the state in which it is used at our tables. Of the latter,-a
tea-spoonful is given to a child, to be repeated if required.  Its operation in spas-
modic croup especially, is represented to be most decisively useful.   I have not
tried, nor am I disposed  to try any one of these remedies.  They each come to
me, however, recommended by very respectable authority.  With the remedies
already known to me I rest satisfied. These in my practice have rendered croup
the most curable of all the violent infantile diseases,  C. 
175
antiphlogistic treatment;  but when it takes place, if issues do not
give relief, we have only  to consider the probable effects of laryn-
gotomy.
  The cedeme de  la glotte, described by the late M. Bayle,* is
merely laryngitis.
                         CHAP. X.

                     Of Hooping-Cough.

  The hooping-cough often begins like a common cold, the child
coughing frequently, and having more or less fever.  In some cases
the fever is slight, going off in the course  of a week; in others
very severe and long  continued, attended with great oppression,
or sickness, and want of appetite.  The cough generally comes
on very abruptly, and is sometimes early attended with that sono-
rous spasmodic inspiration, denominated hooping; in other cases,
not for a considerable time, and this is considered as a favourable
circumstance, but it is not always so, for in  young children, death
may take place, although the disease never fully form.  The fits
are generally most frequent, and most  severe during the night.
When the  cough becomes formed, the paroxysm consists  of a
number of short expirations, closely following each  other, so as
to produce a feeling of suffocation, relieved at last for an instant,
by a violent, full,  and crowing inspiration; then, in  general, the
cough or spasmodic expirations recommence, and the paroxysm,
consisting of these two parts, continues until a quantity of phlegm
is coughed up or vomited, alone, or with the contents of the
stomach, and this ends the attack.  The expirations sound  like a
common cough, but are more rapid, and frequently repeated as in
violent  laughing.  Sometimes the sound is lower, or the cough
resembles the chattering of a monkey, quickly repeated.   These
• Journ. General, Avril, 1819. 
176
paroxysms vary in frequency and duration.   Sometimes they are
slight; at other times, and especially during the night, they are at-
tended with a most painful sensation, and  appearance of suffoca-
tion, the face becoming turgid and purple, the sweat breaking, and
blood gushing from the nose or other parts.  The extremities be-
come cold during the fit, and the whole frame is much agitated.
But even severe as the paroxysms are, if the disease be not attended
with fever, the patient seems quite well after the fit, and begins to
eat with a renewed  appetite.  A fit of crying, will, at times, even
after the disease has been apparently removed, excite the cough-
The features often remain swelled for a considerable time.
   Hooping-cough is very dangerous for infants, as they often  die
suddenly in a fit of suffocation;  elder children escape more safely,
though even they  are sometimes carried  off, the fever continuing,
or anasarca coming on, with exhaustion.  Sometimes the lungs be-
come diseased, and hectic fever takes place, or peripneumony is
produced,  or  the lungs become oedematous.  Convulsions may
also occur, and carry off the child.
   Many remedies have been employed in  this disease, which it
will be proper to divide into those intended to abate the fever, and
those given to relieve the  cough.  Venesection has, for the first of
these purposes, been recommended; but it is very rarely requisite,
and only when the  patient  is plethoric", and we apprehend  that
some vessel may burst in the lungs from the violence of the cough,
or when there are symptoms  of inflammation.   Leeches  may  in
these circumstances be applied to the chest.  The most generally
useful remedies are laxatives and the saline julap, which often  in
a few days moderate the fever greatly.   The tepid bath is useful,
and if there be much irritation and restlessness, hyoscyamus some-
times does good.
   For the relief of the cough, nothing is so beneficial  as emetics.
These have been given in nauseating doses, so as to make vomit-
ing be readily excited by the cough ; but, in general, a full dose
of ipecacuanha will  be as effectual, and is less distressing.   At first,
the emetic should be frequently repeated,  especially to  infants,
perhaps once a-day, or once  in two days, according to circum-
stances ; and this degree  of frequency is by no means injurious. 
177
Antimony has been highly praised by many, but it is more apt to
weaken the stomach, and in very young children it sometimes pro-
duces violent effects.  Stimulating substances, such as a combina-
tion of soap, camphor, and  oil of turpentine; or juice of garlic, or
oil of amber, or of thyme, he., rubbed over the spine, or the tho-
rax and the stomach, have a good effect; and similar applications
to the soles of the  feet have certainly in some cases done much
good.  Antispasmodics, such as asafcetida, ol. succini, musk, &c,
have been recommended, and in some cases are successful. Opiate3
are also of service.  Dr. Willan says, that he found the watery in-
fusion of opium rriore useful than any other narcotic.  When the
disease is protracted, cicuta has been recommended, but it does
not seem to have any advantage  over opium or hyoscyamus.   It
has also been applied externally.  Lactuca virosa,  has  also been
employed.  The most effectual remedy, however, is change of air,
which often has a marked effect  on the  disease,  in a  few hours.
When the patient becomes restless, and  coughs more, it  should
again be changed.  The diet ought to be light  If there be fixed
pain  in the chest, difficulty of breathing,  and fever indicating in-
flammation, either venesection or leeches, according to the age and
circumstances of the child, will be absolutely necessary; but  our
evacuation must be prudently conducted.  Blisters and digitalis in
such cases are useful.   Pain produced merely by the  violence of
the cough, remitting or going at times entirely off, and generally
 seated about the upper part of the sternum, is relieved by those
 means which relieve the cough.   When the paroxysms have been
 very severe, the  breathing oppressed, the cheeks livid, and the
 pulse very weak, some children have been saved by the applica-
 tion of leeches to the'chest, blisters and  small doses of the com-
 pound powder of ipecacuanha.
   When the patient is threatened with hectic, or becomes emaciat-
 ed and weak, nothing is of so much benefit as country air and mild
 diet, at the same time  that we  keep the bowels  open.  Blisters
 should be applied to the breast, if there be fixed pain or dyspncea.
 If there be anasarcous swelling, the digitalis, conjoined with cor-
 dials, will be useful.
    Convulsions sometimes are excited by the fits, or occur at the
      Vol. IL                  23 
178
 same time with them, and immediately suspend the cough.  They
 are very alarming, and may  suddenly carry off the infant, espe-
 cially  if he be very  young.   The child should instantly be put
 into a warm bath, which  is to  be repeated as often as the convul-
 sions come on.  The bowels should be  opened, the head shaved
 and blistered.   If the fits be repeated, and if the child be plethoric,
 leeches ought to be applied to the temples.  The  air ought  also
 to be, if possible,  immediately changed.   In  some cases, tincture
 of hyoscyamus given in a mixture, or clysters  containing camphor,
 seem to  allay the tendency to spasm; and in every instance, it is
 proper to rub the back and belly  with anodyne balsam.
   If the cough return after  it has gone off for a  time, a gentle
 emetic is the best remedy.*  A  sudden  change  of  weather  from
 warm  to cold, is very apt to renew the cough.  If the face or lips
 remain swelled, gentle laxatives are proper.
   During the  continuance of the disease, the diet must be light,
but nourishing, if  the patient be  weak; but more sparing at first,
if he  be, on the other hand, plethoric, and  inclined to inflamma-

  * Like most other contagious diseases, the hooping-cough will run its course
 in spite of all our exertions to cure  it. We can, indeed, do little more than
 mitigate the more violent symptoms.  Among the best of the palliative reme-
 dies is a watery solution of asafcetida.  Where the cough is attended, as is some-
times the case, with convulsions, the sulphate of zinc may be given with advan-
tage.  A  combination of the  salt of tartar and  cochineal, said to  have been
originally suggested by Dr. Pearson of London, ha,s lately become a very popular
remedy in this city.  This, however, is not the prescription of Dr. Pearson.  His
is as follows:
                       R.  Carbon, sod : gr. iii.
                          Vin. ipecac, gtt. v.
                          Tinct. theb. gtt. i.
                          Aq. font. 3j.
 To be given to a child a year old every three hours.  I have tried both the al-
 kalies but with little success.  I am sure that the  above mixture derives its effi-
 cacy, if it have any, from the laudanum and ipecacuanha which it contains.  The
tincture of cantharides, united with the  decoction of bark and elixir paregoric,
has been highly extolled by Dr. Lettsom. I have no experience with it. Emetics,
on the whole, I think are our best means in this disease. They should be given
in the first stage of it, and be repeated at least  once  a-day whilst the violent
 symptoms continue.   Bleeding and blisters are occasionally useful.  C. 
179
fion.   Toward the conclusion of the disease, bark and  tonics are
useful to re-establish the health.
   There is cough very like hooping-cough, and which gives rise
sometimes to the groundless fear  that the  child  is going to take
that disease; or on the other hand, if somewhat prolonged, it may
pass for hooping-cough; and afterwards the child being exposed
to infection, takes the disease, and is  said to have had it twice.
This  kind of cough has less of the suffocating appearance than the
hooping-cough; the expirations are fewer,  and do not follow  each
other so quickly, and the  inspiration is not  performed so rapidly,
and  with  the  distinct  hooping sound.  It sometimes succeeds
measles, or appears as a kind of influenza. It is cured by an
emetic and anodynes.
                         (JHAP. XI.

 Of Catarrh, Bronchitis, Inflammation of the Pleura, and of the
                    Stomach and Intestines.

  Infants are subject, as  in after life, to catarrh, either common
or epidemic.   It is attended  with fever and inquietude, redness
of the cheeks, watery discharge from  the  eyes and nostrils, dis-
position  to sleep, frequent, and sometimes irregular pulse, panting
and shortness of breathing, with frequent cough, which, however,
is not severe.   It generally goes off within a week, by the use of
gentle purges, blisters, antimonials, and, if the fever be consider-
able,  leeches applied to the breast.   A hoarse barking  cough is
cored  by an emetic, and wearing flannel round the throat*
  Bronchitis is far from being an uncommon disease of infants.

  * Blood-letting,  and that profusely, is very often required to cure the catarrh
of children, in this country.  As it appears here, it is generally a highly inflam-
matory disease. C. 
180
It sometimes takes place very early after birth; in other instances
not for several weeks.   It begins with cough and  pretty copious
secretion of mucus or phlegm, which, however, the child will not
allow to come  out of the mouth, but swallows.   The cough is
frequent, but not uniformly so, coming on in paroxysms.  It is of
a stifled sound, and somewhat hoarse, or occasionally even  shrill,
from slight inflammation at the top of the windpipe.   The breath-
ing is oppressed or rattling, but not permanently  so.  Vomiting
is also not an uncommon attendant; the epigastrium is distended,
the stools are generally bad, the face is pale, and  the  child sick
and oppressed.  He takes the breast,  but dislikes all meat.   Pre-
sently, if death be not produced by the accumulation of phlegm,
the secretion becomes more of a purulent appearance.  The res-
piration is more  oppressed, and  the  noisy breathing  is more fre-
quent.  The hands, but especially the feet,  swell a  little,  whilst
the body becomes emaciated.  The cheeks are occasionally flushed
in the evening, and the pulse, which was always frequent, becomes
still more so, and irregular.  The fits  of coughing are severe, and
attended with appearance of suffocation, and at last the  child dies.
On opening the body we find the ramifications of the trachea filled
with purulent-looking  matter, and in some  parts there is an ap-
proach towards the formation of tubercles.  The lungs are some-
times paler than  usual,  in other instances more solid.
  This is a very obstinate disease, but it does not prove very rap-
idly fatal.  In the commencement it resembles common catarrh,
and requires the same treatment, purgatives,  venesection, and a
blister, which ought to be promptly employed.  In the advanced
stage, and under various circumstances, I have tried emetics, blis-
ters, calomel, and expectorants, but without decided benefit.  Blis-
ters, with calomel, combined with ipecacuanha, to act both on the
bowels,  and also as an expectorant, together with a  removal  to the
country, appear to  constitute the best practice.  I think it right to
mention, that though the pectoral disease may be slight, yet by the
sickening effect of a purgative, especially castor oil, great panting,
paleness, and other appearances of danger,  have been  produced,
which have all gone off after having the bowels opened freely by
a clyster, which  brought off the purgative. 
181
   Inflammation of the pleura is more frequent with  children  than
 many suppose.   The skin is very hot,  the face flushed, the  pulse
 quick, the breathing short and oppressed; there is a cough, aggra-
 vated by crying, by motion, and by laying the child down on bed.
 He  is likewise more disposed to cough, and  is more uneasy on the
 one side than on the other.  If not  relieved soon,  the breathing
 becomes laborious, the extremities cold, the cough stifling,  with
 rattling  in the throat  and stupor; or the pulse  becomes  irregular
 and intermittent, the extremities swell, the countenance is sallow
 or dark-coloured, *\w breathing difficult,  with short cough, and frothy
 expectoration, which  oozes from the mouth.  On  inspecting the
 chest, the inflammation is sometimes found to have  terminated in
 bydrothorax, oftener in adhesions.   This disease requires vene-
 section, or the early application of leeches to the sternum, accord-
 ing to the age and constitution  of the child; the use  of blisters,
 calomel, purges, and the tepid bath.  Antimonials and digitalis are
 also sometimes of service.*   In the last stage, diuretics are proper,
 especially a combination of squills and digitalis, whilst  the strength
 is to be supported by  the  breast milk, or light dietf
   This  disease sometimes terminates in abscess  and purulent spit-
 ting, with hectic ; but much more frequently, the pulmohary  con-
 Sumption of infants and children begins, as in adults, more slowly,
 is marked by  a short dry  cough, flushings of the  face,  frequent
 small pulse, difficult breathing,  wasting, and nocturnal sweats.(o)

  * This disease is to be treated exactly as pleurisy in the adult.  If the attack
 be violent, the child will probably require to be bled two or three times.  Blis-
 ters should not be applied till  the disease is somewhat reduced.  Previously,
 they always do injury. The pulse here, will be one of our best guides.  C.
  f The decoction of the senega snake root is an admirable remedy in this stage
 of the disease.  C.
  (o) It may be proper here to observe, that the infantile cough above describ-
 ed by our author is often dependent on a scrofulous diathesis of the system;
 this is very fully illustrated and explained by Dr. Parrish, in an interesting paper?
 inserted in the Eclectic Repertory for January, 1812, entitled, " An Account of
 the Appearances on Dissection of several scrofulous subjects, with a few obser.
 vations on the connexion between scrofula and  phthisis pulmonalis."  Dr. Par-
 rish has denominated the disease scrofula interna, and has found by an accurate
examination after death, that not only the abdominal viscera and the lungs are 
182
 The expectoration is generally swallowed, but sometimes it is re-
 jected, or it is vomited up, and is found to be purulent.   There is
 seldom any cure for this state; all that can be done is to send  the
 child to the country, apply small blisters  to  the breast, keep  the
 bowels in a proper state, give a mixture containing opium and diu-
 retics, and support the strength  with  suitable nourishment.  If  the
 expectoration be only phlegm, then, although all the  other symp-
 toms be present, there is considerable hope  of saving the  child.
 But if it be purulent, and the parents are consumptive, the  danger
 is much greater.  This state, however, does  not in  general suc-
 ceed pleurisy.   It is generally induced more  slowly, by tubercles,
 accompanied with enlargement of the  bronchial  glands.*
   Inflammation of the stomach is not a common disease of infant
 cy, nor is it discovered without considerable  attention.  There is
 great fever, frequent vomiting, the mildest fluid being rejected soon
 after it is swallowed, the throat is first inflamed,  and then covered
 with aphthae, which spread to the mouth.  The child cries much.
 The region of the stomach is full and very  tender to the  touch,

 occasionally affected with scrofula, but that  even  " the heart itself is subjected
 to this destructive malady." In these cases he supposes that a metastasis, or a
 translation of scrofula from the external to the internal parts may take place,
 and that by endeavouring to produce a reverse effect, the  internal disease may
 be palliated or cured.
  From the decided effects produced by  the discharge from blisters on each
 side of the thorax, in  checking the progress of the cough,  dyspnoea, &c. he
 thinks it would be eligible at the very commencement of the disease, to endeav-
 our to produce tumefaction and suppuration in the glands about the neck and
 on the thorax, near the axilla, where external  scrofula is generally seated.
 " Would this attempt, he asks, to excite disease in these parts which [if the  ex-
 pression is allowable] external scrofula chooses for its seat, be more irrational
 than the application of sinapisms to the lower extremities in irregular Or retro-
 cedent gout ?"  Hence, he seems inclined to think, that the  use of setons and
 issues, have fallen too much into disuse.  We would recommend to the student,
 the attentive  perusal of this paper, as justice cannot be done to  it in the short
 and imperfect abstract of a hasty note.
  • Although it is not exactly connected with my present subject, I may men-
tion, that sometimes the bronchial cells are much enlarged, the child has cough
 and difficult breathing.  The air escapes, and passes from the root of the lungs
 to the mediastinum, insinuating itself betwixt its layers, and thence to the neck,
 where it produces emphysema.  Punctures ought immediately to be made. 
183
The bowels are generally loose.   If the child be old enough to
describe the sensations, he complains of heat or burning about the
stomach and throat; if younger,  it is known by the incessant cry-
ing, fever, thirst, with constant vomiting, and increase of crying on
pressing the abdomen.  It is not necessary to be  too minute in
drawing the distinction, between  inflammation of the stomach and
enteritis, as they both require the same treatment, and I have seen
both prove fatal in a few  hours.   There is  sometimes, from the
first, a cough and short breathing, but the constant vomiting shows
the disease to be in the stomach.  It is not easy to say what causes
this, for it cannot always be traced to acrid or stimulating substan-
ces swallowed.   It is proper immediately to bleed, or apply leeches
to the  pit  of the  stomach, according to the age  and strength of
the child ;  then a blister is to be  applied, and stools are to be pro-
cured by clysters and afterwards by mild laxatives.  Fomentations
and the warm bath are also useful.  M. Saillant recommends the
juice of lettuce,* to be given in spoonfuls every hour, but I do not
know any advantage this can have over mucilage and  opiates.f
   There is another state of the stomach, which, from the softness
of the texture, is apt, after death, to be confounded with gangrene.
There are, however, no marks of inflammation;  but  the stomach
seems as if it had  become so soft by maceration,  that it gives way
on being handled.   This state is sometimes confined to one part of
the stomach,J sometimes  it extends even  to the  small intestines,
and more than one child in the same family have died of this dis-

  * The juice of lettuce is a very powerful anodyne. By inspissation an excel,
lent opium may be procured from it.  If it be useful in the above disease, it is
probably owing to its anodyne property.  C.
  f In all cases of this affection, except very slight ones, bleeding is indispen-
sible.  Inflammation in any portion of the alimentary canal runs very speedily
to gangrene,  which can only be avoided by a pretty free use of the lancet.  The
pulse here, as in many instances, is a very fallacious guide. We are not to ex-
pect to find it much altered.   In general, it is lower and more feeble than in
health, and this too in proportion to the violence and extent of the inflamma-
tion. C.                                                        ^
  $ Dr. Armstrong mentions a case of this kind, where the upper part of the
stomach was thus diseased, but the pylorus sound.  The stomach was distended
with food, but the intestines were very empty, which might be owing to diminish.
ed power of contraction in the stomach. 
184
ease.  It is not easily discovered before death, for its most promi-
nent symptoms, namely, purging, with griping pains, occur in other
diseases of the bowels.  It is, however, very early  attended with
coldness of the face and extremities, and the countenance is shrunk
and anxious.   It  affects the intestines  oftener than the stomach.
This state of the stomach cannot always be attributed to the effect
of the gastric juice.  When the stomach is acted on by this solvent
after death, we find that it is very soft, some of it in a state of semi-
solution, the inner surface being dissolved, and some of it actually
removed, so as to make a hole.  When the preparation is put into
spirits,  and held between the eye and the light, the flocculent ap-
pearance of the inner surface  is distinct, and numerous globules
are seen within the peritoneal coat, which are probably the  glands
undissolved.
   Peritoneal inflammation, or  enteritis, is not an uncommon com-
plaint with children.  It begins with violent pain in the belly like
colic, but is  more constant and coutinued, and is  accompanied
with a considerable degree of fever, costiveness, and tenderness in
the belly.   If this disease do not prove speedily fatal, and if on the
other hand, it be not perfectly removed, the child remains long ill,
perhaps for some weeks, and the nature of the complaint may for a
length of time be mistaken.  There is constant fever, but it  is sub-
ject to exacerbation in the evening.   There is increasing emacia-r
tion, and at first occasional attacks of pain in the belly.  The stools
are usually obstructed, and when they are procured, they are slimy,
bloody? ill-coloured, or  scybalous, afterwards there is frequently a
diarrhoea.  On examining  the  belly externally, induration may
sometimes be discovered.  The appetite is lost, the thirst is con-
siderable, the pulse becomes more frequent and feeble,  the debility
increases, and the extremities become  cold, and in this exhausted
state, the  child sometimes lies for many hours before  dissolution.
On mspecting the abdomen,  the bowels are found adhering,  or
forming knots, and sometimes the liver partakes of the disease.
   In younger infants, the consequences of peritoneal inflammation,
when it does not prove rapidly fatal,  or excite convulsions, are ab-
dominal pain or tenderness, obstinate slimy purging, vomiting, and
increasing emaciation. 
185
   In young infants, we cannot'carry  evacuation far.  But when-
ever there is a prolonged attack of colic, we may apprehend a se-
vere disease, and must use  the warm bath, clysters to  open the
bowels  immediately, and  then an opiate clyster to allay morbid
sensibility ; a small blister should be applied to the belly, and if the
symptoms  be very urgent, this should be preceded by the appli-
cation of one or more leeches to the abdomen.  In  elder children,
the attack  is often brought  on by cold, or by  eating indigestible
substances, as for instance, nuts.  No time is to be lost in opening
the bowels by clysters and laxatives, and in detracting blood from
a vein.  Fomentations and blisters are useful.   If these means be
neglected, or do not succeed, there is little hope afterwards of sav-
ing the patient,  unless the bowels adhere to the abdominal mus-
cles and an abscess takes place, which is indeed very rare.  In the
usual state  produced  by this disease, we have  little in our power,
except to regulate the state of the bowels, apply small blisters, and
support the strength.   When abscess has taken  place near the pel-
vis, or about the rectum,  the child cries much on  going to stool,
seems afraid  to pass-the faeces, and may at the time  be seized with
spasm or convulsions.  The faeces are  very offensive, and occa-
sionally purulent matter is discharged.   In such  cases I have found
magnesia useful as a laxative, and hyoscyamus with oil of anise of
great benefit  as an anodyne.   If appetite  be not lost, there is hope
of a cure, and I have known desperate cases recover.  Sometimes
this produces a contraction of the rectum ; or a  stricture may exist
there naturally,  and  produce great pain on going to stool.  In
either case a cure is effected by cutting the  stricture,  which  is
generally membranous and easily divided.
   Cystitis, also, may occur in infants, and is known by the fre-
quent and  painful micturation, pain  on  pressing the pubis, and
fever.   It requires leeches to the pubis, or venesection, and the
tepid bath, with laxatives.
Vol.  II.
24 
186
                         CHAP. XII.

                        Of Vomiting.

   Vomiting is very seldom  an idiopathic disease of children.
Many puke their milk after sucking freely, especially if shaken or
dandled.   This is not to be  counted a disease, for all  children
vomit more or less under  these circumstances.   A fit of  frequent
and repeated vomiting, soon after sucking or drinking, if unattend-
ed with other symptoms, and the egesta are of natural appearance,
may be supposed to  depend on irritability of the stomach, which
can be cured, by applying to the stomach a cloth dipped in spirits,
and slightly dusted  with pepper, or an anodyne plaster.   Some-
times a spoonful or two of white wine whey settles the stomach.
If, however, the egesta be sour or ill-smelled, and the  milk very
firmly curdled like  cheese, and the child is sick, it is probable
that more of that caseous substance regains, and a gentle puke of
ipecacuanha will give relief.  On the other hand, should the egesta
be green and bilious, gentle doses of calomel will be serviceable,
especially after an emetic.   The sickness  which  sometimes pre-
cedes vomiting, especially if it be caused by bile, is accompanied
with great  oppression, panting, deadly paleness,  and an  appear-
ance altogether as if  the child were going  to expire.  The relief
given  in this state, by vomiting, is great and  sudden.
  Vomiting, connected with purging or febrile disease, is  to be
considered  merely as symptomatic.  It is, however, desirable to
restrain it, which is done by giving small doses of saline  julap, and
removing  the  primary disease.    Sometimes  the oesophagus  is
found ruptured in children, and the contents of the stomach poured
into the  thorax.   This  probably happens  from spasm taking
place at the upper part of the  cesophagus, whilst the stomach i?
rejecting its contents. 
m
                        chap, xin

                        Of Diarrhaa.

   When we  consider the great extent of intestinal surface, its
 delicacy, and the intimate connexion which  exists  betwixt  the
 bowels and other organs, we  shall not be surprised at the power-
 ful and important effects produced on the system at large, by  dis-
 order of the alimentary canal.
   In attending to diarrhoea, we must examine the structure of the
 intestine, and  the purposes it  is destined to perform.   The bowel
 itself consists of muscular fibres,  of glandular apparatus, of nerves
 and blood vessels, and of a system of lacteal vessels, which proba-
 bly do more than absorb, assisting also, by glandular action, in
 the formation  of chyle, which  does  not perhaps exist in a perfect
 state in the contents of the bowels.  Now although these different
 parts tend to constitute one organ, yet they are not so blended in
 action, that all must be alike affected when the organ  is deranged.
 All may  be disordered, but one  sooner, and to a greater degree,
 than the  rest.  The fibres may  be  excited to inordinate action,
 producing rapid contraction,  and speedy expulsion  of the con-
 tents ;  and this may, or may  not, be  accompanied with spasms
 and great pain.  The exhalents  may be  greatly affected, produc-
 ing copious discharge of intestinal secretion, which may be watery,
 mucous,  slimy, or, when the vessels  are abraded or open, tinged
 with blood.   The absorbents  may have their action impeded,  and
 the chyle be not duly absorbed.   The injury of one of these sys-
 tems of organization not  only affects  the rest, but this intestinal
 disease influences parts immediately connected with the intes-
tines, such as the stomach, liver, pancreas, &c. This leads us to
consider the contents of the bowels.  If the food be good, and the
stomach  digest properly, the chyme is good and natural.  But if
 the food  be bad, or in exuberant quantity, or the power  of the
stomach  be impaired, the chyme is not properly formed, and  the
food is found in the  intestines not thoroughly changed  or digested; 
188
perhaps little  altered in  its appearance.   If the bowels  have the
same torpor with the stomach, it is retained, and forms accumula-
tions, endtng  in great mischief.  If the bowels be irritable, as in
diarrhoea, it is generally passed  speedily.  The egesta  from the
stomach are  naturally mixed with the bile, pancreatic juice, and
intestinal secretion ; and the colour of the compound is yellow, or
yellow with a brown  tinge;  and during its passage downwards, a
certain quantity of gas, possessing  a peculiar smell, is extricated.*
In young infants, however,  when  they are  properly suckled, the
stools are somewhat  different from their state at a more  advanced
period.  They are of a yellow colour, are something like custard,
or are curdy,  and have by no means the offensive  smell they af-
terwards possess.  If the stools have a very curdy appearance, or
are too  liquid, or green or dark-coloured, or ill-smelled, they are
unnatural.   The changes effected in the passage of the chyme are
not merely chemical, but dependent  on animal action; for the
contents  of the  stomach,  mixed with the fluids found in the intes-
tines, and exposed  to the same  degree  of heat, will not form natu- *
ral-looking faeces, but the substances will simply assume the acetous
or putrefactive fermentation.   If the powers of the stomach  and
intestines be impaired, then  this fermentation  goes on to a great
degree in the stomach and bowels, much  gas is extricated,f infla-
tion is produced, and the aliment becomes sour or putrid.  If too
much bile be added, the faeces are green, sometimes dark coloured.
This redundancy of bile may be produced by causes acting imme-
diately on the liver, at least not through the interposition of the
intestines, and the bile comes  even to be a source of irritation to
the bowels, and excites diarrhoea; or the affection of the bowels

  * Both the smell and the colour of the faeces are found to depend greatly on
the bile.  When the bile is obstructed,  the stools are clay-coloured or pale,
and have not the feculent smell.
  \ Vauquelin has ascertained, that  the stools are always more or  less acid.
When exposed to the air, they become more acid, and soon afterwards exhale
ammonia, which they do till destroyed. The greatest part of the gas extricated ■
in the bowels consists of carbonic acid, with carbonated and sulphurated hydro.
gen, more or less foetid. In indigestion, the greatest part of the gas is inflam-
mable.  Pourcroy's System, &c. Tom. X. p. 75. 
189
may influence the liver, and excite it to a greater secretion. Some
children are more bilious  than others, and  are subject to fits of
paleness,  sickness, and bilious vomiting.  The pancreatic juice
and intestinal secretion, when not changed in quality, but only in-
creased in quantity, are probably not like the bile, a source of ir-
ritation, but only the produce of it.  But these discharges, some-
times mixed with bile, sometimes with blood effused from a small
vessel, may accumulate together with the egesta of the stomach,
and form a black, pitchy-looking substance,* which sooner or later
produces very bad effects.  In other instances, these form a more
watery substance, which  is passed off with griping and purging of
stools like moss water.
   The  colour of stools in diarrhoea varies according to  the vio-
lence of  the disease.  In  slight cases, where  the action of the
bowels is only increased in degree, but not altered in kind, and the
stomach is not injured, the  faeces are of a yellow colour, but thin,
owing to the increased discharge, and have not run into fermenta-
tion.  When in children the digestive faculty is somewhat impair-
ed, and the aliment is improper, fermentation goes on more strong-
ly, and the faeces contain more acid than  usual, which,  although
the bile be not increased in quantity, may give them a  green col-
our,f and  the  intestines  are  distended with  air.  Very  green
stools, however, imply a  redundancy of bile,  and the  darker  the
shade of green the greater is the quantity of bile.   When  the irri-
tation is great and universal, the stools are very watery, and of a
dark green colour; or if the  irritation  be still greater, they  are
brown ;  and in either case, if the child be on the  breast,  portions
of coagulated milk are found  swimming in the  fluid; if  not, we
have  either bits of any solid  food taken by  the child,  or small
masses of dark-coloured fasces which  had been accumulated in the
  * The decomposition of bile by acids, which combine with its soda, furnishes
a precipitate, which is thick, viscid, very bitter, and inflammable.  This is pro-
bably the origin of pitchy-looking stools in some cases, though in others they may
proceed from effused blood.
  f All acids decompose bile, and in general produce a green precipitate.  Ei-
ther an unusual quantity of bile, or of acid in the bowels of children, will pro-
duce green stools ; and stools which are not at first green, often become so in a
short time after they are passed. 
190
 bowels.   When the digestive faculty is almost gone, the stools con-
 sist of the aliment mixed with bile.  Thus, if the child be drink-
 ing milk and water, or be not weaned, the stools consist of green
 watery fluid, with clots of milk,  streaked  with  bile.  When the
 irritation is greatest at some particular part of the intestines, it is
 not unusual for these appearances to  alternate  with discharge of
 slime and blood,  as we see in intus-susception.   When the secre-
 tion of bile is diminished, the stools have a cineritious appearance;
 but this state is not often met with in diarrhoea.   Sometimes, when
 the liver is affected,  or the bowels much diseased, the faeces may,
 among other changes,  put on the appearance of pale yolk of egg,
 or are almost like pus.
   Diarrhoea may be injurious in  different ways.   The increased
 peristaltic motion  of so great a  tract  of sensible  muscular sub-
 stances,  must,  like  other  great  muscular exertion, weaken the
 bowels, and thus the whole body which sympathizes with it.   Great
 debility is often rapidly excited by affections of the intestinal fibres,
 though there has been little  evacuation.   Diarrhoea likewise in-
jures the system by the irritation  and green  secretion which often
 accompanies it;  add to this the diminution of the powers of diges-
 tion, and the obstacle afforded to the absoption of the  due  quan-
 tity of chyle, together with the derangement which  other parts of
 the system may suffer, and the diseases thus excited, such as con-
 vulsions, anasarca, he.
   On inspecting the bowels after  death, they are sometimes found
 in a state of inflammation, but oftener greatly inflated and relaxed,
or with more or fewer intus-suscepted  portions.   In one case, no
 fewer than 47 intro-susceptions were found in the same  body.  On
 examining these portions, the valvular conniventes are found to be
 rather more prominent than usual, but the parts are not inflamed.
 Invagination  of the  intestine is  the most frequent cause  of fatal
 diarrhoea, not less than 50 cases  have  occurred  to  my  brother in
 the course of his dissections.  Intus-susceptio may be produced
 suddenly, in consequence of spasm, and may occasion  great pain,
 with purging ; or it may be caused by acrid  purgatives, or  those
 which produce  much griping, as senna tea,  made  by  boiling the
 leaves ; or it may take place in diarrhoea, when attended with con- 
191
siderable irritation, and it adds to the violence of the disease.  It
is sometimes accompanied with a diseased state of the glands.  In
this case there may be a swelling of the external glands, and there
is often a tendency to cough.  There may be a double intus-sus-
ception, and the tumour so formed may lodge  in the pelvis and
fill it.  Inflammation is very far from being a necessary attendant
on this state, it is even uncommon.
  The diagnostic of intus-susceptio is very obscure, and whatever
may be said to the contrary, I believe we have no  certain  mark
by which to judge.   It has  been discovered,  when  no previous
circumstances led to a supposition of its existence.  But in gene-
ral there is considerable pain, and marks of local  irritation; such
as slimy stools, with or without blood; sometimes a little frothy
slime is passed, sometimes  a substance  like rotten  eggs,  and at
times the contents of the  intestines  are vomited.  It is attended
with stretchings and cryings, as in colic, with occasional attacks of
great paleness, like  syncope ; the belly is tender to the  touch, and
sometimes in infants the pulse is slower than ordinary.  When the
disease continues long, the emaciation is very great, the face re-
sembling the bones, with merely a skin covering them,  whilst the
eyes are sunk.  On the extremities, the  skin  is lax,  and seems
much too wide for the bone and muscles.  Sometimes  the intus-
suscepted portion is thrown off, and passes by the rectum.
  Dissection likewise shows, that a diseased state of the liver not
unfrequently accompanies diarrhoea, and this may be a cause of
purging oftener than is supposed.  It is to be suspected, when the
biliary secretion is most affected, and the region of the liver is ful-
ler than usual, when there are cough, frequent fits of sickness, and
vomiting or purging of bile.   It is most effectually  remedied  by
small doses of calomel.
  In some cases, the intestines become very soft, white or almost
diaphanous, and easily torn, and contain a substance somewhat like
purulent matter, or thin custard.
  Diarrhoea appears under various circumstances, not  only  with
regard to the nature of the  stools, but their frequency, the  pain
which attends them, the duration of the complaint, and  the effect
on other parts.  In some cases the stools are  extremely frequent 
192
 and uniformly so.  In others, the dejections come in paroxysms)
 being worse either through the night or through the day.   Some
 children are greatly griped ;  others are sick, oppressed, and do not
 cry, but moan.   In severe cases, the stomach is very irritable, re-
jecting the food ; but it is not equally so in every stage  of the dis-
 ease, though the stools may be the same in frequency.   The ap-
 petite is more or  less impaired, and in bad cases the aliment quick-
 ly passes off, and every time the child drinks it is excited to purge.
 The mouth, in  obstinate  bowel complaints,  generally becomes
 aphthous, and the anus excoriated or tender, and it is not uncom-
 mon for the feet to swell.   Sometimes the child is flushed at cer-
 tain times of the  day, or the  face is uniformly pale,  and the skin
 waxy in appearance.   In general, if the  disease be severe, a con-
 siderable degree  of fever attends it, and a continued fever in the
 disease  is always unfavourable.  The stools may come  away with
 much noise from wind, or may be passed as  in  health.  When
 there is great irritation, they  are  either  squirted out forcibly, or
 come in small quantity, with much pressing.  Diarrhoea sometimes
proves fatal in 48 hours, but it may be protracted for several weeks,
 as is often the case when intus-susceptio has taken place.  In such
protracted cases,  the emaciation is prodigious, the face  is lank, the
 eyes sunk, and the expression  anxious: the  strength gradually
sinks, the eyes  become covered with a glossy crust,  the extremi-
ties cold, the respiration heaving, and the child dies completely ex-
hausted.
   Diarrhoea may be excited  by a variety of causes ; such  as too
 much food, or sudden change of the kind of aliment,  and hence it
is often  caused  by weaning a delicate  child.   Attempts to  bring
up children altogether on spoon meat, some injurious  quality  of the
nurse's milk,  improper diet after  weaning, the  irritation  of  ill-di-
gested food, redundancy of bile,  previous costiveness,  dentition,
the application of cold to the surface, or a morbid state  of the
bowels connected with general debility,  produced either by bad
air or natural delicacy of constitution,  are causes  of  diarrhoea.
Those children suffer most who are feeble, puny, or delicate.
  As diarrhoea is a frequent cause of death, we  cannot be loo at-
tentive to its treatment, nor too early in the use of remedies, es- 
193
pecially as we find, that if it be neglected in its commencement, it v:
apt to end in a very obstinate or incurable state.  On this account
I have been led to consider this disease very carefully, and  shall
briefly mention the treatment 1 have found most effectual.  When
the stools are natural in colour, but more liquid than usual, the fre-
quency moderate, the continuance short, and no fever is  present,
it will be useful to give  small doses of rhubarb, conjoined with an
aromatic, taking care, however, that these do not end  in  produc-
ing the opposite extreme, or costiveness.  In  many cases, the dis-
ease will subside of itself;  but if it do not abate spontaneously,  or
by the use of small doses of rhubarb, then it comes to be consid-
ered, how far it is proper to check the inordinate action of the
fibres of the intestines.   This  is readily done by an anodyne clys-
ter.  But if the diarrhoea have been excited by improper food, or
redundancy  of food, or if  it  be attended with acute fever, and
especially if the child be plethoric, it will be useful  to give some
mild laxative, such as magnesia and rhubarb, or an emulsion con-
taining castor oil,  or small  doses of  calomel.   The  tepid bath is
also beneficial.  If there be oppression, with  fever or sickness, a
gentle  emetic will  be a proper prelude to the laxatives.  After-
wards, if the disease continue, and there be marks of much  irrita-
tion of the fibres, anodyne clysters will be of signal service.
  If the diarrhoea come on  quickly, and the  stools  are from the
first green or  morbid, and the  stomach be  irritable, or its func-
tions impaired, we should examine the gums,  and cut them if the
child be getting teeth.   This  removes or lessens a source of irri-
tation.   But whether the  disease be  produced  by teething, by
change of food consequent to weaning, or other causes, great at-
tention is necessary.  If the  child be sick and oppressed, a few
grains ofipecacuanha will be  proper ;  and afterwards small'doses
of calomel,* or some other laxative,! should be given morning

  * That excellent practitioner,  Dr. Clarke of Dublin, has strongly advised half
a grain of calonrel to be given every night, or every second night, to infants
when troubled with green stools and griping; observing, that in the course of a
week or two, the stools become natural, and that it is rarely necessary to give
more than from 4 to 5 grains altogether. Mem. of Irish Acad. Vol. VI.
  J Cold drawn castor oil may be given in the following form; R. 01. Kicioij
     Vol.  II.                   'i"» 
                             194

and  evening.   These  carry off the  morbid feculent matter, and
excite a better  action of the bowels.  The calomel  is usually  a
most effectual remedy, and it may be given even to infants a few
days old.   To  them a quarter or half a grain, rubbed up with su-
gar,  is a proper dose, and may be given morning and evening.  To
older children  we give a grain.  If laxative* do not  increase the
debility and pain, and if they render the stools more natural in ap-
pearance,  they do  good, and  may be  continued in decreasing
quantity, till they are abandoned altogether.   But if  they  merely
increase the frequency of the dejections,  without  greatly altering
their quality, the stools continuing watery, ill-coloured, and offen-
sive, and the strength and appetite sinking, we can expect no good
by continuing them, and must restrain the purging  by repeated
anodyne clysters, taking  care that we do not delay their use too
long.  When the secretion is copious, and the stools frequent, and
perhaps squirted out with great irritation, the strength will sink
very rapidly, and a few hours  may decide the fate of the child.
In such circumstances, it is necessary, even although the contents
of the bowels  be morbid, to  moderate the fibrous  and secretory
action, by  anodyne  clysters.   Afterwards the  morbid matter  is
expelled, or can be removed  by gentle laxatives.   Opiates given
by the mouth have often a bad effect on  the child,  and never are
equal in benefit to clysters.   Cretaceous  substances, joined with
aromatics,  are useful when there appears to be a  redundancy of
acid; but astringent medicines, such as  kino or catechu,  though
they sometimes seem in  slight cases to be of service, yet in more
obstinate diseases fail, unless  they be combined with  opium, and
then the beneflt is perhaps more to  be ascribed  to  that drug than
to their effect; or if given in  great quantity, they may perhaps
excite to invagination of the intestines.   In obstinate  cases, small
doses of calomel or of the mercurial-pill-mass, given morning and
evening, with the use of anodyne  clysters at  the  same time, to
keep the purging within due bounds, are of more service than any
other remedies;  I can  speak of this practice  with confidence.

3'iii;  Mannae, gss; Spt. ammon. Arom. 31; Aq. Cassia?, !$ss ;  aq. Font Jiss. fiat
emulsio.  Of this a tea spoonful may be given as often as necessary. 
195
Dr. Armstrong, however, when the stools are liquid or watery,
sometimes colourless or brownish, or streaked with blood, and of
very offensive  smell, advises antimonial  vomits, repeated every
six or eight hours,  till the stools change  their appearance.  But
this remedy operates severely, and may induce no small degree of
debility.   If the plan be rejected, he advises a solution of Epsom
salts,  with a small  quantity of laudanum.   Dr. Underwood, in
this disease, prescribes emetics, then warm purges, and afterwards
small doses of ipecacuanha, with absorbents and aromatics.
   Dr.  Cheyne, in obstinate  and prolonged  purging, which, from
frequently  occurring about the time of weaning, he calls astrophia
ablactatorum, strongly advises small and repeated doses of mercury,
as the most effectual remedy.
   When there  is much  fever, the use of the tepid bath morning
and evening, and small doses of saline julap, or compound powder
of ipecacuanha, and clothing the child in flannel, will be of great
benefit.  When along with fever there is much pain, and the stools
are slimy,  bloody, or squirted out forcibly, there is reason  to fear
inflammation of the mucous  coat, and leeches should precede the
bath.
   In every case, external applications  have, I think, a claim to be
employed.  These consist  of  friction with anodyne  balsam, or
camphorated oil of turpentine, or the application of an anodyne
plaster* to the whole abdomen, which is better.   Small blisters in
succession, applied to the belly, are highly useful.  It is also pro-
per to  bandage the belly pretty firmly, but by no means  tightly,
with flannel.
   During  the whole course of the disease, it is proper to support
the strength with light nourishment, such as beef tea, arrow-root
jelly, toasted flour boiled with  milk,  Stc; or if  the child be not
weaned, it is sometimes of service, in continued or repeated attacks
TDf diarrhoea, to change  the nurse.  The strength should be sup-
ported by  small quantities of white wine whey, given  frequently.

  • Such as the following: R. Saponis, 31; Empl. Lytharg. jvi; Ext. Cicuts,
-ii; Ol.  mentb. pip. 3ss; Fiat empl.  Or R. Empl. resinos. gvi, Pulv.  Opii, 3!:
Camph. 3ii; Ol. Junip. 3ss;  Fiat empl.  Or if there be much spasm, we may
ase the Empl. asafcetida Pharm. Edin. with the addition of opium, 
196
It' the child, as is frequently the case, will not take nourishment,
then clysters of beef tea, or arrow-root are to be employed, mixed
with a few drops  of laudanum.  These  are  of signal service, and
ought to be early and carefully employed till the child can  take
food into the stomach.
   When the mouth becomes aphthous,  it may be washed with a
little syrup, sharpened with muriatic acid ;  or borax may be em-
ployed, along with the proper internal remedies ; and when these
restore the bowels to  a healthy state, the mouth becomes cleaner.
The appearance  and  disappearance of the aphthae, generally mark
the fluctuation of the  bowel complaint.   The excoriations which
appear about the anus require to be bathed with  solution of sul-
.phate of zinc, and call for greattenderness in administering clysters.
   When the  feet become swelled,  and the urine  diminished in
quantity, some diuretic must be added  to the  other means.   The
best is the spiritus etheris nitrosi.
   If the  child become drowsy, or have a tendency to coma, much
benefit will be derived from shaving the head, and  applying a small
blister to the scalp. Affections of other organs, supervening on bowel
complaints, must be treated promptly on general principles.
   It will thus appear, that the practice in diarrhoea  is chiefly con-
fined to the following points :
   First, To remove  every exciting cause, scarifying the gums in
dentition, rectifying the action of the liver when it  is deranged, and
regulating the diet when the quality of the food may be supposed
to have disordered the bowels. *
   Second, To lessen sickness and oppression  of the stomach by a
gentle emetic ; but particularly to remove irritating faeces, and ex-
cite a better action of the intestinal surface, by small doses of calo-
mel in prolonged cases, or by a dose of rhubarb  and  magnesia in
recent cases of purging.  The circumstances under which the
administration of laxatives is beneficial or injurious, have been al*
ready pointed out
   Third, To restrain inordinate peristaltic motion, and excessive
secretion, by anodyne clysters and external applications, neither of
which are incompatible with the occasional use of calomel, or hy-
drargyrus cum creta. 
197
  Fourth, To remove or allay coincident or consecutive symptoms,
by appropriate remedies.
  Fifth, To support the strength from the first by suitable nourish-
ment and cordials ;  and whenever the stomach cannot receive or
retain food, to give  nutritive clysters.
                        CHAP. XIV.

                        Of Costiveness.  ,

   Costiveness is natural to some children,—acquired by others.
hi the former case, it often happens, that the mother is of the same
habit;  and in these circumstances, we find that less detriment ac-
crues than in the other; yet even here it is  necessary to prevent
the costiveness  from increasing, as it may excite  not only colic,
but more serious diseases, such as convulsions,  or diseases in the
bowels.   Some children, of a very irritable habit, have the rectum
spasmodically affected at times, on passing the faeces, which may
be followed by a convulsion.   This being frequently repeated, the
child becomes afraid to go to stool, and  retains the faxes as long
as possible, which  induces a costive state.   Sometimes the terror
is so great, that  the child can only be made to pass the faeces when
half asleep.                                               '
   In hereditary costiveness, it is difficult, if not impossible to indi,;>e
a regular state of the bowels;  and perhaps in some cases, this, if
it could  be done, would, seeing that it is  not natural to the consti-
tution, be  injurious to the child.  But we must beware,  lest, by
indulgence, this habit increase.  Whenever the  child is pale and
puny,  or dull, and does not thrive, there is risk of convulsions or
some  severe disease being induced.  At a more advanced period
of childhood chorea may be produced.  Acquired costiveness may
be overcome by medicine, and  encouraging regular attempts  to
procure a stool.  A variety of means have been employed in these 
198
 cases, such as suppositories, magnesia, and other laxatives.   The
 best remedy for changing the state of the bowels seems to be calo-
 mel, which may be given in a suitable dose, even to an infant, for
 a day  or two in succession, and then omitted; employing in the
 interim a little manna alone, or combined with castor oil, and some^
 times magnesia  may be substituted for a change.  In more obsti-
 nate cases  infusion of senna, or two or three grains of aloes may"be
 given.  A  quarter of a  grain of ipecacuanha,  mixed with sugar,
 may also be tried.  It is also proper to change the  nurse, or alter
 the diet of the child, giving barley-meal  porridge, veal soup, ale-
 berry.^




                         CHAP. XV.

                           Of Colic.

   Colic is a frequent complaint  with children, especially  when
 they are costive.  It is often produced by too much food, exposure
 to cold, irregularities in the diet of the nurse,  or some bad quality
 of her milk.  It makes its attack suddenly, and is known by violent
 screaming, induced without any warning, and  accompanied with
 hardness of the  abdominal muscles, kicking, and drawing up of
the legs, and often suppression of urine.  These symptoms are
 soon removed by a clyster or suppository, which brings away both
 feces and  wind.  The warm  bath, fomentations, and friction on
 the belly with anodyne balsam or laudanum,  will be serviceable;
and if the pain continue,  two or three drops of tincture of opium,
or a rather  larger dose of tincture of hyoscyamus, with oil of anise,
 may be given.*  When the  child is costive, a laxative is to be ex-
hibited after the  anodyne.

  (~pj Or rye mush and molasses, which is easily procured in every family, and
may answer the purpose better than any of the enumerated articles.
  * The anodyne mineral liquor of Hoffman, is an excellent medicine in these
affections.  C 
199
  If a child be subject to repeated attacks of colic, a few drops of
tincture of asafoetida are useful, and we  must always take  care to
prevent the long continuance of pain, as it may end either in vis--
ceral inflammation or convulsions.
                        CHAP. XVI.

 ,                       Of Marasmus.

   Connected with, and generally dependent on, a morbid state
 of the bowels, is the marasmus, or wasting of children.  This dis-
 ease is preceded and accompanied by costiveness, sometimes alter-
 nated with a diarrhoea, in which the stools are foetid,  or unnatural
 in appearance.  It begins with lassitude and debility, loss of appe-
 tite or depraved appetite, foetid breath and foetid stools, tumid belly,
 pale leucophlegmatic countenance, with swelling of the upper lip.
 Presently, fever  supervenes,  the countenance becomes at times
 flushed, and the skin hot and dry, with frequent pulse, thirst, rest-
lessness, picking of the nose, and  disturbed sleep, in which the pa-
tient grinds his teeth and starts.   The debility gradually increases,
and if relief be not procured,  death, preceded by great emaciation,
takes place.  This disease is  most frequent  with  those  who  are
fed on improper food, or eat many raw roots, or much  unripe
fruit;  or those who have the  digestive faculty impaired by con-
finement,  bad air, or neglect of the bowels.  It very often is con-
sidered as produced by worms ;  but these, although they may of-
ten exist in the bowels, are by no means essential to the disease.
   This disease may, in the commencement, and before the  ap-
pearance of fever, be arrested by a course of active purges,  given
at proper intervals; at the same  time we may  give light  nourish-
ing diet, and inculcate the necessity of exercise in the open air.
In the febrile stage, the cure is more difficult, but is to be accom-
plished on a similar  principle, by  attending  to the state of the 
200
 bowels.   For this purpose, purgatives must be frequently repeat-
 ed, especially calomel; and here it is necessary to  remark, that
 the stools are not always hard ; they are often fluid, but generally
 foetid, and dark in the colour, or appear to contain indigested food.
 A course of purgatives, however, by degrees procures discharge
 of faeces of natural appearance.  Whilst this course is conducting.
 the strength is to be supported by proper diet, and the prudent use
 of wine.  The power of the stomach may be increased^by  chaly-
 beates or other tonics, provided these are not nauseated by the pa-
tient  After recovery has taken place, we must, by very  gentle"
laxatives, preserve an open state of the bowels, which will prevent
a relapse.  Sea-bathing is likewise  of advantage.*
  The state of the bowels which gives  rise to marasmus,  some-
times produces speedily more acute'symptoms.  These constitute
a very frequent species of fever,  which we have already noticed.
                         CHAP. XVII.

                     Of Tabes Mesenterica.

  Tabes mesenterica, or hectic from  disease  of the mesenteric
glands, is a very frequent disease.   It is  not often met with before
the time of weaning, nor after  puberty,  seldom  after the  age  of
eight or ten years.   The disease consists in enlargement  of the
mesenteric glands,f which are sometimes universally affected, but

  *  Those who wish to know what other remedies are employed, though with-
out much benefit, may  consult Baumes de ramaigrissement des enfans.
  f  This state is sometimes accompanied with swelling of the thymus gland, and
the lymphatic glands of the neck.   Swelling of the thymus gland, by pressing on
the trachea and oesophagus, produces difficulty of breathing and of swallowing,
and sometimes suffocation.  By pressing on the subclavian vein, it obstructs the
passage of the chyle,  and may thus excite disease  in the mesenteric glands.
Blisters applied to the  top of the sternum sometimes do good. 
201
   are especially enlarged into a hard mass about the root of the me-
   sentery.   These tend slowly to the formation of a cheesy substance,
   but  death  may take  place before that process be accomplished.
   The commencement  of the disease is slow and obscure; the pa-
   tient complains of little or no pain, but is  subject to an irregular
   state of the bowels ; is either costive, or passes dark loose faeces ;
   is unhealthy in his appearance, and liable to occasional attacks  of
   fever.   The urine is  white or turbid.  The appetite is not much
   diminished,  and digestion goes  on ; but the belly is  hard and
   somewhat tumid.  The child is more fretful than usual, and some-
   times, especially  if very young, is troubled with vomiting.  This
   is the  incipient stage, and resembles very much that of marasmus
   proceeding from  affection of the  bowels independent of diseased
   glands.  As the disease advances, the body wastes away, the face
   is pale, and the features become  sharp, the abdomen gradually en-
   larges more, and the patient  complains  of lancinating pains, of
   short duration however, within the  belly, or near the  back.   The
    stools are  now sometimes bound,  but oftener loose, frothy, and
    mixed with bile; occasionally the patient has diarrhoea, with vomit-
    ing.  The fever, which at first is  obscure and intermitting,  be-
    comes more acute and distinct, with exacerbation in the evening,
    attended with restlessness and acceleration  of the  pulse, which
    rises to  120 strokes in a minute,  or even  more.  The  patient is
    listless, and his mind becomes gradually inactive, though he  does
    not lose hopes of recovery.  The  tongue  is generally clean, but
    sometimes covered with a white  or brown crust, especially in the
*   middle ; and in  an advanced stage, the whole mouth and throat
    become aphthous.  The thirst is trifling, but the appetite is usual-
    ly impaired, and  a short cough supervenes.  As the  disease pro-
    ceeds, the emaciation of the body  increases, the eyes are sunk and
    glossy, the nose  sharp, and apparently elongated, the face sallow,
    but the lips are sometimes florid, and the cheeks flushed at night
    The abdomen is hard, and sounds like a drum when  struck upon,
    or if not very tense, knots may sometimes be felt within it*  The

      * Sometimes a hard tumour may be  felt within the belly, pretty early in the
    disease.  It is often felt in the right side, near the origin of the colon.
         Voi,. II                 2(5 
                            202

urine is lessened in quantity, and it often deposits a white or late-
ritious sediment, the feet swell, and during sleep, the forehead,
scalp, and sometimes the breast, are covered with a profuse sweat,
whilst the rest of the skin is hard and dry,   The progress of this
disease is not always alike rapid.  In some cases, the patient lives
for a year or two in bad health; but in general, after hectic has
appeared, a few months, sometimes weeks cut.him off.
  In the commencement of this disease, the  steady and repeated
use of mild purges with calomel, conjoined with some light bitter
infusion, decoction  of  bark, tonic medicines, and gentle  frictios
over the belly continued for a considerable length of time, morn-
ing and evening, would appear to  be  of more  service than  any
other plan of treatment  It has been proposed to give calomel in
small doses, as a mercurial; but it does not appear to have great
efficacy, and is chiefly  of use, in so far as it acts as a gentle purga-
tive.  Copious evacuations in this disease are not required.  It is
sufficient that the bowels be brought into, and kept in a  regular
state, which, in the  incipient stage, at least,  sometimes  requires
pretty strong doses.  But in the confirmed and advanced stage,
stools are easily obtained; and from the loose state of the bowels  .
which often prevails, it comes to be a  question  how  far laxatives
are proper.   Upon this important subject, I observe, that these
medicines ought not to be severe, but gentle, and given frequently,
provided they have the effect of diminishing the tumour of the
belly, making the stools  more natural, and  do not impair  the
strength.  The lax stools which take place in this disease spon-   *
taneously, never abate the tumefaction; but a  gentle course of
laxatives often does, and this is a most favourable effect.   Farther,
if the paroxysms of fever be severe, and early in their appearance,
we  find it necessary to use purgatives more freely than in  opposite
circumstances; evacuation by stool being  in  such cases advanta-
geous.   In the confirmed  and advanced stage, it is sufficient  that
such a dose of calomel be given every night, or every second or
third night, as shall keep the bowels open  if  disposed to be cos-
tive, or, if loose, make  the stools more  natural in their appearance
than they would be without the administration of medicine.   We
must, however, take care that the mercury does not excite much 
203
effect on the constitution, lest debility be increased; it is  merer
fore prudent, sometimes,  to combine the calomel with rhubarb,
or to employ a little castor oil emulsion.  Along  with this plan,
we may, in every stage of the disease, derive  advantage from the
use of tonic medicines, such as bitters and chalybeates, especially
in the form  of mineral waters.   But the last are to  be used cau-
tiously,  if there be marks of inflammation existing in the glands;
and in such  cases, some light bitter infusion is  preferable to chaly-
beates.   In  such circumstances, the laxatives are to be used more
freely, the tepid bath  is to be employed,  and the belly  rubbed
freely with anodyne balsam.  Gentle exercise in  the open air  is
of great service,'and it is useful in the early part of the disease  to
reside near the sea; but if the glands seem to  be in a state of in-
flammation, discovered by shooting pain with fever, the  patient
must not bathe; and indeed, at all times, the utility and safety  of
the cold bath seem  to  be doubtful, except when the  disease is  so
far removed, that we have chiefly to contend with  debility.  The
warm bath is more generally  useful.  The diet should be light
and nutritious, but all stimulating and indigestible substances must
be avoided.   If an inflammatory state exist, milk in  different forms,
soft boiled eggs, and vegetables, are proper.   If no  inflammation
be present,  some animal food  will be of  service ; nay, as in other
scrofulous affections, a very considerable  proportion of animal diet
is  sometimes beneficial, in preventing the tumour  from inflaming
and forming a cheesy substance, or in giving  a favourable turn to
the action, when the acute state of inflammation has abated, in
those cases  where it is met with, for it is by no means a universal
occurrence.
   In the latter end of the disease, little can be done except palliat-
ing symptoms, and  supporting the  strength by soups  and a little
wine.   Diarrhoea should be restrained by anodyne clysters.
   Cicuta, burnt sponge, and some other medicines, have been ad*^
vised in this disease, but I  cannot  say that they have been en>
ployed with advantage.  Electricity is sometimes of service. 
204
                        CHAP. XVIII.

                          Of Worms.

   Worms exist in the bowels, perhaps, of every child,* but espe-
cially in those whose bowels are debilitated by bad management,
or by acute disease ;  and hence, in the end of disease, or after re-
covering  from such  illness, worms are often  expelled, both by
children and adults.   Worms are of different kinds, but infants are
chiefly  infested with  lumbrici  and ascarides, the  teniae  being
rarely met with until children are four or five years old.  We also
sometimes meet with some uncommon species of worm, which
are ejected by vomiting, and some lususes have been passed by
stool;  thus, for  instance, I  have seen a worm about three inches
long, having two large flat heads, with  two bodies, separated for
a little,  and then united into a common trunk, ending in a taper-
ing tail.   Insects of different kinds may also be  introduced  acci-
dentally into the stomach and  bowels,  and live there for some
time.
   Ascarides generally occupy the rectum, producing much itching
in that part, so that sleep is often prevented.  The irritation causes
indigestion and  pain in the belly, with picking of the  nose and
white face, a variable appetite, and sometimes  a desire for  indi-
gestible substances.   The worms are discovered in the stools like
small white threads, and occasionally they creep out from the rec-
tum.  The stools are  often slimy or mucous.  This kind of worms
is removed by injections of aloes mixed with water, or decoction
of semen santonicum, *or any  strong bitter  infusion containing
saltf^j  in solution, or the common turpentine injection;   lime
\vater and olive oil also  sometimes destroy them,  but cannot be

  * Worms rarely appear in the bowels, till after the child is weaned.
  Cq) Dr. Kuhn of Philadelphia, whose experience has been very extensive,
and whose correct  and discriminating judgment is unquestioned, says he has
found no article so useful in the destruction of ascarides, as injections of a solu-
tion of common salt. Vide Barton's Edit, of Cullen's Mat. Met. Vol. U. 
205
depended on.   Calomel purges are proper likewise;  and any dis-
ordered state of the alimentary canal which exists, is  to be treated
on general principles.
  The ascaris lumbricoides  is  often from six  to ten inches  long.
In its general  appearance it resembles the earth worm, but differs
from it, in having, besides other distinctions, a longitudinal line on
each side, whereas the earth worm has three  lines on the upper
surface.   It dies soon after its expulsion, but when alive it moves
like an eel, and does not shorten  the body like a  worm.   Dr.
Hooper, in the fifth vol. of the Mem. of Med. Soc. has a  valuable
paper on intestinal worms.  Lumbrici may exist in every part of
the alimentary canal, and frequently are ejected by  vomiting, as
well as by stool.  The symptoms are those of intestinal irritation,*
pains in the belly, frequent attacks of diarrhoea, variable, and of-
ten voracious  appetite, the child sometimes becoming  hungry al-
most immediately after having ate heartily, foetid breath, pale com-
plexion,  tumour of the lips, with livid circle round the eyes, swell-
ing of the belly at night, and disturbed sleep,  the child occasion-
ally  awaking in  great terror,  and being liable to starting and grind-
ing of the teeth.   When awake, he picks his nose, is  plagued with
temporary headach, sometimes has a dry cough, with slow fever,
or convulsive  affections,  qr  eclampsia.   I have already  pointed
out several diseases proceeding from disorder  of the  bowels, and
these may arise from worms, in as  much as they are  capable of
irritating the bowels, or injuring their action, or increasing such a
debilitated state, as may have predisposed to their accumulation.
A variety of anthelmintics have been  advised, for an  account of
which, I refer to the  writers on the Materia  Medica.   Sulphur,
tansy, aloes, spigelia marylandica, dolichos pruriens,  the  gceffrea,
worm seed, tin powder, filings of steel, &c. have all at times a good
effect;  but in general, calomel  purges given repeatedly and  libe-
rally, provided the constitution  of the patient will bear them, will

  • Hence it is not easy to say that worms are the cause of a child's  complaint,
for other morbid affections of the bowels produce the same symptoms.  A course
of purging removes these symptoms, without  bringing away  any worm*; al-
though the slimy appearance of the stools is attributed to the worms  being dis-
solved. 
206
be found very effectual; or these may be  alternated with  saline
purgatives, oil of turpentine, or suitable doses of aloes or jalap.
   In obstinate cases, much benefit will be derived by giving a
regular course of purgatives, so as to keep up a constant but gen-
tle effect on the bowels.  After the worms are expelled, a bitter
infusion, or chalybeate water, will be useful-to  strengthen the bow-
els, or these may even be employed whilst we are using  the purga-
tives.
   The trichuris, or long thread worm, is about two inches long,
and two thirds of this form a tail like a hair.  The body is  about
the 16th of an inch thick, .and the worm is white like the  ascaris.
It is found in the rectum, and also higher up, even in the ilium.
   The taenia consists of many flat jointed portions, and  is  divided
into the T. Solium, where the orifices are placed  on the margins
of the joints, and the T. Lata, where they are found on the surface.
The usual symptoms are produced.   The best remedies are smart
purges of calomel, alternating with doses  of oil of turpentine pro-
portioned to the age; a dessert spoonful may be given to  a child
of four years of age.frj *The taenia is more difficult to be remov-
ed than other worms.
                         CHAP. XIX.

                         Of Jaundice.

  The jaundice of infants is a disease attended with great danger,
especially if it appear very soon after birth, and the stools evince
a deficiency of bile; for we have then reason to apprehend some

  (r) Oil of turpentine has been given to infants in smaller doses, measured by
drops, for the other species of worms with success.  It may certainly be consid.
ered as a powerful anthelmintic.  The reader is referred to other cases illustrate
ing its effects in the expulsion of tsnia, to Eclectic Repertory, Vol. I. and to Ms-
dico-Chirurgical Transactions, Vol. II. 
207
incurable state of the biliary apparatus.   I conceive that there ate
two species of this disease, which are very opposite in their na-
ture.   In the first there is an obstacle to the passage of the bile
into the intestine, the child is costive, and the  meconium is paler
than usual, and r.fter it  is removed, the stools become light-colour-
ed ;  the skin, very early after birth, becomes of a deep yellow col-
our,  which extends to the eyes.   The child sucks very  little, has
occasionally a difficulty in swallowing, is  languid, becomes ema-
ciated, moans much, is troubled with flatulence, sometimes  with
cough and  phlegm in the trachea, or vomiting, convulsions, colic,
and fever, occasionally supervene.  In some cases, tne liver is felt
enlarged, and the hypochondrium  is tumid.   The water is  very
high-coloured.   This d^ease often proves fatal in  a week, but
it has been  known to continue in variable degrees of violence
for a considerable time, and at last to disappear, though such chil-
dren continue long delicate.  With regard to the cause of this dis-
ease, we find, that sometimes it consists in obstruction of the he-
patic duct, or ductus communis, either by thickening of the coats,
or pressure, in consequence of enlargement of  some part  in the
vicinity of the duct; or it may consist in imperfbration of the duct
Sometimes it proceeds from temporary obstruction in the duct,
owing to viscidityof the bile. Now some of these cases are irremove-
able, others are not; but as we cannot, apriori, say what the cause
may be, in any particular instance, we must use  the means  of cure
in every case.   The most likely remedies for removing this dis-
ease, are gentle  emetics, given very early, and followed by  the ex-
hibition of half  a grain of calomel, morning and evening, till the
bowels are acted on;  or we  may give this medicine even three
times a day, in some cases; but we must be cautious not to  induce
much purging, or push the mercury far, lest we bring on fits.
   The second species differs from the first, in the stools being dark-
coloured or green, showing that there is no obstruction, or  at least
no permanent obstruction, to the passage of the bile.*   Like the
first  species, it appears soon after birth,  and is  accompanied with
gieat oppression, moaning, colic, and convulsive affections.  It is
attended with much  danger, and frequently carries off the infant
  * It is in  this species alone that the opinion can be admitted, that  infantile
jaundice depends on absorption of bile from the intestine': 
208
in a few days.   The early use of calomel would appear to be the
most proper practice,  and the strength  must be supported in all
those cases by> the  breast milk, given with the spoon, if the child
will not suck, and small doses of white wine whey.
  Jaundice, appearing at a considerable period after birth, does not
require a separate consideration here, nor is it a very common oc-
currence.
                         CHAP. XX.

                       Of Diseased Liver.

   Enlargement and inflammation of the liver are not uncommon
in infancy and childhood, but the first is most common in infancy.
It is productive of vomiting, oppressed breathing, cough, fever, and
sometimes purging.   The liver can be felt enlarged, and extending
lower down, or more to the left side than it ought to do, which will
distinguish this complaint from inflammation of the lungs, which is
also not so frequently attended with vomiting.* I cannot say much
that will be satisfactory respecting the treatment.  Mercurial fric-
tion and blisters are chiefly to be relied on.f
   Hepatitis in infancy is marked with the symptoms attending en-
largement of the liver; but  there is more fever, and sometimes
pain, when the liver is pressed on.  The disease often begins with
symptoms of  disordered stomach,  and colic  pain.  Fever comes
on, accompanied with cough, which is sometimes soon succeeded

  * On examining the liver, it is sometimes found soft, and not much altered in
structure, sometimes hard, and almost cartilaginous, with the pori biliari harden-
ed and obstructed, so that secretion of bile does not take place, and the gall blad-
der becomes shrivelled.   This state cannot be attended with jaundice.
  f Active mercurial purges I have found useful in this stage of the disease; after
which, small doses of calomel should be given morning and evening for some
weeks.  If there be pain, leeches should be applied to the side.  C. 
209
by jaundice.   The stools are otten like yolk of egg, or, if there be
obstruction to the passage of the bile, they are clay-coloured, and
the urine red, with much sediment.  On inspecting the body of
infants who have died of this disease, the surface of the liver, some-
times only its convex surface, is often found of a deep red colour,
with an exudation of white lymph,  exactly resembling the cuticle
of a  blistered part.   Betwixt  the  liver and diaphragm, we  find
white flaky  fluid, something like  pus, and  similar matter is often
found among the bowels, mixed with pieces of fatty-looking lymph.
The liver is not  necessarily enlarged, nor its substance affected.
The stomach and bowels  are not  inflamed, but sometimes have a
white blanched appearance, and contain a fluid like  thin custard.
The bile is not changed in its colour.  In some instances of chro-
nic inflammation, the liver is somewhat enlarged, of a dark colour,
and  the veins turgid.   Leeches,  blisters,  and  a gentle laxative
course of mercury, are the means of cure.   In older children we
find hepatitis to commence either  acutely or slowly.  When it be-
gins acutely, the  child, probably after a  surfeit, or some irregula-
rity  of diet, or exposure to  cold,  complains of severe pain in  the
upper part of the belly, like colic, accompanied with  sickness and
vomiting; and either attended, or soon succeeded by fever,  short
cough, and pain, sometimes dull, sometimes sharp  in the right side,
and occasionally affecting the shoulder.   Jaundice also,  not unfre-
quently, is produced and lasts for  a  few days.  There is thirst, no
appetite, but the child feels continually as if he had ate too much,
is subject to fits of squeamishness, and complains when the liver is
pressed.  If the remedies do not check  the disease,  the liver en-
larges, and its region is full; abscess is formed, attended  with irre-
gular chilliness, hectic symptoms, and much pink-coloured sediment
in  the urine.   In a few weeks,  sometimes in a shorter period, the
patient is sensible of a smell like rotten eggs, which he  thinks comes
from the stomach; then a little foetid matter is coughed up, which
is  followed by copious expectoration; or he ejects  pus as if he
vomited it from the stomach.  The cough and spitting,  with hec-
tic symptoms continue long, but at last decline and go off.
  In the early stage, blood-letting, if instantly resorted to, may be
of service, but not if delayed.  Blisters are always proper.   The
     Vol. U.                27 
210
 bowels should be freely opened, and afterwards a gentle course of
 mercury  employed.  In the  suppurating stage,  mercury  should
 not be used, but  the strength  is to be supported  by proper  diet.
 In the expectorating stage, the same plan is necessary, with the
 use of tonics, such as chalybeates joined with myrrh, and occa-
 sionally opiates.  A speedy removal to the country, if the weather
 be mild, is advantageous.  Sometimes the abscess bursts into the
 stomach or intestines, adhesion previously taking place; or, I have
 known it burst into  the general cavity  of the abdomen, and the
 matter accumulate there, forming a tumour like ascites, bursting at
 last by the navel, which inflamed; or it  has been  drawn off with
 a trocar, and recovery has been accomplished.
  The more slow or chronic  species may be excited by a torpid
 state of the  whole chylopoetic viscera,  consequent  to neglected
 bowels, or other causes ; or it may occur after some other disease,
 such as peripneumony,  scarlatina, he. The  child has  fits of sick-
 ness, vomits bile  in the  morning, and  loses his appetite ; or  if he
has a strong desire for particular kinds of food, or feels very  hun-
 gry at times,  he  either cannot eat when he  receives  food, or is
 instantly filled.  The strength diminishes, the  bowels are torpid,
 and the stools white, in  some cases bilious, or dark and offensive;
 in others  there is a constant dry cough,  and  inclination to hawk
 or spit, the pulse  is frequent, the upper part of the belly becomes
 swelled at night, but there is little  or no  pain in the region of the
liver;  if any be felt, it is rather referred  to the bowels.  By and
by considerable pain, like  colic, is felt  near the  stomach, espe-
cially at night, and that part of the belly is then  swelled, but to-
wards morning it  subsides.   On examination, however, the hypo-
chondriac region  is felt  full, and the  liver  can be perceived ex-
tending towards the  left side, and pain,  and  sometimes sickness,
are produced by pressure.  The urine is high-coloured, the feet
swell at night, and the face has a slight hectic  flush.  If the dis-
ease be not checked, it  goes on to  suppuration, producing distinct
hectic fever, terminating in  death, if the matter be not discharged;
or, it  may be, irritation proves fatal, even without  suppuration.
Repeated blisters, laxatives, and mercurial inunction are the reme-
dies, with diuretics, if there be dropsical  symptoms. 
211
   The spleen is frequendy enlarged, and sometimes contains tu-
 bercles.  I do not know any other  diagnostic symptom, than the
 belly being tumid and hard in the region of the spleen;  frequendy
 a coagh attends this  state.   Mercurial laxatives, and blisters, are
 the best remedies, but most cases  I have met with have proved
 fatal.*





                         CHAP. XXI.

                           Of Fever.

   Fever is  a frequent disease in infancy and childhood,  but it is
 generally symptomatic, or produced by some local irritation, and
 has been considered in some of the former chapters. Typhus fever
 is extremely rare  in infancy, but it sometimes  is communicated
 to children a few years old.   It is known by our evidently tracing
 the  channel of infection.f   The child at first  is  languid, pale,
 chilly, and debilitated, the appetite is lost the head becomes pain-
 ful, the skin hot the tongue foul, the eye dull, or suffused, and the
 pulse very quick; and if a favourable crisis be not procured, great
 oppression,  succeeded by stupor, precedes death.   In the  course
 of the disease, the bowels are generally bound,  the stools foetid,
 and  the urine thick.  It requires the early use of emetics in  the
 cold stage, succeeded by saline julap.  If the hot stage, however,
 be fully established, and the  heat considerable,  the affusion will
 be of advantage, succeeded  by calomel purges and saline julap,
 with light diet, and the use  of ripe fruit  A free, circulation of

  • I pursue here the same mode of treatment as in enlargement of the liver.
Exercise, and especially swinging, is useful. Compression of the abdomen by a
flannel bandage is alap beneficial.  C.
  f Many of the fevers of children, not at all originating in contagion, soon  run
into the typhus form.  This, therefore, can  hardly be considered as a diagnostic,
C. 
212
air is of essential benefit.   The skin, in the course of the disease,
especially among  the  poor, should be sponged  daily  with tepid
water, and the bed-clothes, if possible, changed frequently.   If the
head be very painful  in the  first stage, the application of leeches
to the forehead and the use of laxatives will be proper; or if the
pulse be full, a little blood may be taken from the arm.   If pain
continue, or stupor, or constant drowsiness supervene, blisters will
be proper.  The strength, in the latter end of the disease, is to
be supported by the prudent  use of wine.   Cough in general re-
quires blisters to the breast, with squill vinegar. 
 §trtt$ of $8tomavto&>



         WITH



     ILLUSTRATIONS,



SELECTED FROM SMELLIE'S PLATES. 
i '
* 
 
PlafrL.
R.€amphdl  Sc 
215
                          PLATE I.


  Represents, in a front view, the Bones of a well formed Pelvm.


         Tlie five vertebra of the loins.
         The os sacrum.
       A The os coccygis.
       B The os ilium.
    C.C The ossa ischia.
       D The ossa pubis.
       E The foramina magna.
       F The acetabula.
  G.G.G The brim of the pelvis, or that circumference of its cavity, which
           is described at the sides by the inferior parts of the ossa ilium,
           and at the back and fore parts by the superior parts of the
           ossa pubis and sacrum.

  In this Table, besides the general structure and  figure  of the  several
bones, the dimensions of the brim of the pelvis, and the distance between
the under part of the ossa  ischium, are particularly  to be attended to;
from which it will appear that the cavity  of the brim is commonly wider
from side to side than from the back to the fore-part, but that the sides be-
low are in the contrary proportion.   The reader, however, ought not
from this to conclude, that every pelvis is similar in figure and dimensions,
since  even  well  formed ones differ in some degree from each other.  In
general, the brim of the pelvis measures about five inches and a quarter
from side to side, and four inches and a quarter from the back to the fore-
part ;  there being likewise the same distance between the inferior parts of
the ossa ischium.   All these measures, however, must be understood as
taken from the skeleton; for, in  the subject, the cavity of the pelvis i.*
considerably diminished by its integuments and contents.  Correspondent
also to this diminution, the usual dimensions of the head of the full-grown
foetus are but three inches and a half from ear to ear, and four inches and
a quarter from thf fore to the hind head. 
216
                          PLATE  II.


Represents the Uterus in the eighth or ninth month of Pregnancy.  <]


       The uterus, as stretched to near its full extent, with the waters,
         and containing the foetus entangled in the funis,- the head pre-
         senting at the upper part of the pelvis.
     A.A The superior part of the ossa ilium.
     B.B The acetabula.
       C The remaining posterior parts of the ossa ischium.
       D The coccyx.
       E The inferior part of the rectum.
     F.F The vagina stretched on each side.
       G The os uteri, the neck of the womb being stretched to its full
              extent, or entirely obliterated.
       H Part of the vesica urinaria.
        I The placenta at the superior and posterior part of the uterus.
     K.K The membranes.

  This plate shows in what manner the uterus stretches, and how its neck
grows shorter, in the different periods of pregnancy.
  Notwithstanding  it has been handed down as an invariable truth, from
the earliest accounts of the art to the present times, that when the head of
the foetus presented, the face was turned to the posterior part of the pel-
vis ; yet, from Mr. Ould's observation,  as well as from some late dissec-
tions of the gravid  uterus, and from what is observed in practice, it is
most probable that the head presents, for the most part, as is  here  de-
lineated, with one ear to the pubes, and the other to the os sacrum; though
sometimes this may vary, according to the form of the head, as well as
that of the pelvis.
  Consult Dr. Hunter's  elegant plates of the gravid uterus. 
Plate  2.
ILCampheil Sc 
 
 
n<,t* 3.
ftfanpbeV  Sc. 
217
                         PLATE III.


Shows (in  a lateral  view and longitudinal division of the parta)
      the  Gravid Uterus when labour is somewhat advanced.


         A  The lowest vertebra of the back.
         B  The scrobiculus cordis; the distance from which to the last
              mentioned vertebra is here shown by dotted lines; as also
              part of the region below the diaphragm.
       C.C  The usual thickness and figure of the uterus when extended
              with the waters at the latter end of pregnancy.
         D  The same, contracted and grown thicker after the waters are
              evacuated.              »
       E.E  The  figure of the uterus when pendulous.  In this case, if
              the membranes break when the patient is \n an erect posi-
              tion, the head of  the foetus runs a risk of sliding over and
              above the ossa pubis, whence the shoulders will be pushed
              into the pelvis.
       F.F  The figure of the uterus, when stretched higher than usual,
              which generally  occasions  vomitings, and  difficulty of
              breathing.   Consult on this subject  Mr. Levret,  sur le
              Mechanisme de Differenteu Grossesses.
         G  The os pubis of the left side.
      H.H  The os internum.
          I  The vagina.
        K  The left nympha.
         L  The labium pudeifdi of the sitone side.
        M  The remaining portion of the bladder.
         N  The anus.

  In this period of labour, the os uteri being more and more stretched by
the membranes pushing down, and beginning to extend to the vagina, a
great quantity of waters is  forced down at the same time, and (if the mem-
branes break) is discharged ;  whence the uterus contracts itself nearer to
the body of the foetus, which is here represented in a natural  position,
with the vertex resting at the superior part of the ossa pubis, and the fore-
head toward the right os ilium.  As soon as the uterus is in contact with
the body of the foetus, the head of the same is forced backward toward the
os sacrum from the line of the abdomen B  G into that of the pelvis, viz.
from the uppermost  F. to near the end of the coccyx, and is gradually
pushed lower, as in the following plate.
Vol. II                     28 
218
                        PLATE  IV.


Shows the natural position of the head of the foetus when sunk down
  into the middle of the pelvis after the os internum is fully opened ;
  a large quantity of the waters being protruded with the membranes
  through the os externum, but prevented from being all discharged,
  by the head's filling up the vagina.


       The  uterus a little contracted, and thicker, from some of the wa-
         ters being sunk down before the child, or discharged.
    A The superior parts of the ossa ilium.
    B The inferior part of the rectum.
  C.C The vagina largely stretched with the head of the foetus.
  D.D The os internum fully opened.
    E A portion of the placenta.
    F The membranes.
  G.G The ligamenta lata.
  H.H The ligamenta rotunda.  Both these last stretched upwards with
         the uterus.

  The vertex of the foetus being now down at the inferior part of the right
os ischium, and the wide part of the head at the narrow and inferior part
of the pelvis, the forehead, by the force  of the pains, is gradually moved
backwards;  and, as it advances lower,  the vertex and occiput turn out
below the pubes, as in the next plate.  Hence may be learnt of what con-
sequence it is to know, that it is wider from side to side at the brim of the
pelvis, than from the back to the fore  part; and that it is wider from the
fore to the hind head of the child, than from ear  to ear. 
Plak 4.
 
 
 
Plait  5.
fLCampbrJl Sc ■ 
219
                        PLATE V.


Shows the forehead of thefatus turned (in its progression down*.
  wards,from its position in the former plate) backwards to the os
  sacrum, and the occiput below the pubes; by which means the nar-
  row part of the head is to the narrow part of the  pelvis, that is,
  hetween the inferior parts of the ossa ischium.  Hence it may be
  observed,  that, though the distance between the inferior parts of
  the last mentioned bones is much the same as  between  the coccyx
  and pubes ; yet, as the cavity of the pelvis is much shallower at
  the anterior than lateral part, the occiput of the foetus, when come
  down to the inferior part of either os ischium, turns out below the
  pubes.  This answers the same  end as if the pelvis itself had
  been wider from  the posterior part than from side to side; the
  head likewise enlarging the cavity by forcing back  the coccyx,
  and pushing out  the external parts inform of a large tumour.

    The uterus contracted closely to the foetus after the waters are evacu-
      ated.
     The vertebrae of the loins, os sacrum^ and coccyx.
  A  The anus.                                    *
  B  The left hip.
  C  The perineum.
  D  The os externum beginning to dilate.
  E  The os pubis of the left side.
  F  The remaining portion of the bladder.
  G  The posterior part of the os uteri. 
220
PLATE  VI.
Shows in what manner the  head of the fatus is helped along with
  the forceps, as artificial hands,  when it is necessary to assist with
  the same for the safety of either mother or child.

       The vertebrae of the loins, OS sacrum, and coccyx.
    A The os pubis of the left side.
    B The remaining part of the bladder.
    C The intestinum rectum.
    D The mons veneris.
    E The clitoris, with the left nympha.
    F The corpus cavernosum clitoridis
    X The meatus urinaiius.
    H The left labium pudendi.
     I The anus.
    K The perinseum.
  L.M The left hip and thigh.

  The patient, in this case, may be placed as in this plate,  on her side,
with her breech a little over the side or  foot of the bed, her knees being
likewise pulled up to her abdomen, and a pillow placed between them, care
being taken, at the  same time, that the parts are, by a proper covering,
defended from the external  air.  If the  hairy scalp of the foetus is so
swelled, that the situation of the head cannot be distinguished by the su-
tures, as in plate III.; or if, by introducing a finger between the head of the
child and the pubes, or groins, the ear or back part of the neck cannot be
felt, the os externum must be gradually dilated in the  time of the pains,
with the operator's fingers, (previously lubricated with hog's lard,) till the
whole hand can be  introduced into the vagina, and slipped up, in a flatfish
form, between the posterior part of the pelvis and child's head.  This last
is then to be raised up as high as possible, to allow room for the fingers to
reach the ear and posterior part of the neck.  When the  position of the
head is known, the operator must withdraw his  hand,  and wait to see if
the stretching of the parts will renew or increase the labour-pains, and al-
low more space for the advancement of the head in the pelvis.  If this,
however, proves of no effect, the fingers are again to be introduced  as be-
fore, and one of the blades of the forceps (lubricated  with lard)  is then to
be applied along the inside of the hand or fingers, and left  ear of the  child,
as represented in the plate.  But, if the pelvis is distorted, and projects
forward at the superior part of the os sacrum, and the forehead, therefore,
cannot be moved a little backwards, in order to turn the ear from that part
of the  pelvis which prevents the end of the  forceps to pas* the same;
in that case, the blade must  be  introduced  along the posterior part of
the ear at the side of the distorted bone.  The hand that was introduced
is then to be withdrawn, and the handle of the introduced blade held with 
PlMe  H.
ILCzmpbeU Sc 
 
221
it as far back as the perinaeum will allow, whilst the fingers of the other
hand are introduced to the os uteri, at the pubes or right  groin, and the
other blade placed exactly opposite to the former.   This done, the han-
dles being taken hold of and joined  together, the  head is to be  pulled
lower and lower every pain, till the vertex,  as in  this  plate, is brought
down to the inferior part of the left ischium, or below the same.   The wide
part of the head being now advanced to the narrow part of the pelvis be-
twixt the tuberosities of the ossa ischium, it is to be turned from the left
ischium, out below the pubes, and the forehead backwards to the concave
part of the os sacrum and coccyx, and afterwards the head brought along
and delivered, as in plate VII. and VIII. But, if it is found that the delivery
will require a considerable degree of force, from the head being large, or
the pelvis narrow, the handles of the forceps  are to be tied together with
a fillet, as represented in this table, to prevent their position being changed,
whilst the woman is turned on her back, which is  then more convenient
for delivering the head, than when laying on  the side*.
   This plate shows that the handles of the forceps ought to be held as far
back as the os externum will allow, that the blades may be in an imagina-
ry line between that and the middle space between the umbilicus and the
scrobiculus cordis.   When the forceps are applied along the ears and sides
of the head, they are nearer to one another, have a better hold, and mark
less, than when over the occipital and frontal bones. 
222
                    '   PLATE VII.


In this, the os externum is open, the occiput comes low down from
   below the pubes, and the forehead past the coccyx, by which both
   the anus and perinaum  are stretched out in form of a large tu-
   mour.


   When the head is so far advanced, the operator ought to extract with
great caution, lest the parts should be torn.   If the labour-pains are suffi-
cient, the forehead may be kept down, and helped along, in a slow man-
ner, by pressing against it with the fingers on the external parts below the
coccyx ;  at the same time, the forceps being taken off, the head may be
allowed to stretch the os externum more and more, in a  gradual manner,
from the force of the labour-pains, as well as  assistance of the fingers;
But, if the former are weak and insufficient, the assistance of the forceps
must be continued.  (Vide  the description  of the parts  in plate VI.)
S.T. in this, represent the left side of the os uteri.  The dotted lines  de-
monstrate the situation of the bones of the  pelvis on the right side, and
may serve as an example for  all the lateral views of the same.
   A.B.C.H. The outlines of the os ilium.
    D.E.F. The same of the pubis and ischium.
       M.N.  The foramen magnum. 
Plait  J.
 
 
J 
Phlk  f..
 
223
                       PLATE  VIII.


In the same section of the parts, but with a view of the right side,
  shows the head of the foetus in the contrary position  to  the  three
  last figures, the vertex being here in the concavity of the sacrum
  and the forehead turned to the pubes.


  A The anus.
  B The os externum not yet begun to stretch.
  C The nympha.
  D The labium pudendi of the right side.

  When the head is small, and the pelvis large, the parietal bones and the
forehead will, in this case, as they are forced downwards by the labour-
pains, gradually dilate the os externum, and stretch the parts between that
and the coccyx, in form of a large tumour, till the face comes down below
the  pubes, when the head will be safely delivered.   But, if the same be
large, and the pelvis narrow, the difficulty will be greater, and the child
in danger;  as in the following plate. 
224
                         PLATE IX.


Shows, in a lateral view, the face of the child presenting, and forced
   down into the lower part  of the pelvis, the chin  being below  the
   pubes, and the vertex in the concavity of the os sacrum ;  the wa-
   ters likewise being all discharged, the uterus appears closely join-
   ed to the body of the child, round the neck of which is one  circum-
   volution of the funis.


   A The inferior part of the rectum.
   B The perinaeum.
   C The left labium pudendi.

   When the pelvis is large, the head, if small, will come along in this po-
sition, and the child  be saved ; for, as the head advances lower, the  face
and forehead will stretch the parts between the frsenum labiorum and coc-
cyx, in form of a large tumour.  As the os externum likewise is  dilated,
the face will be forced through it; the under part of the chin will rise up-
wards over the anterior part of the pubes; and the forehead, vertex, and
occiput, turn from the parts below.  If the head, however, is large, it will
be detained, either when higher, or in this position.   In this  case, if  the
position cannot be altered to the  natural, the child  ought to be turned and
delivered footling. 
Piatt 9 ■
 
*' 
//•" 
Pfa/s  J<>.
 
225
                         PLATE  X.


Shows, in a front view of the parts, the forehead of the foetus pre-
  senting at the brim of the pelvis, the face being turned to one side,
  the fontanelle to the other, and the feet and breech stretched toward
  the fundus uteri.


         A  The perinseum.
         B  The os externum ; the thickness of the posterior part before
             it is stretched with the head of the child.
     C.C.C  The vagina.
         D  The os uteri not yet fully dilated.

  If the face is not forced down, the head  will sometimes come along in
this manner; in which case the vertex will be flattened, and the forehead
raised in a conical form; and when the head comes down to the lower part
cf the pelvis, the face or occiput will be turned from the side, and come out
below the pubes.  But, if the head is large, and cannot be defivered by
the pains, or if the wrong position cannot be altered, the child must be de-
livered with the forceps.   If they should fail, recourse must be had to em-
bryulcia.
Vol. II.
29 
226
                           PLATE XI.


  Shows, in a lateral view of the right side, the face of the foetus pre-
    senting,  as in Plate ix. but in a contrary position ; that is, with
    the chin to the os sacrum, and the bregma to the pubes, the waters
    evacuated, and the uterus contracted.


    In such cases, as well as in those described in the last Plate, if the child
  is small, the head will be pushed lower with the labour-pains, and gradu-
  ally stretch the lower part of the vagina and the external parts;  by which
  means the os externum  will be more and  more dilated, till the vertex
• comes out below the pubes, and rises up on the outside ;  in which case
  the delivery is  then the same as in natural labours.   But, if the head is
  large, it will pass along with great difficulty, whence the brain, and ves-
  sels of the neck, will he so much compressed and obstructed, as to destroy
  the child.  To prevent which, if called in time, before the bead is far ad-
  vanced  in the pelvis, the child ought  to be turned, and brought footling.
  If the head, however, is low down, and cannot be turned, the delivery is
  then to be performed with the forceps, either by bringing along the head
  as it presents, or as in the following Plate. See the references in Plate IX.
    N. B. Alarming floodings only excepted, it is bad to turn the child when
  the  head presents; and, in cases of relative disproportion between  it and
  the pelvis, we can never propose to save the child by turning. 
PlaUlT.
fttiimphell $&. 
""N 
\
y
f
/ 
Plate Z? .
 
227
                         PLATE  XII.


Represents, in a front view of the pelvis, the breech of the foetus pre-
   senting, and dilating the os  internum, the membranes being  too
   soon broken.  The fore-parts of the child are to the posterior part
   of the uterus;  and the funis, ivith a knot upon it, surrounds the
   neck, arm, and body.

   Sometime after this and the other Plates were engraved,  Doctor Kelly
showed me a subject he had opened, where the breech presented, and the
child lay much in the same position with its body as in the second plate,
Supposing the breech in that figure turned down to the pelvis, and the head
up to the fundus uteri.
   I have sometimes felt, in these cases, (when labour was begun, and be-
fore the breech was advanced into the pelvis,) one hip at the sacrum, the
other resting above the os pubis, and the private parts to .one side; but,
before they could advance lower, the nates  were turned to the sides and
wide part of the brim of the pelvis with the private parts to the sacrum, as
in this plate; though sometimes to the pubes.   As soon as the breech ad-
vances to the lower part of the basin, the hips again return to their former
position, viz. one hip turned out below the os pubis, and the other at the
back parts of the os externum.
   In this case, the child,  if not very large, or the pelvis narrow, may be
often delivered alive by the labour pains ; but, if long detained at the infe-
rior part of the pelvis, the long pressure of the funis may obstruct the cir-
culation. In most cases where the breech presents, the effect of the labour-
pains ought to be waited for, till at least they have'fully dilated the os inter-
num and vagina, if  the same  nave not been  stretched before with the
waters and membranes.   In the mean time, whilst the breech advances,
the os  externum may be^dilated gently during every pain, to allow room
for introducing a finger or two of each hand to the outside of each groin of
the foetus,  in order to assist the delivery when the nates are advanced to
the lower-part of the  vagina.  But, if the foetus is larger than usual, or the
pelvis narrow, and after a long time, and many repeated pains, the breech
is not forced down into the pelvis, the patient's strength at the same time
failing, the operator must, in a gradual manner, open the parts,  and, hav-
ing introduced a hand into the vagina, raise or push up the breech of the
foetus, ^and bring down the legs  and thighs.   If the uterus  is so strongly
contracted that the legs cannot be got  down, the largest end of the blunt
hook is to be introduced.  As soon as the breech or legs are brought down,
the body and head are to be delivered, as described elsewhere, only there
is no necessity here to alter the position of the child's body.
   The description of the parts in this plate is the same as in that of plate
XI.  only the dotted  lines in this describe the place of the ossa  pubis, and
anterior parts of the ossa ischium which  are removed, and may serve in
this  respect as an example for all the other front views, where, without dis.
figuring th»' plate, they could not W so well put in. 
V
 
a»a^«
*/ The letter n. after the number of the page, indicates that the article referred to
                         it contained in a note.

                               A

ABERNETHY, his mode of treating congenite marks, vol. ii. page 25-6
Aberration, mental, ii. p. 129
Abscess in the labium, i. p. 52
Abscess in the mammary, i. p. 572
Abdomen, distension of, effect of pregnancy, i. p. 242
Abortion, i. p. 258                                 .
Acid, citric, to be introduced into uterus in hemorrhage, i. p. 500 n.
Adams, Dr., his remarks on inoculation, ii. p. 94
After-pains, and treatment of, i. p. 523 et seq.
After-pains, distinguished from inflammation of uterus^&c. i. p. 524
Air, cool, proper in uterine hemorrhage, i. p. 503-4 '
Alopecia and Ophiasis, ii. p. 66            .   '
Amenorrhoea, i. p. 145              <*"
Anus, excoriation about the, ii. p. 55
Anus, imperforated, ii. p. 21
Apoplexy, occurring during labour, i. p. 48?
Aphthae of children, ii. p. 75
Aphthae, treatment ot ii. p. 78
Aphthae on the tonsils, ii. p. 80
Arrest of head, i. p. 434
Arteries of the pelvis, i. p. 8.
Articulation of bones of the pelvis, i. p. 7
Ascarides, ii. p. 204
Ascaris lumbricoides, ii. p. 205
Ascites, effect of pregnancy, i. p. 233
Asthama, acute, of children, &c. ii. p. 170
Asthama, treatment, ii. p. 172
Axis of the brim and outlet of the pelvis, i. p. 25

                                 B

 Baudelocque, his positions of vertex explained, i. 344 and 581 & seq.
 Baudelocque, preternatural presentations—Table, i. p. 593 
230
INDEX.
 Bandage to be applied after delivery, i. p. 497
 Bathing, cold, when proper for infants, ii. p. 16
 Bladder, its distention may produce puerperal convulsions, i. p. 484
 Bladder, affections of, i. p. 79
 Bladder affections, the effect of pregnancy, i. p. 225
 Blemishes and marks, ii. p.  24
 Blisters to the head proper in puerperal convulsions, i. p. 484
 Blisters used to remove marks in infants, ii. p. 25
 Boils and pustules in children, ii. p. 45
 Bowels, constipated, producing fever, i. p. 538-9
 Brain, inflammation of the, i. p. 568
 Breech, presentation of, i. p. 381
 Brim of pelvis, description of, i. p. 21
 Rreasts, swelling of, in infants, ii. p. 28
 Bronchocele, after parturition, i. p. 569
 Bronchitis, infantile, ii. p. 179
 Bronchitis, treatment, ii. p. 180
 Burns and scalds in infants, how cured, ii. p. 29, 30
 Bryce, his use of vaccine scab, ii. p. 97 n

                                  C

 Cavity of pelvis described, i. p. 22
 Caesarian operation, i. p. 470 & seq.
 Cauliflower excrescence from the os uteri, i. p.  101
 Calculi in uterus, i. p. 104
 Camphor recommended in puerperal convulsions, i. p. 486
 Cardialgia, effect of pregnancy, i. p. 183
 Cathartics proper after<Ielivery, i. p. 499
 Cathartic to be given  on the third day after parturition, i. p. 536
 Carthartic proper in intestinal  fever, i. p. 539
 Canker or ulceration of gums, ii. p. 72" ' «*
 Catarrh, infantile, ii. p. 179
 Cerebral irritation, ii. p.  120
 Cheek, erosion of, in children, ii. p. 73     -    ^
 Cheek, gangrene of, ii. p. 74
 Chicken-pox, ii. p. J01
 Children, on the management and diseases of, ii. p. 8 &seq.
 Children, still-born, treatment of, ii. p. 8 & seq.
 Child-murder, signs of, not decisive, ii. p. 12
 Chorea, sancti viti, ii. p.  160
 Citric acid, applied to uterus in hemorrhage, i. p. 509 n.
 Clitoris, description of, i. p. 43
 Clitoris,  diseases of, i. p.  61
Clysters, stimulating, recommended in  puerperal convulsions, i. p. 48*
Clysters, proper after delivery, i. p. 499
 Cleanliness, dress and temperature of children, i. p. 14 & seq.
Coccyx, os, description of, i. p. 5.
 Conception, i. p. 163
 Contraction, uterine, two kinds, i. p. 297
 Coloured spots, effect of pregnancy, i. p. 226 
INDEX.
231
Cough and dyspnoea, effect of pregnancy, i. p. 228
Cough, from affections of spinal marrow, ii. p. 125
Convulsions, effect of pregnancy, i. p. 229
Convulsions, in infants, ii. p. 153
Convulsions, treatment, ii. p. 156
Convulsions, from cerebral irritation, ii. p. 131
Convulsions, attending hooping.cough, ii. p. 177
Convulsions, puerperal, i. p. 479—venesection recommended in, i. p. 483
  —jugular vein to be opened, ibid.—enema stimulating, proper, ibid.—
  blisters to the  head,  ibid.—purgatives  proper, ibid.—bladder to be
  evacuated, i. p. 484—delivery of the child, when proper, zfoVf.—-opium,
  musk and camphor, their use,  ibid.—emetics not useful, i. p. 485—
  camphor recommended by Hamilton, i. p.  486
Cold, the application of, recommended in uterine hemorrhage, i. p. 505
Cold bathing,  when proper for infants, ii. p.  16
Cooper, Astley, his mode of treating spina bifida, ii. p. 24 n.
Corpus luteum, appearance of, after miscarriage, i. p. 580
Cord, umbilical, presentation of, i. p. 403
Cord, umbilical, how to be tied, ii. p. 12
Coagula, retention of in uterus, and expulsion, i.  p. 304
Contraction of uterus, how produced in flooding, i. p. 305
Colic, after delivery, i. p. 532
Colic, in infants, ii. p. 198
Costiveness, effect of pregnancy, i. p. 221
Costiveness, in children, ii. p. 197
Cow-pox, or vaccine inoculation, ii. p. 95
Cow-pox, spurious, ii. p. 96
Cow-pox, test of, ii. p. 100
Cramp, effect of pregnancy, i. p. 241
Cramp, in stomach after delivery, i. p. 532,,.
Crinones, a species of pustule, ii.  p. 45
Crotchet, of cases requiring the, \rjf. 459
 Croup, ii. p. 163             /
 Croup, treatment, ii. p. 165
 Croup, spasmodic, ii. p. 126,170
 Croup, spasmodic, treatment, ii. p. 172
 Cutaneous diseases of infants, ii. p. 38
 Cynanche trachealis, ii. p. 163
 Cynanche, treatment, ii. p. 165

                                 D

 Dandrifjf or Pityriasis of children, ii. p. 56
 Death,'sudden, from uterine hemorrhage, i. p. 502
 Decidba, membrana,  i. p. 192
 Defieiency and malformation of the uterus, i. p.  87
 Deformity of pelvis from rickets, i. p. 30
 Deformity from malacosteon, i. p. 32
 Deformity from exostosis and tumours, i. p. 35
 Delivery, treatment after, i. p. 497
 Delivery, speedy, when proper in puerperal convulsions, i. p. 484 & seq. 
232
INDEX.
  Delivery, recent, signs of, i. p. 578
  Denman's spontaneous evolution, i. p. 397
  Dentition, ii. p. 34
  Dentition, producing spasm of windpipe, ii. p. 174
  Despondency, effect of pregnancy, i. p. 243
  Dimensions of the pelvis, i. p. 21
  Diet, what proper in the puerperal state, i. p. 500
  Diet, proper for infants, ii. p. 16
  Diarrhoea, effect of pregnancy, i. p. 222
  Diarrhoea, after parturition, i. p. 570
  Diarrhoea, attending dentition, ii. p. 37-8
  Diarrhoea, of children, ii. p. 37 and 187
  Diarrhoea, of children, treatment, ii. p. 192
 Distortion of feet, ii. p. 26
 Diseases of organs of generation, i. p.  52
 Diseases of pregnant women, i. p. 563
 Diseases of infants, congenite and surgical, ii. p. 20 & seq.
 Diseases, cutaneous, of infants, ii. p. 38
 Douglass's case of rupture of uterus, i. p. 488
 Dress of infants, ii.  p.  15
 Dropsy of the ovarium, i. p. 126
 Dyspnoea and cough, effect of pregnancy, i. p. 228
 Dyspnoea, in the puerperal state, i. p. 531
 Dysmenorrhoea, i. p. 154

                                  E

 Ears, foetid discharge from, ii. p. 30
 Ears, exeoriation behind the, ii. p. 71
 Ear-ache in infants, how to "be treated, ii. p. 30
 Ecthyma, a species of pustule, ii. p. 45
 Eczema mercuriale, in infants,  ii. p. 86
 Emetics, their use doubtful in puerperal convulsions, i. p. 486
 Emetics, occasion expulsion of portions of the placenta, i. p. 514
 Emetics, proper in intestinal fever, i. p. 539
 Enclavement of a locked-head, i. p. 433
 Enemata, stimulating, proper in puerperal  convulsions, i. p. 485
 Enteritis of infants, ii. p. 184
 Ephemeral fever or weed, i. p. 533
 Ephemeral fever, treatment, i. p. 534-5
 Erythema nodosum, of Dr. Willan, i. p. 70
 Ergot, its use in tedious labours, i. p. 410 n.
 Erosion of the cheek, ii. p. 73
 Eruption, miliary, of infants, i. p. 47
 Eruption, anomalous, of infants, ii. p. 44
 Erythema of infants, ii. p. 68
 Erysipelas of infants, ii. p. 68
Evrat, his mode of checking uterine hemorrhage, i. p. 507 n
Evolution, spontaneous of foetus, i. p. 394
Excrescences of the labia, i. p. 56
Extra-uterine pregnancy, i. p. 196 
                              INDEX.                          233

Extra-uterine pregnancy, treatment of, i. p. 204
Examination, per vaginam, i. p. 355
Exanthema, or herpes labialis, ii. p. 52
Excoriation of nipples, i. p. 571
Excoriation behind the ears in infants, ii. p. 71
Excoriation of the tongue, ii. p. 82
Excoriation about the anus, ii. p. 55
Excoriation of navel in infants, ii. p. 28
Extremities, inferior,  presentation of, p. 386
Extremities, superior, presentation of, i. p. 387
Eyes, inflammation of, in infants, ii. p. 31
Eye, spongoid disease of, in infants, ii. p. 32

                                 F

Face, presentation of, i. p.  399
Fallopian tubes, description of, i. p. 50
Fastidious taste, effect of pregnancy, i. p. 220
Febrile state of pregnancy, i. p. 215
Feet, distortion of, ii.  p. 26
Fever, milk, how obviated and relieved, i. p. 536
Fever, milk, i. p. 536
Fever, milk, treatment of, i. ibid.
Fever, ephemeral, or  weed, i. p. 533
Fever, ephemeral, treatment of, i. p. 534
Fever, miliary, i. p. 536
Fever, miliary, treatment of, i. p. 538
Fever, intestinal, i. p. 538
Fever, intestinal, treatment of, i. p. 540             A
Fever, puerperal, i. p. 549
Fever, puerperal, distinguished from peritonitis,' i. p. 553
Fever, puerperal, treatment of, i. p. 55S & seq.
Fever, in infants, ii. p. 211      ■■**
Fever, remittent, of older children, ii. p. 211
Fits, inward, ii. p. 154
Flooding from a detachment of part of the placenta, i. p. 296
Flooding, treatment proper in, vide hemorrhage, uterine
Fluor albus, i. p. 74
Foetus, description of, i. p.  172
Foetus, spontaneous evolution of, i. p. 394
Foetus, peculiarities of, i. p. 178
Forceps, on cases admitting the use of, i. p. 431
Forceps, Haighton's,  described, i. p. 450 n
Froenum of tongue, division of, seldom necessary, ii. p. 27
Furunculus, or acute boil, ii. p. 45
Funis umbilicalis, presentation of, i. p. 403
Funis umbilicalis, how to be tied, ii. p. 12

                                 G

Gangrene of the cheek in children, ii. p. 74
     Vol.  II.                  30 
234
INDEX.
Generation, external organs of, i. p. 42
Generation, internal organs of, i. p. 46
Goldson's case of rupture of uterus, i. p. 488
Griffitts, Dr., on vaccine scab or crust, ii. p. 97 n
Gums, on the treatment of, in dentition, ii. p. 37
Gums, ulceration of, in children, ii. p. 72
Gum, red, or strophulus intertinctus, ii. p. 39


                                H

Hand, introduced into the uterus in uterine hemorrhage, i. p. 505
Hartshorn, Dr., immense tumours of labia extirpated by, 57 n.
Haighton's Forceps described, i. p. 450 n.
Hare-lip of infants, ii. p. 20
Hemorrhage, uterine, i. p. 296
Hemorrhage, uterine, attending labour, i. p. 477
Hemorrhage, uterine, from retention of part of placenta, i. p. 505
Hemorrhage, uterine, causes of, i.  p. 300
Hemorrhage, uterine, effects of, i.  p. 305
Hemorrhage, uterine, remedies for, i. p. 311
Hemorrhage, uterine, from connexion of the placenta with os uteri, i. p.
   307
Hemorrhage, uterine, after delivery, i. p. 501 & seq.
Hemorrhage, uterine, symptoms of, i. p. 503
Hemorrhage, uterine, apparent and concealed, i. p. 511
Hemorrhage, uterine", after expulsion of placenta, i. p. 512
Hemorrhage, uterine, pressure and bandage proper, i. p. 513
Hemorrhage, uterine, cold applications proper in, i. p. 509,—hand to be
   introduced, ibid.—placenta not to be hastily extracted, ibid.—uterus to
   be stimulated, and how, ibid.—Le Roy's advice injudicious, i. p. 509 n.
   —Ice to be introduced into uterus, i. p. 506—Citric  acid  to be intro-
   duced,  507 n.—rest to be enjoined, i. p.  509—opiates proper, ibid.
Hemoptysis, effect of pregnancy, i. p. 229'
Hematemosis, effect of pregnancy, i. p. 229
Head of child, and its progress through the pelvis in labour, i. p. 25
Head-ache, effect of pregnancy, i.  p. 229
Head ache, causes of, ii. p. 123
Head-ache, nervous, ii. p. 125
Heart-burn, effect of pregnancy, i. p. 219                ■
Heart, diseases of, may  occasion death immediately after delivery, i d
   502 n.                                                     J'  v
Heart, malformed, ii. p. 27
Hernia, i. p. 58
Hernia, of uterus, i. p. 125                                     x
Hernia, umbilical, of infants, ii. p. 22
Herpes of infants, ii. p. 50
Herjics farinosus, ii. p. 57
Herpes mijiaris, ii. p. 51
Herpes liabilis, or exanthema, ii. p. 52
Hectic fever, from retention of placenta, i. p. 5^7 
INDEX.
235
Hemiplegia, [puerperarum,] i. p. 564
Hepatitis of infants, ii. p. 208
Hives, or croup, ii. p. 163
Hives, treatment, ii. p. 165
Hour-glass contraction of uterus, i. p. 492
Hooping-cough, ii. p. 175
Hooping,cough, treatment, ii. p. 176
Hull, Dr., his theory of phlegmatia dolens, i. p. 56l
Hymen and orifice of vagina, i. p. 45
Hymen, diseases of, i. p. 62
Hydatids, of the uterus, i.  p. 112
Hysteritis, i. p. 89
Hysteria, i. p. 142
Hysteria, treatment of, i. p. 144
Hysteralgia, symptoms of, i. p. 525 & seq.
Hysteralgia, distinguished from inflammation, i. p. 526
Hysteralgia, treatment of, i. p. 526
Hydrocele of infants, ii. p. 28
Hydrocephalus, acute, history, ii. p. 142
Hydrocephalus, treatment, ii. p. 148
Hydrocephalus, chronic, history, ii. p. 150
Hydrocephalus, chronic, treatment, ii. p. 152
 Hydrocephalus, secondary, ii. p. 152

                                  I

 Ice to be introduced into uterus in hemorrhage, i. p. 506
 Ichthyosis of children, ii. p. 54
 Ignis sacer, ii. p. 234                            /■
 Impaction, or locked-head, i. p. 433
 Imperforated anus, urethra, &c. ii.  p. 21  ^
 Impetigo of children, ii. p. 58
 Inflammation of viscera distinguished from after-pams, i. p. :>2:.
 Inflammation, distinguished from hysteralgia, i. p. 526
 Inflammation of uterus, i.  p. 541
 Inflammation, slight, j^p. 541
 Inflammation, slight, treatment of, i. p. 542
 Inflammation of uterus, extensive, i. p.  542-3
 Inflammation of uterus, treatment of, i.  p. 544
 Inflammation, peritoneal, i. p. 545 & ii. p. 184
 Inflammation, peritoneal, treatment of, i. p. 547 & u. p. 184   •
 Inflammation of the brain after delivery, i. p.  566
 Inflammation of mammae, after delivery, i. p.  571
 Inflammation of pleura, ii. p. 181
 Inflammation of stomach, ii. p.  182
 Inferior extremities, presentation of, i. p. 386
  Intestinal fever, i. p. 538
 Intestinal fever, treatment of, i. p. 540
  Intestine, protrusion of, at the umbilicus, n. p. 22
  Inoculation for small pox, ii. p. 93
  Intertrigo, ii. p. 44 
236                          INDEX.
Inversion of uterus, a cause of flooding, i. p. 516 & seq.
Inversion of uterus, its symptoms and causes, i. p. 517
Inversion of uterus, its termination and treatment, i. p. 518-19 & seq.
Inversion of uterus, distinguished from prolapsus, &c. i. p. 542
Inversion, partial, of uterus, i. p. 516 n.
Inversion, partial, its treatment, i. p. 516 ».
Intus-susceptio, connected with diarrhoea, ii. p. 190
Invagination of intestines, frequent cause of diarrhoea, ii. p. 190
Irritation, spinal and cerebral, ii. p. 120
Itch, or scabies, ii. p. 48
Itch, dry, of children, ii. p. 54

                                  J

Jaundice, effect of pregnancy, i. p. 226
Jaundice, of infants, ii. p. 206*
Junction, sacro-iliac, of pelvis, i. p. 8
Junction, vertebral, of pelvis, i. p. 9
Jugular vein to be opened in puerperal convulsions, i. p. 479

                                 K

Kidney, pain in the region of, after delivery, i. p. 532

                                 L

Labia and nymphae, description of, i. p. 42
Labia, abscess in the, i. p. 52
Labia, ulceration of, i. p. 53
Labia, excrescences of, i. p. 56
Labia, scirrhous tumours of, i. p. 56
Labia, polypous tumours, of i. p^ 57 . -
Labia, oedema of, i. p. 58
Labia, gangrene of, ii. p. 74
Laceration of parts  of generation, i. p. 64
Labours, classification of, i. p. 343-4
Labour, natural, i. p. 349
Labour, stages of, i. p. 349
Labour, causes of, i. p. 364
Labour, management of, i. p. 366
Labour, preternatural, i. p. 380
Labour, tedious, i. p. 408
Labour, premature, i. p. 378, 46S
Labour, impracticable, i. p. 470
Labour, complicated, i. p. 476
Lactation or suckling, observations on, i. p. 577
Laudanum, proper to prevent uterine hemorrhage, i. p. 504
Lever, on cases admitting its use, i. p. 431
Le Roy, his advice in uterine hemorrhage, i. p. 505 n. 509 n.
Lemon juice to be introduced into uterus in hemorrhage, i. p. 507 n.
Leg, swelled, or phlegmatia dolens, i. p. 558 
INDEX.
237
Leg, swelled, treatment of, i. p. 562 and seq.
Lepra, ii. p. 57
Liquor amnii, and membranes, L p. 191
Liquor amnii, redundance of, i. p. 235
Ligaments, diseases of, i. p. 137
Liver, diseased, of infants, ii. p. 208
Liver, a diseased state of, frequently attends diarrhoea, ii. p. 191
Lichen, ii. p. 42
Lichen lividus, ii. p. 67
Locked-head, i. p. 433
Lochia, profuse, from rising too soon after delivery, i. p. 501
Lochial discharge obstructed in hysteralgia, i. p. 526
Lumprici, ii. p. 205
Lymphatics of pelvis, i. p. 20

                                 M

Mastodynia, effect of pregnancy, i. p. 232
Mania, puerperal, i. p.  564
Mania, treatment of, i. p. 565
Mammae, inflammation of, after delivery, i. p. 571
Mammae, abscess of, i. p. 572
Malignant, aphthous, or putrid sore throat, ii. p. 81
Malformed heart, ii. p. 27
Management and diseases of children, ii. p. 8 & seq.
Marks and blemishes, ii. p. 24
Marasmus of infants, ii. p. 199
Menstruation, i. p. 137
Menstruation, Hunter's theory of, i. p. 140 /*-.
Menstruation, diseases of, i. p. 141
Menses,  cessation of, i. p. 162
Menorrhagia, i. p. 155
Menorrhagia lochialis, i.  p. 512
Menorrhagia lochialis, treatment of, i. p. 515
Membranes and liquor amnii,  i. p. 191
Meconium, how to be evacuated, ii. p. 16
Meatus auditorius, imperforated, ii. p. 22
Melancholy, puerperal, i. p. 568
Mercurial disease in infants, ii. p. 86
Measles, ii.  p. 113
Measles, treatment of, ii. p. 116
Milk, secretion of, when it takes place, i. p. 499
Milk-fever, and how obviated, i. p. 536
Milk-fever, treatment of, ibid
Milk, as the diet of infants, i. p. 17
Miscarriage, recent, signs of, i. p. 578
Miliary fever, i. p. 536
Miliary fever, treatment of, i. p. 538
Miliary eruption in infants, ii. p. 47
Moles, i. p. 110
Monsters and plurality of children, i. p. 405 
238
INDEX.
 Monro's case of rupture of uterus, i. p. 488
 Muscles of pelvis, i. p. 7                          «
 Muscular pain, effect of pregnancy, i. p. 239
 Musk recommended in puerperal convulsions, i. p. 485

                                 N

 Natural labour, description of, i. p. 349 & seq.
 Navel, excoriation of, in infants, ii. p. 28
 Navel-string, how to be tied, ii. p. 8
 Nervous and spasmodic diseases in the puerperal state, i. p. 530
 Nerves, irritation of the extremities of, ii. p. 121
 Nerves of pelvis, i. p. 9
 Nettle-rash, or urticaria, ii. p. 104
 Nipples, excoriation of,.i. p. 575
 Nose, foetid secretion from, ii. p. 31
 Noma, or grangrene of the check, &c. in infants, ii. p. 74
 Nymphae, diseases of, i. p. 59

                                 O

 Obliquity of pelvis, i. p. 9
 CEdema of labia, i. p. 58
 OXdema, effect of pregnancy, i. p. 58
 CSsophagus, rupture of, ii. p. 186
 Oleum terebinthinae, recommended in taenia, ii. p. 206 n.
 Opftim, when proper in puerperal convulsions, i. p. 486
 Opiates recommended in flooding after delivery, i. p. 509
 Operation, Caesarean, i. p. 470
 Opthalmia infantilis, ii. p.  31
 Os uteri, rigidity of, cause  of rupture  of uterus, i. p. 488
 Os uteri, cauliflower excrescence of, i. p. 92
 Ossa innominata, description of, i. p. 2
 Outlet of pelvis, i. p. 21
 Ovaria, description of, i. p. 50
 Ovaria, dropsy of, i. p. 126
Ovaria, other diseases of, i. p. 136
Ovaria, deficiency of, i. p.  137
Ovum, its connection with the uterus, i. p. 277
Ovum, hemorrhage from its  separation, i. p. 278
Ovum, blood effused in consequence of a partial detachment of,  i. p. 270
Palpitation, effect of pregnancy, i. p. 227
Palpitation after delivery, i. p. 530
Pains, false, i. p. 338
Parturition, i. p. 343 & seq.
Paralysis [puerperum] i. p. 563
Paralysis of children, i  p. 160
Parrish, Dr., on scrofula interna, ii. p. 181 n. 
                                     INDEX.                          239

       Pelvis, bones of, general view, i. p. l
       Pelvis, difference of female from male, i. p. 5
       Pelvis, brim and outlet of, i. p. 21
i       Pelvis, above the brim, i. p. 24
 1      Perinaeum, laceration of, i. p. 64
       Peritonitis pue'rperalis, i. p. 545
       Peritonitis, treatment of, i. p. 547-8
       Peritonitis of children, ii. p. 184
       Peritoneum, chronic, inflammation of, i. p. 549
       Pemphigus of infants, ii. p. 46
!       Petechias, sine febre, ii.  p. 66
        Pertussis, ii. p. 175
        Pertussis, treatment, ii. p. 176
        Phagedenic herpes, ii. p. 52
        Phlegmatia dolens [puerperarum] i. p. 561
        Phlegmatia, treatment of, i. p. 562 & seq.
        Phrenitis, puerperal, i. p. 564
        Phymosis of infants, ii. p. 28
        Phyma, or tedious boil, ii. p. 45
        Philadelphia, success of vaccination in, ii. p. 101 n.
,       Piles, treatment of, i.  p. 223
        Pityriasis, or dandriff of children, ii. p. 56
i       Placenta, description of, i. p. 185
        Placenta, in twin cases, how managed, i. p. 406
        Placenta, treatment after expulsion of, i. 497
        Placenta, hemorrhage, after expulsion of, i. p. 501 & seq.
        Placenta, not to be hastily extracted in uterine hemorrhage, i. p. 505,,
        Placenta, portion of remaining keeps up flooding, i. p. 508
        Placenta, portion of, how to  be treated, i. p. 509
        Placenta, rashness in extracting, occasions inversions of uterus, i. p. 511
        Placenta, retention of part of, i. p. 514-527
        Placenta, retention, treatment of, i. p. 529
        Plurality of children  and monsters, i. p.  405
        Pleurisy in the puerperal state, i. p. 530.
        Pleura, inflammation of, ^children, ii. p. 181
        Pleuritis in infants, ii. pi 181
        Pneumonia in the puerperal state, i. p. 530
        Presentation of breech, i. p. 38
        Presentation of the inferior extremities, i. p. 386
        Presentation of superior extremities, i. p. 387
        .Presentation of the trunk, i.  p. 399
        Presentation of the umbilical cord, i. p. 403
        Presentations requiring turning, table of, i. p. 593
        Polypous tumours of labia, i. p. 57
r       Polypi of uterus, i. p. 104
        Polypi, malignant, i. p. 109
        Posture erect, improper immediately, after delivery, i. p. 498
         Pompholyx of infants, ii. p. 46
I        Porrigo, or scabies capitis, ii. p. 60
         Pregnancy, extra-uterine, i. p.  196   \         «
         Pregnancy, signs of, i.  p. 173-206 
240
INDEX.
 Pregnancy, general effects of, i. p. 212
 Pregnancy, febrile state of, i. p. 215
 Pregnant women, diseases of, i.p. 212
 Pregnant women, treatment of, i. p. 217
 Premature labour, i. p. 378, 467
 Preternatural labour, i. p. 380
 Prickly-heat, ii. p. 43
 Prolapsus uteri, i. p. 117
 Prolapsus uteri, from rising too soon after delivery, i. p. 500
 Prolapsus ani, in infants, i. p. 28                +
 Prurigo of infants, ii. p. 48
 Psoriasis of Dr. Willan, ii. p. 54
 Puerperal state, treatment proper in, i. p. 497 & seq.
 Puerperal convulsions, i. p. 478 & seq.
 Purge to  be given on third day after parturition, i. p. 536
 Purgatives recommended in puerperal  convulsions, i. p. 481 & seq.
 Purpura, or petechiae sine febre, ii. p. 66
 Pubis, symphysis, description of, i. p. 7
 Pubis, division of, i. p. 474
 Puerperal fever, i. p. 549
 Puerperal fever, distinguished from peritonitis, i. p. 553
 Puerperal fever, treatment of, i. p. 553-4 & seq.
 Puerperal mania, i. p. 564
 Puerperal mania, treatment of, i. p. 565
 Pustules and bolls in children, ii. p. 45

                                 R

 Remittent, infantile, ii. p. 131
 Remittent distinguished from hydrocephalus, ii. p. 136
 Remittent, treatment of, ii. p. 139-140
 Retention of part of the placenta, i. p. 527
 Retention of part of the placenta, treatment of, ii. p. 529
 Respiration, how excited in new-bom children, ii. p. 11
 Rheumatism distinguished from after-pains, i. p. 525
 Rigidity of the os uteri, cause of rupture of uterus, i.p. 488
 Rickets, ii. p. 33
 Roseola annulata, of Dr. Willan, ii. p. 105
 Roseola infantilis sometimes mistaken for scarlatina, ii. p. 109
 Roseola aestiva, ii. p. 118
 Roseola autumnalis, ii. p. 119
 Roseola infantilis, ii. p. 119
 Rupture of the uterus, i. p. 488
 Rupture of the vagina, i. p. 494
Rubeola or measles, ii. p. 113
Rubeola, treatment of, ii. p. 115
Rubeola sine catarrho, ii. p. 117
Rye, spurred, its use in tedious labours, i. p. 410 n

                                 S
Sacrum, os, description of, i. p. 5 
                               INDEX.

Sacro-iliac junction, i. p. 8
Salivation, effect of pregnancy, i. p. 232
Scirrhous tumours of labia, i. p. 56
Scirrho-cancer in uterus, i. p. 93
Scalp, swelling of in infants, ii. p. 26
Scalds and burns in infants, how cured, ii. p. 29-30
Scabies, capitis, or porrigo, ii. p. 60
Scabs from vermin, ii. p. 65                  i
Scab, vaccine, employed in vaccination, ii. p. 97
Scarlatina simplex, ii. p. 105
Scarlatina simplex, treatment of, ii. p. 109-10
Scarlatina anginosa, ii. p. 106
Scarlatina anginosa, treatment of, ii. p. 110
Scarlatina maligna, ii. p. 108
Scarlatina maligna, treatment of, ii. p. 111-12
Scrofula, ii. p. 32
Scrofula, treatment of, ii. p. 33
 Scrofula interna of infants, ii. p. 181 n.
 Scabies, or true itch, ii. p. 48
Separation of the bones of pelvis, i. p. 9
' Sectio pubis, i. p. 474
 Secretion of urine diminished, i. p.  495
 Secale cornutum, recommended in tedious labours, i. p. 410 n.
 Shoulder, presentation of, i. p. 387
 Signs that a woman has been recently delivered, i. p. 578
 Sigaultian operation, i. p. 474
 Skin-bound, ii. p. 87
 Skin-bound, treatment of, ii. p. 89                   ..■4^*Fe
 Sleeping not  to be entirely prevented in flooding cases, i. p. 511
 Small-pox, distinct, ii. p. 89                  'f
 Small-pox, confluent, ii. p. 91        — ■'  '
 Small-pox, re-infection from, ii. p^SS
 Sore throat of infants, ii. p. 8(jf
 Spasmodic and nervous diseases in the puerperal state, i. p. 530
 Spasms of windpipe  in children, ii. p. 174
 Spina bifida, ii. p. 2jy*"~
 Spinal irritation, ii Jp. 120
 Spinal marrow, inflammation of, ii. p. 125
 Spongoid turnout, i. p. 72-100
 Spongoid disease of the eye in infants, ii. p. 32
 Spleen enlarged in infants, ii. p. 211
 Stomach and duodenum, spasms of, i. p. 220
 Stomach to be watched in uterine hemorrhage, i. p. 509
 Stomach, inflammation of, in infants, ii. p. 182
 Stomach, inflammation of, in infants, treatment, ii. p. 183
 Sterility, i. p. 194
 Stimulants generally improper after delivery, i. p. 498
 Strangury, i. p. 529
 Still-born children, treatment of, i. p. 10
 Strophulus intertinctus, ii. p. 39
 Strophulus albidus, ii. p. 40
      VOL.  II.                  31
241 
242                         INDEX.
Strophulus confertus, ii. p. 41
Strophulus candidus, ii. p. 42
Suckling, observations on, i. p. 576-7
Superior extremities, presentation of, i. p. 387
Suppression of urine after delivery, ii. p. 123,494,499
Swelled leg of puerperal women, i. p. 558
Swelled leg, treatment of, i. p. 562  & seq.
Swathing infants, formerly practised, ii. p. 15
Swelling of the breasts in infants, ii. p. 28
Swelling of the scalp, ii. p. 26
Swine-pox, ii. p. 103
Symphysis pubis, description of, i. p. 7
Symphysis pubis, section of, i. p. 474
Syncope, effect of pregnancy, i. p. 228
Syncope, produced by uterine hemorrhage, dangerous, i. p. 477
Syncope, treatment proper in, i. p. 477> 510
Syphylis in infants, ii. p. 82
Syphylis, treatment, ii. p. 85

                                 T

Table of presentations requiring turning, i. p. 593
Table of cases and presentations at I'Hospice de la Maternite, i. p, 594
Tabes mesenterica, ii. p. 200
Taenia, ii. p. 206.
Temperature proper for infants, ii. p. 16.
Teeth, on the formation and cutting of, ii. p. 34 & seq.
Tetter, dry, of infants, ii. p. 56
Tetter, scaly, of children, ii. p. 57
Throat, sore, in  infants, ii. p. 80
Tooth-ache, effect of pregnancy, i,  p. 231-
Torpor of uterus, occasioning flooding, i. p. 503 & seq.
Tongue-tied, ii. p. 27                  ""%
Tongue, excoriation of, in infants, ii. p. 82  ■
Tonsils, aphthae on the, ii. p. 80
Touching, or examination per  vaginam, i. p. 355-6 ..
Trunk, presentation of, i. p. 399
Trismus nascentium, ii. p. 158
Trichuris, or long thread worm,  ii. p. 206
Tubes, fallopian, diseases of, i. p. 50
Tubercles in uterus, i. p. 97
Turning, table of presentations requiring it, i. p. 593
Turpentine, oil of, used in expelling taenia, i. p. 206 /
Twins and monsters, i. p. 405
Tympanites of uterus, i. p. 117,577
Typhus fever of infants, ii. p. 211

                                  u

Ulceration of the labia, i. p. 53
Ulceration of uterus, i. p. 90 
INDEX.
243
 Ulceration of the gums in children, ii. p. 72
 Ulcer, herpetic, ii. p. 45
 Umbilical cord, i. p. 182
 Umbilical cord, presentation of, i. p. 403
 Umbilical, hernia, ii. p. 22
 Undimiam of Avicenna, or humid erysipelas, ii. p. 68
 Uterus, and its appendages, i. p. 48
 Uterus, substance of, i. p. 44,48
 Uterus, arteries of, i. p. 44,49
 Uterus, nerves of, i.  p. 45, 49
»« Uterus, lymphatics of, i. p. 49
 Uterus, broad, ligaments of, i. p. 50
  Uterus, round, ligaments of, i. p. 50
  Uterus, aqueous, secretion from, i. p. 115    *
  Uterus, gravid, description of, i. p. 167
  Uterus, muscular, fibres of, i. p. 170
  Uterus, development of, and state of its cervix, i. p. 169
  Uterus, gravid, ligaments of, i. p. 171
  Uterus, gravid, vessels of, i. p. 171
  Uterus, retroversion of, effect of pregnancy, i.p. 243
  Uterus, antiversion of, effect of pregnancy, i. p. 253
  Uterus, rupture of, effect of pregnancy, i. p.  253
  Uterus, rupture of, i. p. 487
  Uterus, symptoms of approaching rupture of, i. p. 488 & seq.
  Uterus, hour-glass, contraction of, i. p. 503
  Uterus, torpor of, produces hemorrhage, i. p. 507
  Uterus, inversion of, i. p. 516 & seq.
  Uterus, inversion of, its symptoms and causes, i. p. 517
  Uterus, inversion of, terminations and treatment, i. p. 518
  Uterus, inflammation of, i. p. 520
  Uterus, inflammation of, treatment of, i. p. 521
  Uterus, state of, after recent delivery, i. p. 579
  Uterine hemorrhage, i. p. 296  MF
  Uterine hemorrhage, after dettrery, i. p. 501 & seq.
  Uterine hemorrhage, symptoms of, i. p. 503
  Uterine contraction, twtf-kinds, i. p. 297
  Uterine contraction ^racited by gentle pressure on-abdomen, i. p. 503
  Uteri, prolapsus, from rising too soon after parturition, i. p. 500
  Urethra, i. p. 43 ^r
  Urethra, excrescences in, i. p. 85
  Urethra, imperforated, ii. p. 21
  Ureter, spasm of, effect of pregnancy, i. p. 240
  Urine, suppression of, i. p. 494
  Urine,"secretion diminished, i. p. 495
  Urine, retention of,  how caused by uterine hemorrhage, i. p. 513
  Urticaria, or nettle-rash, ii. p. 104
Vagina, description of, i. p. 45
Vagina, imperfections of, i. p. 66
% 
244
INDEX.
Vagina, inflammation and gangrene of, i. p. 67
Vagina, induration of, i. p. 68
Vagina, ulceration of, i. p. 68
Vagina, polypi of, i. p. 68
Vagina, inversion of, i. p. 69
Vagina, watery tumour of, i. p. 69
Vagina, hernia of, i. p. 70
Vagina, encysted tumour and varices of, i. p. 71
Vagina, erysipelatous,  inflammation of, i. p. 72
Vagina, rupture of, i. p. 488
Varicose veins, effect of pregnancy, i. p. 239
Variola discreta, ii. p. 86
Variola confluens, ii. p. 94
Vaccination, ii. p. 101
Vaccination, success of, in Philadelphia, ii. p. 101
Varicella or chicken-pox, ii. p. 102
Varicella lenticular, ii.  p. 102-3
Varicella conoidal, ibid.
Varicella swine or bleb pox, ibid.
Vertebral junction and obliquity  of pelvis, i. p. 9
Vertigo, from nervous irritation, ii.  p. 125
Venesection, when proper in tedious labour, i. p. 413
Venesection, recommended in puerperal convulsions, i. p. 483-4
Ventricles of heart, inequality of, may occasion death, i. p. 502 n.
Venereal disease in infants, ii. p.  83
Venereal disease in infants, treatment, ii. p. 85
Vermin,scabs from, ii. p. 65
Vertex, six diflfeent presentations of, described, i. p. 581 & seq.
Vomiting, effect of pregnancy, i. p. 217
Vomiting, sometimes useful in uterine hemorrhage, i. p. 509
Vomiting, in infants, ii. p. 186
Vulva, gangrene of, in infants, ii. P^1^^

                                W    '

Watery discharge from vagina, effect of pregnancy, j. p. 238
Weed or ephemeral fever, i. p. 533               \
Weed, treatment of, i. p. 535                       '.
Weaning, treatment of women whilst, i. p. 577
Weaning, period at which a child should be weaned, ii. p. 19
Wine occasionally proper in uterine hemorrhage, i. p. 509
Willan, on cutaneous diseases, ii. p. 38 & seq.
Wild fire, [eruption of infants] ii. p. 51
Worms in uterus, i. p. 116
Worms, intestinal, ii. p. 204
THE  END. 
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