Hi ■ w rag i ■ ,A\SMi OF THE •School oj^iAedicine <^fe^>7T0 jl 3-^- V PRACTICAL TREATISE ON THE MANAGEMENT AND DISEASES OF CHILDREN. BY RICHARD T. EVANSON, M.D., PROFESSOR OF MEDICINE, HENRY MAUNSELL, M . D . , PROFESSOR OF MIDWIFERY, IK THE BOTAL COLLEGE OF SURGEONS IJT IRELAND. HASWELI., BARRINGTON, AND HASWELI, ZBO^fi 1838. Cbr(kt\\ CoU, PREFACE. A Preface usually embraces two topics, viz. : — the Author's reasons for publishing ; and such an account as he chooses to give of his qualifications for the task he has undertaken. With regard to the first, we have only to state, that our publisher informed us that a concise practical work upon the Management and Diseases of Children was a desider- atum in British medical literature. Respecting the second, all that becomes us to say is, that wTe have been con- nected with the Institution for Diseases of Children ever since its establishment in this city: first, as students; and, subsequently, as medical attendants. We had thus, at least, ample opportunity of attaining experience in the subject. If it should now prove that we have profited by this so far as to enable us to render the following chapters (incomplete as we know them to be) in any degree useful to society, we shall be more than recompensed for the labour they have cost us. H. M. R. T. E. Dublin, Nov. 1836. CONTENTS CHAPTER I. PECULIARITIES OF THE INFANT STRUCTURE AND CONSTITUTION. Sect. 1. General Considerations, 2. Digestive Organs, 3. Organs of Respiration, 4. Circulation, 5. Cerebro-spinal System, 6. Locomotive Apparatus, 7. Growth, . R. T. Evaxson Page 9 11 13 14 15 18 19 CHAPTER II. MANAGEMENT AND PHYSICAL EDUCATION OF CHILDREN. Sect. 1. Management immediately after Birth, . . .26 2. Food and Medicine do. do. ..... 28 3. in First Period, 30 4. Choice of a Nurse, ....... 33 5. Artificial Feeding, ....... 34 6. Weaning, 35 7. Food in Second Period, 30 8. Cleanliness, 39 9. Clothing, 40 10. Sleep, 42 11. Exercise, 44 12. Medicine, 47 13. Light, 49 14. Air, ib. 15. Temperature, 50 16. Mental and Moral Education, ib, II. Mauxsell April, 1S3S.— L 6 CONTENTS TO MANAGEMENT, ETC., OF CHILDREN. CHAPTER III. PECULIARITIES OF DISEASE. Page Sect. 1. Etiology, 56 2. Diagnosis, 61 3. Prognosis, 64 R. T. Evanson. CHAPTER IV. INFANTILE THERAPEUTICS. Sect. 1. General Observations, ...... 67 2. Mercury, 68 3. Sedatives, ........ 69 4. Alkalies and Alkaline Earths, 72 5. Carminatives, ........ 73 6. Stimulants, ........ 74 7. Tonics, 76 8. Antiphlogistic Plan, 77 9. Blood-letting, 78 10. Blisters, 79 11. Emetics, . 81 12. Expectorants, . 82 13. Diaphoretics, 85 14. Refrigerants, 86 15. Baths, 87 16. Purgatives, . . 88 R. T. Evanson. CHAPTER V. ACCIDENTS AND DISEASES OCCURRING AT BIRTH, OR SHORTLY AFTERWARDS. Sect. 1. Still-born Children, 95 2. Imperforate Anus, 98 3. Vagina, ib. 4. Penis, .99 5. Spina Bifida, . . . . . . . . ib. 6. Short Frenum Linguae, 101 CONTENTS TO MANAGEMENT, ETC., OF CHILDREN. 7. Hare Lip, 8. Deformed Feet, 9. N«vi Materni, 10. Ruptures, 11. Injuries received during Birth, 12. Blue Disease, 13. Trismus Nascentium, 1 1. Infantile Erysipelas, . 13. Abscesses, 16. Induration of Cellular Tissue. 17. Jaundice, 18. Purulent Ophthalmia, 19. Red Gum, 20. Swelling of the Breasts, H. Maunsell. CHAPTER VI. DENTITION. Page 101 ib 103 105 107 108 109 111 112 113 114 115 116 117 117 R. T. E vanson. CHAPTER VII. DISEASES OF DIGESTIVE ORGANS Sect. 1. General Observations, 2. Affections of Mouth, &c. 3. Stomach and Bowels, 4. Mesenteric Disease, 5. Worms, . 6. Remittent Fever, R. T. Evanson. CHAPTER VIII. DISEASES OF THE RESPIRATORY ORGANS. Sect. 1. Catarrh, 2. Bronchitis, ....... 3. Pneumonia, 4. Pleuritis, 5. Cronn. ........ 125 126 137 168 177 183 191 192 195 196 S CONTENTS TO MANAGEMENT, ETC., OF CHILDREN. Page 6. Laryngitis, 202 7. Foreign Bodies in Larynx, 204 8. Spasm of the Glottis, 205 9. Hooping Cough, 209 H. Maunsell. CHAPTER IX. ERUPTIVE FEVERS. Sect. 1. Measles, 214 2. Scarlet Fever, 219 3. Small-Pox, 230 4. Chicken-Pox, 237 H. Maunsell. CHAPTER X. VACCINATION, 238 H. Maunsell. CHAPTER XL CONSTITUTIONAL DISEASES. Sect. 1. Scrofula, . . . 260 2. Rickets, . 269 3. Syphilis, 271 4. Purpura, . . . 275 5. Pemphigus, 277 H. Maunsell. CHAPTER XII. DISEASES OF THE CEREBRAL SYSTEM. Sect. 1. Functional Diseases, 280 2. Inflammatory Affections, 286 R. T. Evanson. PRACTICAL TREATISE, &C. <fec. CHAPTER I. PECULIARITIES OF THE INFANT STRUCTURE AND CONSTITUTION. I. GENERAL CONSIDERATIONS. In considering our present subject, as well as in the observations which we propose to make upon the diseases of children, we mean to regard the period of childhood as consisting of two epochs — the first commencing at birth, and continuing until the twelfth month ; the second commencing at the termination of the first year, and continuing until the eighth. This division, which has been generally adopted, possesses the merit of being nearly in accordance with one definitely marked out by nature herself. About the tenth or twelfth month, the child, by its acquisition of teeth, becomes fitted for the use of other nourish- ment than the mother's milk ; and the stomach and bowels receive, not merely with impunity, but advantage, kinds of food, which, during the earlier months, would have been productive of serious derangements of the digestive functions : at the same time, very obvious external changes have their commencement, and indicate marked alterations, both bodily and mental.'* During the first period, also, the child is subject to some peculiar diseases and dangers, to which the attention of the physician requires to be specially- directed, and the diminished liability to which, upon the commence- ment of the second epoch, appears materially to increase the chances of existence. Beyond the eighth year, we would not employ the term, child — though sometimes continued until the age of puberty ; but before then, the peculiarities characteristic of childhood have been merging into the attributes of adult age; while the influence of sex begins to be discernible, and the individual may thenceforward be designated boy or girl. The infant, at birth, is endowed with the same organs as the adult ; but so different, for the most part, in structure or development, as to constitute those essential characters which distinguish childhood, *" At this time," says Wend t, "the hitherto projecting forehead hecomeB flattened, the countenance receives expression, the eyes intelligence, the limbs firmness." — Die Kinderkrankheiten systematise?! dar^estcllt von Dr. J. Wendt, Wien 1827. March, 1S38. — E 3 10 MANAGEMENT AND DISEASES OF CHILDREN. and without a knowledge of which, neither the management nor diseases of children can be correctly understood. Infancy may be emphatically termed the period of growth. We find the infant, at birth, fully provided with the organs of nutritive or organic life — those which are essential for the sustenance and nutrition of the individual ; while the organs of animal life or rela- tion,— those which connect man with the external world, and make him, on their completion, the superior being that he is, — are as yet but imperfect in development or structure — herein being to be found the basis of that great difference observable between the infant and the adult. In the former, we have the organs of nutritive life alone, fully developed, and actively employed; but in the latter, we have both classes of organs, relative as well as nutritive, brought to com- pletion and in full activity, constituting the period of maturity or perfect growth. To speak in general terms, we may say, that the anatomical struc- tures in the infant differ from those in the adult, by their greater softness or want of consistency ; being surcharged with fluids, and many of them as yet unfitted for the full discharge of their appro- priate functions: while in advanced life, on the contrary, the quan- tity of fluids diminishes, and the structures become condensed, so that the organs, instead of being too soft, have become too rigid,, as we find them to be in old age. In the infant, the capillary system, in particular, predominates ; absorption and deposition are active, and the processes of interstitial growth most vigorous; secretion is abundant,and excretion frequent; the nervous sensibility being acute, and the membranes remarkable for their vascularity ; all which phenomena depend, not- merely on the abundance of blood present, but on the preponderance of the arterial over the venous vessels. Before proceeding to a particular review of the several organs, and the properties by which they are characterized in childhood, it may be well to take a glance at the general appearance of the newly born infant. The length of the body varies from about one foot and a half to less than two feet. Baudelocque states sixteen inches, and twenty- two, (or at most twenty-three) inches, as the extreme limits. The average weight is from about six to seven pounds and a half ; more has been assigned, but is not common : six pounds is by far the most common weight, according to Camus's Tables. The skin is thin, tender, and of a reddish hue: but covered at birth with a whitish unctuous matter, called vernix caseosa. There is some hair upon the scalp, and the nails reach to the ends of the fingers : the articulations are commonly flexed, the limbs round, and the body plump. The relative dimensions of various parts differ materially from those observed in after life. The lower extremities are less deve- loped than the upper ; the median point, — that lying midway between the two extremes of the body, — -being found at the umbili- cus, or a line or two below it. DIGESTIVE ORGANS. 11 The pelvis in the infant is small and contracted, being less deve- loped in proportion than the thorax, which is flattened at the sides, but prominent in front ; while the abdomen and head present dimen- sions, not only very large in comparison with the other cavities, but also as compared with their own dimensions in after life. The newly born infant possesses little power of motion ; none of independent support. Sensation and perception are dull or absent. Its cries and movements may be looked on as involuntary — its search for food as instinctive. One third of its time is chiefly occupied in taking nourishment, the remainder is passed in sleep. Peculiarities not less striking or important, arrest our attention, on turning to the consideration of the internal organs ; and these we shall briefly notice in succession, commencing with those of or- ganic life, as being first called into action ; and of these the digestive organs naturally claim precedence, and will be found in a high state of development. II. DIGESTIVE ORGANS. The mouth of the infant is fully formed, and in some respects particularly adapted to the performance of its proper office of suc- tion, as we see in the disposition of the palate and lips and the obli- quity of the posterior nares ;■ yet appearing to be imperfect from the want of teeth, which, however, can hardly be said to be want- ing— only absent ; as they already exist within the gum, in due time to make their appearance and mark a new era, when the child becomes fitted for a different aliment, from that hitherto provided by nature for its sustenance. The mucous membrane lining the fauces, pharynx, stomach, and the whole tract of the intestinal tube, is thick and villous ; being more sensitive and vascular than in after periods of life ; softer in texture, and more bedewed with mucus, which is abundant, but thin ; becoming viscid, however, and much increased in quantity, on the occurrence of any irritation. The sensibility of the mucous membrane is adapted to the mild and unirritating fluid provided by nature as the suitable nourishment for the infant : any other substance proves irritating in a greater or lesser degree, and is therefore to be avoided. The stomach and duodenum are fully formed, their mucous mem- brane being thick, villous, and of a rosy tint. The small intestines in the infant are a third longer in propor- tion to the length of the whole intestinal tract, than in the adult ; and the large intestines are longer in proportion to the small, but their calibre is relatively less. The val vulae conniventes are scarcely apparent ; the vermiform process is very long, and the coecum is largely developed. The salivary glands and the pancreas are very large, and seem particularly active. Digestion is rapid and incessant ; the child frequently requiring 12 MANAGEMENT AND DISEASES OF CHILDREN. food, which, if permitted, will be often taken to repletion ; so as to be ejected without effort from the overloaded stomach, which is not capable of containing more than a few ounces of fluid at a time. The chyle, which is rapidly eliminated, is quickly absorbed, the tract of the small intestines being long, as we have seen ; while the lacteal vessels and mesenteric glands are largely developed, and in a high state of activity. The gall bladder, though small at birth, soon enlarges ; and is found to contain bile, bitter in taste, and green in colour: but bile, in the infant, is less viscid and less charged with the principles pecu- liar to this fluid, than at a more advanced age, when concretions are liable to form. The liver undergoes a remarkable alteration in function and form after birth. The mode of circulation is changed ; the left lobe diminishes, the umbilical vein and canalis venosus are obliter- ated ; while the vena portae is developed, and the secretion of bile becomes the peculiar function. The parenchyma of the liver becomes darker as life advances ; and the size of the organ diminishes relatively in volume — but instances are recorded, where the proportions of the liver remained through life as in the foetus. The spleen presents little peculiarity that we are as yet able to notice; too little is known of its functions to enable us to appreciate any changes that may occur ; but we have observed, that it is sub- ject to disease at a very early period. The bowels, at birth, are found to contain a dark coloured, inodo- rous, insipid substance, which is called meconium* and appears to result from the accumulation of intestinal secretion, for which pas- sage had not before been provided. This is, however, soon expelled, and its place occupied by the residue of the food ; which, from the nature of the infant's aliment, we might conjecture, would be but little characterized by the properties of fecal matter. Accordingly, we find the contents of the bowels in infants, much less feculent than they afterwards become ; being thin, charged with mucus, and of a yellowish colour ; possessing little fetor, but abundant and fre- quently expelled, the infant passing a stool three or four times each day. In a similar manner we find the other excretions less odorous, more watery, and not so largely charged with their peculiar princi- ples, saline or otherwise, as in the adult ; but they are quickly ex- pelled, though not very abundantly secreted. The perspiration is less saline and odorous, but more watery, though not copious. The urine differs in like manner from that of the adult (in particular, the quantity of urea is much less); and it is retained a much shorter time, being, like the feces, quickly expelled. This does not depend merely on the constant supply of food, or less relative capacity of the containing viscus ; but is connected with the peculiar sensibility of the lining membranes and irritability of the muscular coats of these viscera; which, like the other involuntary ORGANS OF RESPIRATION. 13 muscles, are more irritable in the infant, than they are subsequently found to be. In their tissue, they are softer and of a paler hue, nor has command over their actions been yet acquired. This latter character in particular, attaches to the urinary bladder in the child, and occasionally continues to give annoyance for some time, by leading to frequent wetting of the dress or bed-clothes. The bladder, in the infant, is more elongated in shape, and situated higher up, than that of the adult ; but is less capacious in proportion, while the ureters are particularly large. But it is upon its differ- ence of anatomical structure, as regards the position of the urethra, more than perhaps other circumstances, that this difficulty of retain- ing the urine depends ; for the pouch or fundus of the bladder ('bas fond') does not exist in the foetus, the cervix or urethral opening being then most dependent ; and this state of parts still obtains to a certain degree in the young subject ; probably in some more than others. The kidneys undergo remarkable alteration; their lobular forma- tion disappearing, and the supra-renal capsules rapidly diminishing; but the relation which these changes bear to the functions of the organ, is not very obvious. III. ORGANS OF RESPIRATION. Having considered the digestive organs, or those which generate the materials for the biood, we shall now notice the respiratory organs, or those by which the blood is regenerated, and fitted again for the purposes of the circulation. In no organs do more important changes occur, at birth, than in the lungs; in nothing does the infant more remarkably differ from the foetus, than in being a respiratory animal. The lungs, which before birth had been condensed, of a brownish red hue, very vas- cular, and not as yet permeated by air, now suddenly augment in size, becoming, after respiration, of a rosy colour, soft and vesicular in structure, and crepitant to the touch. The respiratory process is carried on with rapidity and force, consonant with the general activity observable throughout the sys- tem ; and in particular, the constant demand for fresh supplies of blood. The inspirations are frequent, counting from 35 to 40 in the minute, or nearly double those of the healthy man ; while the sound emitted on the passage of the air, is so peculiar, from its force and clearness, as to obtain the distinguishing appellation of puerile respiration. This character, respiration in the adult occa- sionally assumes, when the healthy portion of a lung is obliged to take on a compensatory action, in consequence of obstruction in the diseased portion (as in Pneumonia), — when the respiration in the sound part is said to be puerile, as significant of its force. Notwithstanding this activity in the process of respiration, it would appear that less oxygen is consumed in the infant than the 3* 14 MANAGEMENT AND DISEASES OF CHILDREN. adult, and that the power of generating heat (a process closely re- lated to respiration,) is also less. The thymus gland, which occupied a large and conspicuous space within the upper and anterior part of the thorax in the foetus, gradu- ally diminishes after birth, and is hardly to be recognized in the adult. It is freely supplied with veins and arteries, and contains at first a whitish fluid somewhat like chyle, which shows the gland to have a secreting power; but no excretory ducts have been discovered. Its supply of blood-vessels and softness of texture, seem to allow of sudden augmentation of size; and this, in instances where the gland is larger than ordinary after birth, may cause, by the pressure exerted on subjacent and important parts, very distressing or dan- gerous symptoms. To such cause has been attributed a spasmodic affection to which some children are liable, and which often proves fatal; at least, the thymus gland has been found distended or en- larged in such instances. In common, it does not exceed a couple of inches in length, one and a half in breadth, and a quarter of an inch in thickness. IV. ORGANS OF CIRCULATION. The blood, having undergone the requisite changes in the lungs, is conveyed again to the heart, thence to be sent throughout the system. From the moment the act of respiration is performed, the circulation undergoes a total change; and the heart is altered ac- cordingly, becoming complete in its functions, but still retaining some remarkable peculiarities. Its volume is proportionably large; but the relative capacity of its cavities differs from what is after- wards observed, those of the left side, — or the ventricles, and, in connection, the arteries, — preponderating decidedly at first: the balance, however, is gradually altered, until we find, in the adult, the cavities of the right side of the heart nearly three times the size of those of the left. The thickness of the parietes of these cavities, however, changes inversely with their capacity; for, from being nearly equal, the parietes of the left ventricle become almost four times as thick as those of the right — a change which rapidly proceeds after the obli- teration of the ductus arteriosus, and the closure of the foramen ovale, when the left ventricle has the sole conduct of the circula- tion through the system. The parietes of the heart are softer and paler than in after life, when the relative bulk is less, but the texture firmer, and colour deeper; this organ being then called upon to propel its contents with greater force, as they have to traverse a longer space. In the infant, the large volume but feebler power of the heart fits it for the propulsion of a larger quantity of blood, but through a less dis- tance; while the peculiar irritability of this, as well as the other hollow muscles during infantile life, ensures more active contrac- tility, and so, more rapid action, suited to the constant demand for CEREBROSPINAL SYSTEM. ] 5 fresh supply. Accordingly, we often find the pulse in the infant, like the respiration, nearly double in frequency that of the adult, varying from 120 to 140 beats in a minute. That part of the nervous system more immediately connected with the class of organs which we have just been considering, should naturally be in a high state of development, to allow of the fulness of function which we have seen these organs to possess : and accord- ingly, we find the ganglions, or system of the sympathetic nerve, very perfectly formed at birth ; while the brain, and its nervous connections, on the contrary, are very imperfectly formed, though largely developed — more especially the brain itself. We now come to the consideration of the second class of organs, — those of animal life, or relation to external objects; and here we shall find remarkable changes manifested in the advance of organs from a state of essential imperfections, to one of completeness — this advance in organization, and successive development of func- tion, constituting the most interesting eras of infantile life, looked forward to with eagerness, and remembered with pleasure as the periods of dawning intelligence, and independent muscular exertion — when the infant first begins to take notice, to walk alone, and to speak. V. CEREBRO-SPINAL SYSTEM. The brain, though large in volume, is very imperfect in structure in the infant, being so soft as to be almost fluid, and of a reddish hue, but with the cortical portion less deeply coloured than in adult age, and the convolutions less deeply marked. The brain is altogether inadequate to perform, on first entrance into life, those exalted functions which afterwards render it so im- portant an organ, and so characteristic of the superiority of man ; and accordingly, we find the newly born child incapable of thought, and apparently devoid of perception. The precise changes which the brain undergoes, in its progress towards perfection of structure, are not accurately determined; but those appear to be as important which regard alterations in the quality, as in the quantity of the cerebral substance. The increase in size is not perhaps so remarkable as that in the density of the organ; which, according to Wenzel, does not attain its greatest weight until the seventh year, — the size and weight of the brain at that time being said to differ little from what they are at mature age, when the power of function is so far superior. Whatever may be the case as to the density, however, it will be found that alteration does occur in the size, and even form of the brain, long after this age; and that to an extent and with a fre- quency, now little known, and the importance of which is as yet but little noticed. In advanced life it has been ascertained, according to Desmoulin and Cruvelhier, that the brain diminishes in specific gravity, as most probably it does also in general or in relative size. It grows 16 MANAGEMENT AND DISEASES OF CHILDREN. rigid in its quality, becomes again unequal to the due performance of its functions, as it had before been in infancy, though from an opposite cause, and second childishness is said to take place. The cerebellum is at birth somewhat more advanced in organiz- ation than the brain ; but it is about the period of puberty that the relation between the cerebrum and cerebellum undergoes the most remarkable change, the latter becoming considerably augmented in relative size, being then nearly twice as large, in proportion as it had been at birth. The spinal marrow is largely developed, like the brain in the infant, but appears to be more matured in structure, and farther ad- vanced in the performance of its functions. The general sensibility is acute, and the nervous susceptibility in the infant remarkable; so that all impressions are violently felt, and sympathetic affections are presented in a very aggravated form, and are very prone to occur, constituting a peculiar feature in the infant constitution, which may be emphatically said to be nervous. The large endowment of nervous matter, and its peculiar susceptibility of impression from the softness of its texture, appear to confer this quality, which is never to be lost sight of in the treatment of in- fantile disease — a remark as old as the time of Boerhaave, but which is nevertheless too frequently forgotten. As the infant grows older, the brain becomes capable of perceiv- ing impressions made through the senses. Signs of intelligence begin to be manifested: the infant takes notice, and becomes sensi- ble of the qualities of bodies, recognizing them and exhibiting symptoms of gratification or annoyance. The nerves of sensation, however, though freely developed, are as yet but imperfect in their functions, and inadequate to the conveyance of their appropriate impressions; while we find that the apparatus by which the exter- nal sources of these sensations are supplied, is more or less imper- fect, and destined to undergo much alteration. To notice particular senses, we shall commence with vision, which does not appear to exist in the newly-born babe, though the eye is fully developed : and it has been ascertained, that perfect images are formed on the retina. Vividly illuminated objects seem soon to attract notice; but the eye follows, or is fixed on them, at first, in an apparently passive manner, little dependent on the will. Light is at all times agreeable to the infant, which seems naturally to dislike darkness; but a very bright light is injurious, as well as annoying to the eye. The sense of hearing is as little exercised as that of sight, in the first instance. It is doubtful if the young infant can hear at all ; at least, for some time it does so but very imperfectly : and that this must be so, is manifest, from the deficiency of structure in the ex- ternal ear, which is as yet ill calculated to collect or receive vibra- tions of sound, the pinna being very inelastic, the tympanum small, and its membrane oblique, while a soft matter, little favourable to vibration, covers all. CEREBRO-SPINAL SYSTEM. 17 Taste early exists, and provision is made for its exercise in the full development of the mouth ; but probably perception of flavours is en- joyed to a less extent than we might at first suppose. The apparatus connected with the sense of smell, is much lc*s fully formed ; and although this sense be manifested early, there is little probability that delicacy of perception is early enjoyed by it. The absence of speech, or of the capability of uttering articulate sounds, is a deficiency characteristic of infancy, but not to be ac- counted for by mere anatomical examination of the organs of voice, though these certainly are but imperfectly developed. The larynx is small, and nearly circular; the lips of the glottis, and the superior ligaments, being, therefore, very short. This, combined with an immature muscular endowment, sufficiently accounts for the shrill, feeble tone, and wailing cry, peculiar to the infant : but the acqui- sition of the power of speech is connected with the advance of intel- lect, rather than alteration of mechanical structure, in this part of the apparatus of voice. The gradual alteration going on in the larynx, does not become very evident until the period of puberty, when the rima glottidis enlarges, the thyroid cartilage, and thyro-arytenoid muscle, become elongated, and achangeinthetoneof voice is consequently occasioned. In the male it assumes the deep and grave sound, which characterizes the full-toned voice of manhood : while in the female little change takes place in the larynx ; and the acute tones still remain charac- teristic of the female voice, which always more or less resembles that of childhood. The mechanism on which depends the power of articulating intel- ligible sounds, is more connected with the increased growth and power of the muscles of the mouth and pharynx, which, even before intellect begins to dawn, become, by a happy provision, early developed, being necessary both for sucking and deglutition. The infant begins to articulate at from half a year to a year old ; and usually speaks plainly, or so as to be understood by a stranger, at from two to three years of age. The general sense of tact, or perception of contact, makes us con- scious of the presence of external bodies ; and, to a certain extent, is exercised by the whole cutaneous surface, though not in like de- gree. In the young infant, however, the skin does not seem well disposed for the active exercise of this power, the papillae being less developed, and its structure more gelatinous than in after life. The sense of touch, strictly so called, — or that perception by contact, in virtue of which we not only recognise the presence, but certain of the qualities of bodies, exists only in some organs — almost solely in the hands — and is but little developed in the infant. Whether the skin be less sensitive or not, the muscularendowment necessary for the exercise of this sense is but very imperfect, — the use of the fingers for this purpose being as yet unknown, or the at- tempts to employ them sufficiently awkward. The assistance of muscles is necessary for the exercise of all the 18 MANAGEMENT AND DISEASES OF CHILDREN. special senses ; and the imperfection of the muscular apparatus, is a principal cause of the deficiencies of these senses in the infant. VI. LOCOMOTIVE APPARATUS. The organs of locomotion are those that enable us voluntarily to come into contact with external objects; and these organs are but little developed in the child, in either of their chief component parts, bone or muscle. The osseous system, in particular, is imperfectly and unequally developed, varying according to the purposes of its different parts. The bones necessary to contain and protect important organs, as the bones of the head or chest, are much more advanced in ossification than those destined merely for muscular support, or locomotion, — which are but imperfectly ossified, or exist as yet only in the form of cartilage.* The bones in general are characterized by their small- ness of size, redness of colour, and softness of texture, being very vascular, and the earthy part not only much less in proportion than in the adult bone, but even the animal portion being less firm, in consequence of the larger proportion of gelatine. The bones in the infant, then, are little calculated, from their for- mation or structure, for the support of the body in the erect posture, or the endurance of strong muscular exertion : nor are the muscles themselves better prepared for such efforts. We have already noticed the characters of the muscular tissues of organic life, or the involuntary muscles in the infant. Similar characters of structure belong to the voluntary muscles. They are pale in colour, and easily torn, being soft in .consistence* and slender in shape, the bellies of the muscles not being yet formed. They contain less fibrine than in after life, and have their fibres but loosely united, the fasciculi not being embraced by fasciae or apo- neuroses. Similarly imperfect are the tendons and ligaments, or muscular appendages. In the child, the irritability of the muscles, or tendency to contract, is more easily excited, but less easily sustained, than in after life. Hence, the motions of the child are quick or sudden, and frequent, but fail in capability of effecting powerful action, or sustaining con- tinued exertion. The first efforts of the infant at voluntary movements are thus necessarily imperfect. It begins to attempt walking at about twelve months of age, and has generally acquired the power of walking * "The most striking fact of this kind," to use the words of Dr. Symonds, in his able article 'Age,' Cyclopaedia of Anatomy and Physiology, "is presented in the spinal column. The annular portions of the vertebrae, which form the canal of the medulla spinalis, are found strongly ossified at birth ; but the bodies of these bones, which are to be used hereafter in supporting the weight of the head and trunk, are very slightly expanded, and all but devoid of earthy particles ; while the processes to which the muscles employed in the flexion, and extension of the column, afterwards contract attachments, are either only shaped in cartilage, or may be said to have no existence." GROWTH. 19 alone between the second and third year. But many are the mis- chances which such efforts entail ; foreseeing which, nature has pro- vidently furnished a shield of defence in the yielding and elastic cellular tissue, in which the body of the child is so liberally encased. VII. GROWTH. We have already designated infancy as the period of growth ; and this character, which continues during childhood, is sufficiently manifested by the progressive and rapid advance made in the body at large, and its several organs in detail. The progress of this advance is uniform ; so that the successive developments of differ- ent parts observe stated periods, and a well known order. In this progress we are most attracted by the advance made in the organs of animal life : but the changes which take place in the organic functions are not less remarkable, though less noticed ; con- sisting principally of a decrease in activity, if not power, and occur- ring out of sight, so as to be little obnoxious to observation. As the infant grows older, digestion ceases to be so active, and the digestive tube so sensitive. Food is less frequently required ; and the kind of food may be more varied, a more stimulating variety being borne and necessary. The secretions begin more to resemble those of adult life, and the evacuations require less frequently to be voided, being no longer passed independently of the will. The involuntary muscles generally acquire more tone, grow firmer in structure, and deeper in colour, losing their puerile irritability. Respiration becomes slower, and the pulsations of the heart less frequent, — the respiration gradually parting with the attributes of puerility, and the pulse diminishing in rapidity. The activity of secretion becomes abated, and the membranes are not so vascular or sensitive. Less mucus is secreted naturally, or poured out on the occurrence of irritation. The capillary vessels are no longer so abundant, nor do the arte- rial branches preponderate so much over the venous. As the child advances in age, the activity of the ganglionic system of nerves is less manifested, while that of the cerebro-spinal system comes more into play ; and the body, gradually losing the characters of infancy, begins to assume the attributes of adult age. In these various stages of advance, we are particularly struck by the progress made in the powers of sensation, perception, and vo- luntary motion, or in the organs of animal life. Sensation awakens,and thesenses successively and rapidly expand. Perception is manifested, and reflection in due time succeeds. Thus endowed, the child is competent to voluntary efforts ; and muscular power is proportionably developed, and brought into action. The several senses improve as they are exercised, and mutually aid each other by corroborating orcorrectingthe impressions received by each. Our perceptive faculties are thus brought first into action, and we 20 MANAGEMENT AND DISEASES OF CHILDREN. obtain a knowledge of the existenceand propertiesof external objects. Memory/' the store-houseof the understanding," becomes furnished, and the intellect is supplied with the materials of knowledge and business for thought. The progress of growth in the organs devoted to the exercise of the senses, the intellect and voluntary motion, is remarkable and characteristic, but unequal in advance, and tardy in completion. The perfecting of these organs finishes the process of growth : and is not fully completed until the period of maturity, or near to the meridian of life. Full development of the bones and muscles connected wilh the apparatus of the organs of sense, is necessary for the full exercise of the several senses, and is not finally completed until long after the period of childhood ; nor are the powers of sensation brought to perfection before then. The acuteness of the early impressions is probably great, whether in consequence of their novelty, or the sensibility of the nerves ; and such impressions seem tobe recollected as peculiarly pleasurable. But it is only by practised experience that the perfection of sensation can be attained, as is remarkably exemplified in the sense of touch. The advance in the organs of voluntary motion, — the knitting of the frame, and development of the muscular power, — constitute the most noted feature of growth ; and the completion of these organs, the most characteristic attribute of manhood. The form of the skeleton, and its several parts, alters much ; and the chemical constitution of the osseous system, also, undergoes change. The relative development of the pelvis and lower extremi- ties, comes to bear a better proportion to that of the thorax and the rest of the body. The form of the spine assumes more of the alter- nate curvatures of full growth. The shafts of the bones become firmer, and more closely united to their heads, and the processes shootout; while the quantity of calcareous matter gradually increases, until the completion of bony growth, when the frame-work of the muscular system is brought to perfection. The muscles are not stationary, as the bones advance. Their colour deepens, and the fibres become well defined and firm, being developed so as to form the belly or central fulness : more fibrine enters into their composition. The aponeurotic sheaths, and tendi- nous appendages, have become necessary, and are added. Muscular exertion now comes into busy operation, but continues to be characterized by activity rather than power. The child has a constant tendency to muscular movement, and loves exercise ; but the power is soon expended, and rest is required, — well-concerted, or long-sustained, muscular exertion being beyond its capability. This is an important moral as well as physical check, the corporeal power being limited, and full strength not acquired, until the con- trolling influence of a matured intellect has been provided. This brings us to consider the progress of growth in the cerebro- spinal portion of the nervous system ; particularly the brain, the GROWTH. 21 organ of thought and feeling, and that in which remarkable changes take place. As the body elongates, the spinal marrow of course becomes enlarged, until it bears to the brain a greater proportion in size than it did at birth ; but having been more forward in structure from the first, its advance in this respect is less remarkable. The brain grows, and the head enlarges remarkably, within the first year after birth — particularly, during the first few months. The imperfect state of ossification in the bones of the skull at this period, admits readily of the rapid enlargement of the cranium and its contents ; this being one of the uses of the fontanelles, in addition to the facility which they can afford in delivery, by allowing the bones to overlap each other, and so diminishing the bulk of the head. Six of these deficiencies in ossification are found at birth, the spaces being covered by membrane : nor have the sutures yet begun to form. The principal of these openings is called the bregma, and is situated at the top of the head, between the frontal and parietal bones ; another is found behind, between the occipital and parietal bones ; and of the remaining two, (each of which is double, thus constituting six in all,) one is found in the temporal fossa, at each side, the other above each mastoid process. The presence of these fontanelles (particularly that on the top of the head,) is a source of uneasiness to the ignorant, imparting to the hand an uncomfortable sensation, as if the brain were devoid of pro- tection ; and improper, and often injurious attempts are accordingly made to remove them, by compressing the head, for the purpose of bringing the bones together. But so far from being a cause for alarm, these openings are a source of advantage. The effects of blows or falls on the head (to which the infant is so liable,) are thus mitigated, the shockbeing intercepted before it has affected the brain ; while, in cases of disease, the danger from effusion is lessened by the possibility of quick expansion thus permitted, and which dimin- ishes the effects of compression. The full or sunk state of thebregma is an important point in diagnosis. These openings gradually close by a natural process, and will be found completely united by the fifth year, when the sutures are well marked and formed. Occasionally, the fontanelles are later in closing, the process of ossification being slow or imperfect; and this is a just cause for uneasiness, having its source usually in a general delicacy of constitution, often connected with a strumous taint. The brain not only increases much in size in the child, but also alters sensibly in structure, advancing towards more complete organ- ization ; and this remarkably, at the time when signs of intelligence begin to be displayed. From about the period when the first teeth appear, this advance in structure is striking, that in size having been before more remarkable. The brain now becomes firmer, more consistent, and less vascular ; the difference between the medullary and cortical portions is more March, 1838.— F 4 22 MANAGEMENT AND DISEASES OF CHILDREN. pronounced ; the former is less red, the latter deeper coloured ; the convolutions are better marked, and so the peripheral surface more extended. The advance in quantity and quality continues manifest to the age of seven years, or about the period of second dentition, which appears to be on many accounts remarkable. The brain has now assumed considerable volume, and its structure apparently resembles that of adult life ; but after this period, advance in structure, and increase of size, may still be observed, though not so remarkably.* The character begins now to be defined, and some indications of the mental endowments of the future man are afforded ; the features form, and the physiognomy begins to exhibit traces of a marked dis- position. But in regarding the countenance, we must take into ac- count the development of the bones and muscles connected with the head and face, which occurs about this age : yet, the general enlarge- ment of the head is not so much connected with the expansion of the skull and its integuments, as some insist. When the circumference of the head, taken above the orbits, does not exceed thirteen inches in the adult, idiocy always attends, accord- ing to Gall : and Dr. Voisin found, on careful examination, that idiocy was complete, when this measurement varied from eleven to thirteen inches: while that from the root of the nose over the head, to the occipital spine, measured only between eight and nine inches. In the full-sized head, the former measurement averages two and twenty inches ; the latter fourteen. A very small head is usually accompanied by feebleness of cha- racter ; but the head may be large,and the person dull, or even idiotic, — the deficiency existing in the structure, not size of the brain. The advance of growth in the brain does not seem to proceed equally, either as to size or structure, in all parts. Vimont notices, that the increase of size, during the first months, is most remarkable in the parts situated at the base of the skull, and occupying the ante- rior and inferior regions of the frontal bone: while, of the cerebral convolutions, those soonest acquiring firmness of structure are placed in the lateral and middle parts of the base. All know that the cere- bellum does not acquire its full development, until about the period of puberty. The head varies with the progress of growth not only in size, but shape, — the different regions of the brain being found to bear a differ- ent relative proportion at different ages — particularly during youth ; while at all periods there exists a certain degree of individual pecu- liarity. Not less remarkably do we observe a certain order or relation in the successive development of the several moral and intellectual powers : which is, doubtless, dependant upon this relative advance * The concretions of the pineal glands have begun to form about this period ; and they are redder in colour, but fewer in number, than in afterlife : but in some instances they never form. GROWTH. 23 in size or structure in different parts of the brain, though not yet directly connected therewith — observations for determining this point having been but partially made, and the importance of the subject not yet duly appreciated. However this may be, it is certain, that the disposition and intel- lect are gradually unfolded : and that attempts to force the one or the other before its appointed time and proper progression, are sure to be attended with injurious, if not dangerous consequences. The rea- son is obvious and physiological ; because, what is called the culti- vation of the mind, is in truth but the exercise of the brain ; and this, like every other organ, if overtasked, will be worn out or des- troyed. In noticing the development of the intellectual powers, we see that the child observes before he reasons — that the perceptive faculties come into play before the reflective. The child early observes and recollects things, and the qualities and relations of things ; and is in- quisitive about events. He constantly asks what this or that is. But the senses advance still more rapidly than the perceptive fa- culties, and are thus prepared to furnish these faculties with know- ledge of the various properties of matter. The differences to be observed, however, in the power of appreciating these qualities of bodies depend on differences in the constitution of the perceptive faculties — not of the senses. The eye may see well, and clearly perceive differences in size or form, and yet not be able to distinguish differences in colours: the ear that hears best, is not that which best appreciates those vari- ations in sound that constitute melody. The various degrees of talent exhibited by some children more than others, depend much on the different degrees with which they are endowed with those faculties that take cognizance of the physical properties of things. In these qualities and relations of bodies we have the foundation of the physical and natural sciences; and for these sciences, (espe- cially the latter,) mental capacity exists at a much earlier age than seems commonly supposed. The gift of language as a mental power, is that which earliest attracts attention, and is first cultivated. Hence, facility in this respect, with a quick observation, are taken as indications of great intellectual capacity. But the reflective faculties must be in full operation, to constitute a really good understanding; and these are always the latest to be developed, and often not very liberally bestowed. It is, indeed, upon a due balance between the reasoning and per- ceptive faculties, that the superiority of the intellect will depend. Where the latter preponderate, they early show themselves, and give a quickness of apprehension, which, in a child, is often taken for superior talent. But the smartest boy does not necessarily make the cleverest man ; there must be a full endowment of the reflective faculties, to give depth of thought, or soundness of under- standing. 24 MANAGEMENT AND DISEASES OF CHILDREN. When these faculties early preponderate, however, the child will be slow in apprehension, and may be esteemed dull ; but when the period for their exercise arrives, powers will be exhibited which had not been anticipated. Peculiarities of disposition, moreover, will affect these results as much as differences in talent, though sel- dom, if at all, taken into the account. The child often exhibits (from the earliest age,) a marked disposition, as it occasionally does some peculiar talent. Almost from the moment of birth some in- fants are observed to be peevish, passionate, or obstinate; while others are gentle and affectionate, or timid. A determined infant may be seen to rule a weak parent, and even exercise an influence over a whole family. A very gentle child may never acquire sufficient force of character to make his way in the world, no matter how intellectual he may be. The higher sentiments, generally speaking, are the more slowly developed ; and superior moral powers, as the sense of justice and religion, are among the latest to come into operation, requiring some assistance from the understanding for their direction and support. No doubt can exist that the child is endowed with certain powers, moral and intellectual, varying in different individuals, and consti- tuting natural differences of character; but this militates not against the necessity for education or training, and the vast influence exer- cised thereby ; on the contrary, it serves as a guide and a limitation, — pointing out what requires to be cultivated, and what to be re- pressed ; and shows us what is possible to be done. How important, then, to acquire a knowledge of the primitive faculties of man, and the laws by which they are regulated in their natural development, or influenced by artificial training. Nor is the necessity for such knowledge confined to the system more im- mediately connected with mental manifestation. The same holds good respecting all the other systems in the body ; for without due attention to each, we shall not be able to do justice to any, or secure for the whole its best advantages during the period of development or growth. With regard to the general growth of the body, and the advance in height, weight, and strength, differences arise from age and sex; and these have been accurately investigated by M. Quetelet.* According to him, the average weight of the male infant at birth is about half a pound more than that of the female, and the length about an inch more; and the annual growth of the female infant is less than that of the male, but her development is more early com- pleted. The growth of the stature is most rapid during the first year, when it amounts to nearly eight inches: it is less rapid as the child approaches the fourth or fifth year, but afterwards increases with a tolerably regular progression. A remarkable difference is often to be observed in the degree of * See Eclectic Journal of Medicine, February, 1838. — Ed. GROWTH. 25 development, or proportional growth of one organ or system of organs more than another. In some children the head is very large, and great liveliness and intelligence are early displayed, the cerebro-spinal system of nerves being that which preponderates; and this lays the foundation for a particular temperament, which, according to the rational view of M. Thomas, would, in this instance, be the nervous temperament. In other children, great muscular power is early displayed, the chest is large, the body well nourished, and the complexion florid. This constitutes the thoracic, or, as it is more commonly called, the sanguineous temperament — the circulatory system predominating. The child is strong and active, but not particularly intelligent. When the abdomen is very large, and the circulation languid, — the child being pale, indolent, and dull, with a large appetite, but little activity of mind or body, — the abdominal organs preponderate, and the temperament is abdominal or lymphatic. Other varieties of temperament exist, and in some individuals no temperament is strongly marked, or more than one are mixed together. But attention to the subject is important, as modifying our plan of management both in health and disease. These varieties of constitution may be born with the child, and looked on as hereditary: but they will be much influenced by the manner in which the individual is managed; according as one sys- tem of organs, or another, is exercised or neglected. The great principle that should guide us, is to afford to all and each its proper or appropriate share of exercise or occupation, so as to strengthen the weak or ill-developed organs ; while we repress those that arc disproportionately developed, or over active, by con- signing them to quiescence. To be enabled to do this, however, we must study the subject as physiologists. Thus have we, in a brief and summary manner, sketched those peculiarities of infancy, a knowledge of which must, serve as our guide in understanding aright the management of children in health or disease. This object we have kept exclusively in view, and re- sisted the temptation of pursuing any of these subjects, however interesting, further than the object proposed would warrant. We have seen the infant presented to us, in the first instance,. as a mere vegetative being, with the organs of nutritive life prepon- derating in development and activity. As growth proceeds, however, the little being asserts its claim to a higher order of existence. The organs of organic life dimininish relatively in importance, while those of animal life advance, and ultimately preponderate — the infant becomes a rational being. To promote this preponderance, and ensure the mens sana in corpore sano, is the great end proposed in the rearing and manage- ment of children. The principles by which we are to be guided in our attempts to attain this object, have been already pointed out ; and the manner in which these principles are to be carried into effect, will constitute a chief part of the ensuing chapter. 4* 26 MANAGEMENT AND DISEASES OF CHILDREN. CHAPTER II. MANAGEMENT AND PHYSICAL EDUCATION OF CHILDREN. In the consideration of the subject of this chapter, we shall adopt the division, already made into the two epochs of infancy and child- hood ; and shall, therefore, at once proceed to consider the manage- ment of the infant directly after its birth. I. MANAGEMENT IMMEDIATELY AFTER BIRTH. Let us suppose, then, a child to be placed in our hands immediately after birth; any mucus obstructing its breathing has been removed from its mouth, the cord has been tied and divided three or four inches from its navel, it is crying stoutly, and moving its limbs in such a manner as forcibly to convey to us the impression that it is suffering pain. That such is really the case, we can readily admit, when we recollect the sudden transition of temperature which it has experienced, from about 98°, the heat of the mother's body, to that of the atmosphere, which, at the highest, will seldom exceed 70°. The production of pain, however, is but a necessary consequence of the access of air to the surface of the body ; the vivifying influence of which, as we learn from the ingenious researches of Dr. Edwards,* is calculated powerfully to counteract the greater or lesser degree of insensibility induced during birth. The pain, also, by exciting the infant to cry, contributes materially to the perfect expansion of the lungs by air ; the non-effecting of which, as we shall subsequently find, is notunfrequently attended by fatal results. The good effects, however, of exposure to cold are but momentary. "Instinct," says Dr. Edwards, "leads mothers to keep their in- fants warm, though philosophers, by more or less specious reasoning, have at different times, and in different countries, induced them to abandon this guide, by persuading them that external cold would for- tify the constitutions of their children, as it does those of adults." To this distinguished physiologist we are indebted for the observa- tions, that the heat of mature infants at birth is from 3° to 5° less than , that of adults — varying between 93° and 95°; that the heat of prema- ture infants is still less ; and that the power of producing heat being in all young animals at. its minimum at birth, they have not the same capability of resisting a diminution of their temperature, from expo- sure to cold, as adults. From Dr. E.'s discoveries, indeed, we are fully warranted in concluding that the philosophers of whom he speaks are in the wrong; and that nature, as she usually does, has conferred a proper instinct upon mothers, in teaching them to keep * Dr. Edwards on the Influence of Physical Agents on Life. Translated by Doctors Hodokin and Fisher. MANAGEMENT IMMEDIATELY AFTER BIRTH. 27 their offspring warm. It is for us, therefore, immediately upon taking charge of the newly-born child, to have it warmly wrapped up in flannel, and to take care that, in cold weather, it shall be dressed in the neighbourhood of a comfortable fire, and lhat, during the operation, it shall not be unnecessarily exposed to cold.* When we examine more carefully the body of the infant, we shall find that it is more or less covered with a white, greasy, or curd-like substance. This is the vernix caseosa, and appears to be provided for the pur- pose of defending the tender skin from the injurious effects of the warm, watery fluid in which it floats while in its mother's womb. After birth, however, this coating has no useful purpose to serve, and would be injurious by intercepting the vivifying influence of the air of which we have already spoken. t It is, therefore, advis- able to remove it ; and, accordingly, the first act of the nurse is, to wash the new-born child. The washing should be performed with warm water, and a fine sponge. Particular care should be taken to remove all extraneous matters from the eyes, and from the folds of the skin, in the arm-pits, &c. ; but no force likely to hurt the sur- face should be employed : and we have not found soap to be re- quired, although it is recommended by many writers. In this country, where whiskey is of universal use, the nurses generally employ a little of it for washing the child's head, under the idea that it prevents the taking of cold. This practice is certainly not a necessary one in ordinary cases ; but at the same time, it does not appear to be attended with any injurious consequences : and when we can say so much for any popular custom, it is as well to let people have their way, and direct our own attention the more closely to the prevention of what may be really prejudicial. The washing being accomplished with as little delay as possible, and the surface having been carefully dried with a soft napkin, the next business of the nurse is, to dress her charge. This process is commenced by an arrangement for the protection of the remnant of the navel string. The surface of this should be carefully exa- mined, lest, as frequently happens, secondary bleeding should take place, in consequence of the loosening of the ligature — dependent on the oozing out of the gelatinous fluid, which makes up the bulk of the cord. If such an occurrence has taken place, a fresh ligature must be applied firmly, and its ends cut off close to the knot. The * The views of Dr. Edwards have been practically confirmed by some observa- tions of Dr. Milne Edwards, and Dr. Villerme. It is the custom in France, to convey infants, within a few hours of their birth, to the office of the mayor of the commune, in order that their birth may be registered; and Drs. E. and V. discovered, that the proportion of deaths, within a very limited period after birth, compared with the total births, was much greater in winter than in summer — in the northern and colder, than in the southern and warmer departments, and in parishes where the inhabitants were scattered over a large surface of ground, than in others, where they were more closely congregated round the mayor. f If any authority were wanting for the removal of the vernix caseosa, we have it in the practice, which obtains universally among animals, of licking their off- spring immediately after birth. 28 MANAGEMENT AND DISEASES OF CHILDREN, cord is then to be drawn through a circular hole, cut in a piece of old linen, about four or five inches in diameter, which is to be gently folded round it. In the preparation of this envelope, the nurses are particularly anxious to have it extremely dry and warm. It is always held carefully to the fire, and sometimes even scorched, before they will permit its application — a prejudice which is cer- tainly harmless, and probably but one indication of the general instinct which teaches them that a new-born infant requires its heat to be carefully husbanded.* The cord, thus enveloped, is to be placed flat upon the child's abdomen, and secured there by a band of thin flannel, five or six inches broad, and long enough to go twice round the body. The chief use of this band appears to be, to sup- port the navel string and its covering; and we cannot think that it is required, as Dr. Deweest supposes, as a support to the abdomen: it never should be applied so as to make any pressure upon that cavity ; and on that account, it is well to have it made of the thin- nest flannel, cut diagonally or bias, so as that it may be perfectly elastic. In fastening it, pins are usually employed ; but the fewer of these used in dressing an infant, the better: and it would be well, if we could have strings substituted for them in every possible case. The further dressing of the body of the child, is very much a mat- ter of fashion, with which the physician has little to do further than to see that its clothing is sufficiently warm, and not calculated to place any restrictions upon the movements of the limbs. The ar- rangement of the headdress must be conducted upon similar princi- ples as that of the other clothing : the head is to be protected from the cold air by a moderately thick muslin cap, but so as that it shall suffer no compression, and not be placed in a constrained position. Over all, a thin flannel shawl is to be wrapped in such a way as neither to impede free access of air to the mouth, nor to hamper the extremities, so as to prevent their spontaneous movements. The infant is then to be placed in a cradle or bed, so situated, as that it shall not be exposed to draughts of cold air ; and that, without being in the dark, its eyes may be protected from a strong light, which, as yet, they are unable to endure : thus placed, it will usually fall asleep, and remain so for several hours, until awakened by the calls of hunger. II. FOOD AND MEDICINE IMMEDIATELY AFTER BIRTH. During fcetal existence, the various organs designed for the per- formance of digestion, produce a greater or lesser quantity of their ♦As a curious instance of this dread of abstracting heat from the child, we often find the peasants of this country carefully warming- the scissors, before using it for the division of the cord. It is easy, and no doubt appears scientific, to ridicule popular customs and superstitions ; but would it not be more discreet and philosophical, to endeavour to discover their origin from some instinct to which they may generally be traced 1 f On Physical and Medical Treatment of Children. London. 18*26. FOOD AND MEDICINE IMMEDIATELY AFTER BIRTH. 09 peculiar secretions; and, as there is no exit provided for these, they accumulate in the intestines of the child, constituting the dark green or brownish, pitch-like substance denominated meconium. By many persons, even at the present day, this meconium is supposed to exert a most baneful influence upon the health of the child ; and it is believed that no time should be lost in effecting its speedy removal. Accordingly, very few children, in this country, are fortunate enough to escape being dosed with castor oil, immediately upon their arrival in the world ; and many are obliged to undergo the additional peril of having a quantity of calomel forced down their throats. Neither of these practices, however, is constantly necessary, and the last is positively injurious : the delicate mucous membrane of the child's intestines, only fitted for the reception of the mildest nutriment, is always injured by the operation of a medi- cine so active and so irritating as calomel. To the milder action of castor oil, the same objection does not apply ; and where the abdomen of the child is full, and no evacuation takes place for three or four hours after birth, it will usually be found advantageous to administer half a drachm of oil, provided we can procure it fresh and free from rancidity. We are, however, decidedly of opinion, that it is better and more natural to allow an infant to sleep quietly for three or four hours after birth ; and not before that period to disturb it, or irritate its stomach, by the administration of anything whatsoever. Those who advise the immediate employment of pur- gatives, assert that such practice is consistent with the plans of nature,* inasmuch as they suppose the milk first secreted by the mother (or colostrum, as it is termed,) to possess a purgative pro- perty. The argument is obviously a contradictory one ; for, if nature herself provides a purgative, why should we seek to super- sede her efforts by artificial means? The fact, however, of the first milk being purgative, is not proved, and is altogether denied by some.t It is probable that it possesses no distinct purgative quality, but excites the intestines merely by mechanical distention, and so in effect produces expulsion of the meconium, as other food is found to do in cases in which the secretion of milk is not established, for two or three days after labour. So much for medicine immediately after birth ; and upon the same principle, viz. that sleep is what the infant most requires, we do not think it necessary to give any food for some hours. Should the mother be able to supply the natural nutriment at the end of eight or ten hours, as is often the case, we think the infant should be then applied to the breast ; and that it is highly desirable to avoid giving, in the interim, any other food whatsoever. Should the secretion of milk not be perfectly esta- blished for two or three days, as sometimes happens, the child will be cross, and evince signs of hunger, and we shall generally find it necessary to give a small quantity of thin gruel with a little milk. * Dewees. I Jorg. Handbuch zum Erkennen u. Heilen der Kinderkrankheiten. 30 MANAGEMENT AND DISEASES OF CHILDREN. Even in these cases Professor Jorg recommends, that nothing should be given but a few tea-spoonfulls of lukewarm water ; and we happen to know that such is his practice, without any bad results, in the Lying-in-Hospital of Leipzig. Notwithstanding this, should it not be practicable to have the child suckled within ten or twelve hours after birth, we think it advisable to give, every five or six hours, a few tea-spoonfulls of such food as has been mentioned above, but to stop this immediately upon a nurse being procured, or the mother becoming herself capable of supplying sufficient nourishment. The infant being now established as a denizen of the nurser}7, we shall proceed to consider its further management with regard to food, cleanliness, clothing, sleep, exercise, medicine, and the action upon it of physical agents, as light, air, and temperature. III. FOOD IN THE FIRST PERIOD. It is unnecessary to go at any length into the question of the pro- priety of mothers nursing their own children. The weight of the moral and physical considerations which leave no choice as to the propriety of obeying the dictates of nature, is now universally acknowledged. Women are not, at least at the present time, the unnatural deserters of their offspring that systematic writers would lead us to suppose ; and we think most experienced physicians will join us in declaring that our duty is less frequently to urge maternal nursing, than to explain* and even enforce, in individual instances, the exceptions whereby nature herself does sometimes render it impossible or inexpedient to comply with her general law. We are, in fact, oftener obliged to save an infant from destruction, and a delicate mother from injury, by forbidding ineffectual attempts at nursing on the part of the latter, than we are called upon to remind a stout and healthy parent of the urgency of the claims upon her. We shall therefore assume, as a general rule, that all mothers should nurse their own children, and merely indicate those cases in which it becomes necessary to substitute another mode of rearing the child. Women who labour under any mortal or- weakening disease, — as phthisis, haemorrhages) epilepsy, &c, — are obviously disqualified for the office of nurses ; some who are in other respects healthy have breasts incapable of secreting a sufficient supply of milk, and this may be temporarily the case with one child (especially the first), while upon other occasions the same individuals make excellent nurses ; in other cases, the breast may perform its functions well, but the nipple may be naturally so small, or may be so completely obliterated by the pressure of tight stays, as not to admit of its being laid hold of by the child. These are actual, physical hindrances to nursing. Women may, and the higher classes frequently do pos- sess such extremely sensitive and excitable temperaments as will render it imprudent for them to suckle their own children. Fright- ened and excited by every accidental change in the infant's counte- nance, and inordinately moved by the common agitations of life,auch FOOD IN THE FIRST PERIOD. 31 persons are kept by their own tenderness, and over-anxious desire to do their duty well, in a state of continual fever, which materially interferes with the formation of milk, both as to quantity and quality. Women, also, who become mothers for the first time at a late period of life, have seldom the flexibility of disposition, or the physical aptitude for secretion of milk, required to constitute a good nurse. Another disqualification for nursing we must notice, although we hope and believe that it is rarely observable among our country- women : if women of fashion are not contented to give up their engagements in society in favour of their domestic duties, it is better for them not to undertake the latter — " In this matter/' says Wcndt, " it is better to do nothing, than only half." We have already stated, that the child should be put to the breast as soon as the latter contains any thing for it to extract ; this generally happens when the mother's system has been relieved, by sleep and ten or twelve hours' rest, from the fever, which is always more or less attendant upon labour. Unless there has been some se- cretion of milk, it is better not to apply the child, as it becomes disap- pointed by continued ineffectual attempts at obtaining nourishment, and there may subsequently be some difficulty in getting it to en- gage seriously in the business of sucking. As soon, however, as it has fairly commenced, it will require no other food ; and if the mother be a good nurse, she should be able to support her infant inde- pendently of any other nutriment, during at least two-thirds of the period of infancy, — that is to say, until the sixth or seventh month. About that time the teeth usually begin to appear, and to indicate that the digestive system is assuming a capability of doing more work than it was adequate to at first ; and, accordingly, we should then take the hint from nature, and begin gradually to train and exercise its powers. The suckling of the infant, which during the first months should be performed at regular intervals of about four hours, should now be repeated not more than three or four times during the day and night ; and twice during the same period some artificial food should be given. This at first may consist of soft bread, steeped in hot water, with the addition of a little sugar and fresh cow's milk ; subsequently some light broth, free from fat and vegetable matters, may be given once during the day. With re- spect to the mode of feeding at this period, the spoon will be the best vehicle, as it is an object to give food somewhat more solid than could be drawn through the sucking bottle. The child, how- ever, should not be placed horizontally on its back, and gorged until it is filled to the throat, as is often done; but its head should be kept elevated, and its actions be carefully attended to, so that we may know, and at once stop, the moment it appears to be satisfied. During the first five or six months, the infant must be suckled during the night as well as day, but this should be done at regular intervals of four hours; and if it sleeps with the mother or nurse, the nipple should not be allowed to remain in its mouth, as it is not our object to keep the stomach constantly full, but to give it time, 32 MANAGEMENT AND DISEASES OF CHILDREN. when filled, to digest its contents. A child nursed as we have re- commended, will be found to awaken, with a good deal of regularity, at the proper periods for its meals. During the process of weaning, the intervals between the times of suckling at night, may be first gradually lengthened; and it is desirable, not to accustom the child to receive any artificial nourishment during the hours proper for sleep. We have been hitherto supposing the mother to be a perfect nurse, and the relative supply and demand to be well adjusted be- tween her and her infant; but these are not exactly the cases which we always meet in practice. We shall frequently have a demand greater than the supply, long before the sixth or seventh month ; and in such instances, we shall be obliged to give food at an earlier period, and will often find it to agree well, if its kind and administration be regulated upon the rules just laid down. The great maxim to be observed is, not to let the infant want nourish- ment which will agree with it. If this can be furnished by the mother alone, so much the better, if the deficiency can be supplied by artificial food, without the infant suffering, there will be no ne- cessity for making any further change: but if neither of these con- ditions obtain, we must have recourse to a strange nurse. As we have stated it to be desirable, that as much as possible of the infant's nourishment should be derived from the nurse, it of course becomes an object to render our source of supply as available as may be ; and we are, therefore, legitimately called upon to con- sider how this may be done most efficiently. The grand secret is, in a word, to keep the nurse in good health; if we succeed in this, we render the milk, both as to quantity and quality, as good as it can beproduced by the individual. Now, how is this to be done? Is it by overloading the stomach with a mass of indigestible food and drinks, and keeping the system under a continued fever of diges- tion ? or is it not rather by allowing the person to live, as much as possible, in the manner customary with her, supposing that to be one which has hitherto preserved her in good health, — permitting her to eat her usual meals, which she will probably do with in- creased appetite, and not inculcating upon her the necessity of taking drinks more stimulating or in larger quantities (relatively with her probably increased consumption of food,) than she has been in the habit of using ? With hired nurses, it is especially necessary to act upon the principle just laid down ; for these persons coming from the scanty table of their own homes, are apt to indulge their appetites from mere novelty, if, as is usually the case, their employ- ers show any disposition towards a stall-feeding system. Nurses should not be kept upon any one description of food exclusively, but should have, as is natural, a wholesome, mixed, animal and vegetable diet, with or without wine, according as they have been accustomed to live ; but we may, perhaps allow them, with advan- tage, somewhat of an extra, though never an unreasonable quantity CHOICE OF A NURSE. 33 of malt drink, providing always that it will agree with their digest- ive system. Irritability of temper, and indulgence in passion, interfere with the secretion of milk to such an extent, that a child has been known to be attacked with convulsions immediately after being suckled by a nurse, while suffering under the effects of a fit of anger. A know- ledge of this circumstance influences many persons to indulge nurses in the most extravagant whims, lest their temper should be crossed, and the child thereby injured. Irritable persons are unquestionably unfitted to nurse or manage children ; but we apprehend, that over- indulgence is not the way to improve temper: and as we fear that the most learned diatribe from us, would have little efficacy in sup- plying a good disposition where Providence has not created it, we shall not pursue this subject farther. IV. CHOICE OF A NURSE. When circumstances prevent a parent from sucklingherown child, it is important that we should have some principle to guide us in our selection of a strange nurse. Medical men are constantly asked for an opinion upon this subject, and we shall therefore offer a few rules, which may be useful in enabling us to form one. The great thing we have to look to is, to ascertain that both woman and child are in good health ; and of this, we must endeavour to judge from the following signs : — The woman's general appearance and form should be observed ; and they ought to be such as betoken a sound constitution. Her skin should be free from eruptions ; her tongue clean, and indicating a healthy digestion ; her gums and teeth sound and perfect ; the breasts should be firm, and well formed, — not too large, or flabby, — and with perfect, well-developed nipples. We should see that the milk flows from them freely, upon slight pres- sure ; and we should allow a little of the latter to remain in a glass, in order that we may judge of its quality. It should be thin, and of a bluish-white colour; sweet to the taste ; and when allowed to stand, should throw up a considerable quantity of cream. A nurse should not be old ; but it is better that she should have had one or two children before, as she will then be likely to have more milk, and may also be supposed to have acquired experience in the man- agement of infants. Having examined the mother, we must next turn to the child, which should be well nourished, clean and free from eruption, especially on the head and buttocks. We should carefully examine its mouth, to ascertain that it is free from sores or aphthae. If both woman and child bear such an examination as we have mentioned, we may, with tolerable security, pronounce the former as likely to prove a good nurse.* * The following is the beau ideal of a good nurse, according to Wendt. Some of its Germanisms may amuse. "Youth, fulness of health, plenty of milk, and a good build of breasts and nipples — a rather phlegmatic temperament, a quiet disposition, and no inclination to sensuality or dissolute habits, a white delicate March, 1838.— G 5 34 MANAGEMENT AND DISEASES OF CHILDREN. V. ARTIFICIAL FEEDING. What we have already stated as to the management of an infant's food, negatives altogether the question of the propriety of ever choosing to rear a child entirely by artificial feeding. Certain cases occur, however, in which we have no alternative. Peculiar circum- stances may preclude the possibility of procuring a nurse ; or an infant, whose mother is incapable of nourishing it, may be the sub- ject of some contagious disease, to contamination from which, we cannot, in common honesty, permit a stranger to be exposed. The necessity of resorting occasionally to artificial feeding, obliges us, therefore, to consider how we can render it least injurious, for such is really the question ; although, we do not mean to deny, that in certain instances extremely healthy children have been reared in this way. These are, notwithstanding, but exceptions ; for a very ex- tended experience, in different countries, has proved that spoon-feed- ing is generally unsuccessful. — The kind of artificial food proper to be employed, forms the subject of our first inquiry ; and, as a general rule, we may say, that it should be as like the natural nutriment as possible. This rule, however, is easier laid down than acted upon ; "for nature," says Dr. Prout, "will not permit the chemist to officiate as her journeyman, even in the most trifling degree."* In the present state of our knowledge, then, it is vain to attempt any preparation, upon chemical principles, of a food resembling human milk. It will be better to be satisfied with employing the food of some other young animal, and modifying it, so as to make its sensible properties as nearly similar as we can to the milk in question. For this purpose, good cow's milk is usually the most convenient ; and as it is thicker and whiter, and not so sweet as human milk, we may add to two parts of it, one of very thin barley water, and sufficient white sugar to make the necessary increase in sweetness. Asses' milk approaches more nearly, in sensible pro- perties, to what we require ; but it is richer, and requires to be diluted with about a third part of water. So modified, it may be used, if the cow's milk disagrees, or if it can be conveniently pro- cured. As the child becomes a little older, thin bread pap, made as we have already directed,! may be advantageously employed ; and it will also be advisable to give, occasionally, some light beef or chicken tea. In managing spoon-feeding, all our ingenuity will fre- quently be required for varying the kinds of food ; as a description skin, traversed by blue veins, and covered with freckles, — fair or reddish hair, large blue eyes, sound teeth, a fresh breath, a clean skin, no disagreeable odour, no unnatural discharges, a bluish-white, — rather thin, than thick and tenacious milk, which, dropped upon the thumb nail, flows off rather quickly, — it should have no smell, and a mildy sweet taste, — along with these^ large and firm nip- ples, a cleanly person, and a harmless temper, — form the ideal of a good nurse." — Die Kxnderkrankheitcn systematisch dargestellt von Dr. Johann Wendt. Wien. 1827. 2te ausgabe. * Gulstonian Lecture, 1831. f p. 31. WEANING. 35 which agrees well with the infant at first, may, after a little, derange the bowels, producing acidity, gripes, and purging, or perhaps cos- tiveness. Thus, prepared barley dressed with water and unboiled milk, will sometimes purge, — an effect which may be obviated by having the milk boiled. In other cases, we must have recourse to the use of arrow-root, for a short time, for the purpose of restraining the bowels, and again recur to the barley when costiveness is pro- duced. A great matter is accomplished, if we can prevent the production of acid fermentation in the stomach and bowels; and, on this account, we must be most particular in requiring every article of food to be freshly prepared before use, and in enforcing the strict- est attention to cleanliness with respect to every vessel employed. Every kind of food should be tepid or lukewarm. Our second inquiry relates to the mode of administering artificial food. This may be accomplished either with the spoon or sucking bottle.* The former has the advantage of leaving less opportunity for uncleanliness, as a spoon is easily washed, and its condition at once perceptible ; while the bottle may appear clean, and yet con- tain a leaven of acidity, which will do material injury. On the other hand, the bottle has the advantage of giving out the food in a mode somewhat analogous to that employed by nature ; the child has some trouble in procuring what it wants, and will therefore not be likely to take too much ; the action of sucking is also practised, whereby a degree of pressure is made upon the child's salivary glands, and the necessary secretion from those organs, in all probability, usefully promoted. In the earlier periods, we think, the bottle possesses, on these points, decided advantages : but while using it, too much precaution cannot be taken against uncleanliness. No food should ever be allowed to remain in it after the infant has been fed ; and there should be always two in the nursery, in order that one may be exposed to the air, and dried, while the other is in use.t VI. WEANING. The time of weaning, we have already intimated, should be that indicated by nature, (that is to say, between the seventh and twelfth months in ordinary cases,) when by providing the child with teeth she furnishes it with the means of obtaining nourishment from sub- stances of a somewhat solid nature. The mode of weaning may be easily deduced from the rules which we have laid down for the feeding of the infant. If it has been gradually accustomed to a diminished supply of maternal, and an increase of artificial food, • These bottles have a narrow neck, about the size of the nipple, with a small orifice, covered with a teat of washed shammy leather, through which the infant sucks the food. They can be had at any druggist's, ready for use. | Dr. Zwierlein of Briickenau, has written a book to prove that goats are the best and cheapest wet nurses. We fear it would be difficult to introduce the practice in this country. — Die Ziege els heste u.wohlfe.ilste Saidgamme, 1816. 2r theiL 1819. 36 DISEASES AND MANAGEMENT OF CHILDREN. weaning will be an easy process, and a great deal of suffering will be spared both to parent and offspring. No violent change should be made ; and by proceeding gradually, the child will come to pre- fer artificial food contemporaneously with the failure of the mater- nal supply. This is what the term weaning imports, and this is the mode in which it should be accomplished. VII. FOOD IN THE SECOND PERIOD. For some time after weaning, the child's food should consist of those materials which we have mentioned as proper during the latter months of suckling. Regularity in the times of feeding, is pro- bably of nearly as much importance as the quality of the food itself. No definite rules, however, can be laid down in this respect, as muchrnust be dependent upon the habits of the child, and its guar- dianSj as to sleep, &c. ; but the general principle should, under all circumstances, be observed, of permitting no variation, from day to day, in the time for the different meals, and of not breaking in upon these by giving food at irregular periods : while, at the same time, too long fasting must not be allowed. During the day-time, about four hours is quite sufficient interval between any two meals : this will give time enough, in children, for the stomach, and com- mencement of the small intestines, to perform their offices in the process of digestion, and allow the former an opportunity of recov- ering energy after the discharge of its function.* It is better not to allow a child to acquire a habit of being fed during the night, as uninterrupted sleep is what they then require most ; to ensure which, it is necessary that the stomach should be in a state of comparative rest. Perhaps, the best mode in which we can illustrate our ideas with respect to the plan upon which a child should be fed, will be to describe specifically a day's feeding of a healthy child, — premis- ing that we do not mean to enforce a literal observance of certain hours, &c. specified, but merely to give an example of the working of the principles we have laid down. A healthy child, of two or three years old, commonly awakes, hungry and thirsty, at five or six o'clock in the morning ; sometimes even earlier. Immediately after awaking, a little bread and sweet milk should be given to it, or (when the child is too young to eat bread,) a little bread pap. The latter should be warm ; but in the former case the bread may be eaten from the hand, and the milk allowed to be drunk cold, as it is as well, at this meal, to furnish no inducement for eating, beyond that of hunger. After eating, the child will generally sleep again for an hour or two ; and about nine o'clock, it should get its second meal, of bread softened in hot water, which latter is to be drained * The importance of not setting the stomach to work during the latter stages of digestion, is well put by Dr. Paris, in his able article on Dietetics, in the Cyc. of Pract. Med. The maxim should be carefully attended to in feeding children. FOOD IN THE SECOND PERIOD. 37 off, and fresh milk, and a little sugar added to the bread. Be- tween one and two, the child may have dinner, consisting, at the younger ages, of beef, mutton, or chicken broth, (deprived of all fat,) and bread. When a sufficient number of teeth are developed to admit of chewing being performed, a little animal food, as chicken, roast or boiled mutton or beef, not too much dressed, should be allowed, with a potatoe or bread, and some fresh, well-dressed, vege- table, as turnips or cauliflower. After dinner, some drink will be requisite ; and a healthy child requires, or indeed wishes for nothing but water. Light, fresh table beer would not be injurious to a child of four or five years old ; but it is unnecessary, and no advantage would, in this instance, result from the creation of a new want. Be- tween six and seven o'clock, the child may have its last meal, of bread steeped in water, &c, as at nine o'clock in the morning. A healthy child who has been in the open air during the greater part of the day, will be ready for bed shortly after this last mentioned supply, and will require nothing further until morning. Similar regimen and hours may be adopted throughout the whole period of child- hood ; only, as the fourth or fifth year approaches, giving, for break- fast and supper, bread and milk, without water, and either warm or cold, according to the weather, or the child's inclination. The supply of food, upon first waking in the morning, may also be gra- dually discontinued, and breakfast given somewhat earlier. The foregoing, we conceive, may fairly be offered as a model of a suitable diet for childhood ; but, as Dr. Barlow* very judiciously observes, " No exclusive system can be right, nor can any precise rule of diet be possibly laid down, as this requires to be adapted, in every case, to the particular constitution concerned." With the sto- mach of one child, for example, so much milk as we have recom- mended may disagree, and produce acidity, and it may be advisa- ble to substitute for it tea or cocoa ; with another, a meat dinner every day may produce plethora, and it may be necessary to alter- nate it with rice, or some other vegetable substance. The constitution of the child, its habits of exposure to the air, and its residence in a city or the country must be taken into account : and something must also be allowed for the customs of the commu- nity in which it is being brought up. A judicious parent or physi- cian will recollect all these matters : and while, as we hope, they will be able to derive something like a foundation of principles from our recommendations, they will yet recognize the expediency of occasional modifications in matters of detail. It is of great im- portance, than no pre-conceived system or theory, with respect to diet, should be assumed and adhered to with unreflecting obstinacy, as is but too often the case. Thus one class of persons, arguing that the growth of a child requires an active nutrition, adopt the theory that an excess either in the quantity or quality of nutritious matter cannot be committed ; and then, by cramming and overloading the ♦See his excellent article on Physical Education, in the Cyc. Pract. Med. 5* 38 DISEASES AND MANAGEMENT OF CHILDREN. stomach, impair the digestive powers, and produce the defect in supply of new material which it is their object to prevent. Others, observing a healthy remnant of potatoe-fed children in an Irish cabin, and hearing, that the Hindoos live and thrive upon rice, instantly infer that scanty vegetable food is the true panacea for health and longevity ; and, accordingly, condemn their offspring or patients to the miseries and perils of an insufficient* non-animal diet. Most unfounded prejudices are also taken up from exparte observations as to the wholesomeness or unwholesomeness of indi- vidual articles of food. Fruits, for instance, are under a general interdict from the dietary of children ; and the consequence is, that the schoolboy, impelled by his instinct* on the one hand, and restrained by the soi-disant science of his managers on the other, devours in secret, the unripe, ill-cultivated, and pernicious trash of the fruit-stall, instead of being permitted a moderate use of* the wholesome, cooling, and antiseptic produce of the garden. Much learned trifling has also escaped from writers with respect to the propriety and necessity of " living naturally and on such food as is presented to us by nature :" and we are often told that children should be fed upon bread and milk alone : because the former is prepared by the simplest cookery, and the latter in what they call the laboratory of nature. Dr. Fordyce, however, has met the ques- tion, and settled it at once, by declaring that " man has no natural food/' Let those who may be startled by this proposition, call to their recollection the difference between the milk afforded by a cowr kept alive upon the weeds and scanty vegetation of a neglected waste, and one fed upon the riches of a pasture which has experienced the transforming power of cultivation ; let them recollect that the wheat, of which their so-called natural diet is composed, is itself the result of a long course of cultivation, and a full employment of all the resources of the complicated art of agriculture. " The potatoe," says Dr. Paris, among many other examples — " the potatoe, whose introduction has added so many millions to our population, derives its origin from a small and bitter root which grows wild in Chili, and at Monte Video."! The science of Dietetics is, in truth, an uncertain one, — any facts that we know respecting it being liable to be influenced by many varying conditions, all of which should be taken into the consideration of every individual case ; and after all, no theory should be permitted the slightest weight in a particu- lar instance in which it may be contradicted by experience. If an article of food, in favour of whose wholesomeness we have universal testimony, should disagree with a certain individual, its use with that person must not be insisted upon. * We have the authority of Dr. Paris for the fact, " that artisans and labourers in the confined manufactories of large towns, suffer prodigiously in their health, whenever a failure occurs in the crops of common fruits. This fact was remark- ably striking in the years 1804 and 1805." — Art. Dietetics, hi Cyc. Pract. Med. f Op. citat. CLEANLINESS. 39 VIII. CLEANLINESS. The importance of the excretion from the skin is universally ac- knowledged, and is sufficiently proved by the amount of the daily perspiration', which was estimated by Lavoisier and Seguin at an average of lib. 14 oz. in the adult.* This will probably render obvious enough the necessity of removing from the body of the child any obstructions to this discharge which might be offered by the adhesion of extraneous matters. The beneficial action of the physical agents upon the system (of which we shall again speak), as these agents must act through the medium of the skin-, leads us to infer a similar necessity. The accumulation of dirt upon the sur- face will also be observed to produce very distressing excoriations, and even permanent cutaneous diseases; which, when once esta- blished, are often with difficulty removed. With these considera- tions in view, we therefore feel authorised to advance the dogma, that too much attention cannot be paid to the subject of cleanliness, during both periods of childhood. The infant's body, we have already stated, requires to be carefully washed immediately after birth ; and the same operation should be performed daily, until the child becomes old enough to attend to its own comforts. Washing should at first be performed with warm water and a fine sponge — taking care, in the early periods, that no exposure be permitted long enough to produce an impression of cold. As the infant grows stronger, and when the weather is warm, we may gradually lessen the temperature of the water, until at length it may be used nearly quite cold. It i^ better, however, for the reasons assigned in p. 26, to be in no hurry about employing a perfectly cold bath ; and under any circumstances, we would not recommend water to be used with- out allowing it to remain during the night in the nursery, and so acquire a slight increase of temperature. It is not necessary to use soap, except with parts of the body (as the hands and arms,) which are particularly exposed to the reception of dirt, and with these only occasionally. Brown soap is better than white, as being less likely to cause cracking of the skin, which is often a source of much annoyance to the child. In all cases, great care should be taken to dry the surface well with a soft napkin, especially where there are folds of skin, as between the nates, on the front of the neck, arm- pits, &c. A neglect of this precaution will be sure to occasion, ex- coriation, and often troublesome sores; to make matters more secure, we shall do well in fat children, after careful drying, to dust over the skin in such situations with some fine dry powder, as hair-pow- der, or starch finely levigated, and contained in a muslin bag. This will absorb the secretions from the surface, and prevent friction. When the infant is being washed, during the first few days of its life, attention must be paid to the condition of the navel string. In * Lavoisier's Traite Elcmcntairede Chimie. 40 MANAGEMENT AND DISEASES OF CHILDREN. ordinary cases, this dries up and falls off between the sixth and tenth days, ulceration taking place at the navel. A small healthy sore remains for a few days longer, which will heal up without any interference, except the daily application of a piece of dry old linen. The linen in which we have at first enveloped the navel string, commonly adheres firmly to it; and if it remains dry, we need not disturb it, but merely raise it gently, so as to have the abdomen underneath carefully washed and dried. The frequency of the dis- charges from the bowels and bladder of an infant, requires us to enforce especial care in changing the napkin placed for the recep- tion of those matters — otherwise the skin will be injured, and dis- agreeable excoriations produced. We are to recollect, that, in the natural state, those evacuations are regularly periodical ; and an ob- servant nurse will soon discover the periods when they are about to take place, and not only anticipate them, but teach the child, at a very early age, to give intelligible warning of its necessities ; the complaint is often made to us of a child's being dirty, but it may be relied upon that the fault is almost always with the nurse. Indeed, we have no doubt that an orderly education of these functions com- menced in the earliest infancy, will be the means of establishing a regularity of the bowels which will continue throughout the whole of life, — and the more tenaciously, as in such training we are not altering or improving nature, but merely working in unison with her tendency to periodicity. As the child advances, we must con- tinue an unabated attention to cleanliness ; the hair must be care- fully combed and brushed ; and the ears, eyes, and all other open- ings of passages from the interior of the body, must be kept per- fectly clean, as well as the skin itself. By adopting such a line of conduct, we may count upon certainly preventing most of the erup- tions upon the scalp or skin which have not been directly commu- nicated by contagion, and of materially diminishing any tendency that may exist to scrofula, marasmus, or rickets. Mere washing would, of course, have little effect, if scrupulous exactness was not observed in making frequent changes of the child's clothes : an infant and young child should have a complete change of dress every day ; and the linen of elder children should be changed very frequently, — so often as never to allow the accumulation of the slightest quantity of dirt. IX. CLOTHING. We have already dwelt at sufficient length upon the principles which guide us in the clothing of an infant immediately after birth. They are, simply, to preserve a sufficient quantity of heat, and to do so without setting any restrictions to the free movements of all parts of the child's body and limbs, or irritating its tender skin. Although the discoveries of Dr. Edwards, to which we have refer- red at the commencement of this chapter, lead directly to the esta- blishment of the first principle now laid down, yet the subject is one of such great importance, and so much mystified by the phan- CLOTHING. 4 1 tasies of systematic writers, that we shall make no apology for the following long quotation. " It (mortality from cold) is not con- fined to children whom the misery of their parents cannot guard from the rigour of the weather, but it operates to a great extent, without being either perceived or suspected, in families enjoying affluence, and in which it is believed that the necessary precautions are taken, — because, cold being relative, it is difficult from our own feelings to judge of its effects on others, and because it does not always manifest itself by determinate and uniform sensations. They do not feel the cold, but they have an uneasiness or an indisposition which arises from it :. their constitution becomes deteriorated by- passing through the alternations of health and disease, and they sink under the action of an unknown cause. It is the more likely to be unknown, because the injurious effects of cold do not always manifest themselves during or immediately after its application. The changes are at first insensible : they increase by the repetition of the impression, or by its long duration : and the constitution is altered, without the effect being suspected. "* We wish we could, as a commentary upon the foregoing passages, adequately depict one of those miserable victims of parental vanity, whose appearance in our streets will sometimes, upon a March or November day, strike cold into our hearts. The cap and feathers set upon, not covering the child's head, and probably of a colour and richness contrasting mournfully with blue eyes, sharpened nose, and shrunken cheeks, in which cold has- assumed the features of starvation — the short kilt and Highland hose, exposing between them cracked and quivering knees — altogether require for their description more graphic power than we presume to lay claim to. We hope, how- ever, that we have said enough to call attention to the absurdity of the " hardening" system, as it is called, and to show that a clothing regulated so as to obviate the rigours of our climate is both demand- ed by our sensations and sanctioned by our knowledge. The ma- terial of clothing is not, we conceive, of very great consequence. We are rather inclined to discourage the use of flannel next the skin in children ; it is liable to injure the tender and irritable sur- face, and it is more likely than linen to permit the concealed accu- mulation of dirt. Upon these accounts, and as children need not be exposed to wet, we think flannel next the skin had better be avoid- ed. The feet should be protected in winter by warm stockings, and sufficiently strong shoes; and when the weather is particularly cold, woollen gaiters should be drawn over the legs when the child is about to be exposed to the air. It has latterly been a good deal the fashion to allow children, when a little advanced, to sleep with- out night-caps; and this, we think, may be permitted without injury, as the non-confinement of the hair certainly promotes its growth, and in this instance we may safely leave nature to herself. In every article of dress the principle should be carefully followed, of placing * Edwards, op. chat. 42 MANAGEMENT AND DISEASES OF CHILDREN. no constraint upon the motions of any part. For the boy tight- waisted trowsers or braces, and for the girl stays of all kinds, must be forbidden during the whole period of childhood. The injuries that may be committed upon the organs in the chest and abdomen, by the latter article, are well known to be of the most serious nature ; the chest may be completely altered in shape by a conti- nued pressure, and the lungs diminished in their capacity, while at the same time the stomach and liver are driven from their natural position, and made to press upon the other organs of the abdomen. Derangements of the functions of respiration, circulation, and di- gestion follow as natural consequences, and but too often lead to an early grave, or, what is perhaps worse, a life of prolonged delicacy and ill-health. After all these risks, the object held in view in the use of stays is not attainable by their means. By active and con- tinued compression upon the lower part of the chest, its shape may no doubt, be altered, — the ribs may be brought together, so as to form a narrower circle, and a shape be produced which however it may be fancied to constitute the ideal of beauty, yet bears no re- semblance to the human form, either as it comes from the hands of nature, or exists in the conception of the artist. The only way in which we can assist in the production of a really fine figure is, to remove all restrictions, and secure, as far as possible, so^free an action of the muscles as will lead to their perfect development. By such a course, also, we shall best promote the acquisition of a good carriage, which is infinitely more likely to be the result of a perfect balance of the muscles, than of any mechanical support whatsoever. If the principle of avoiding constraint be held in view in the man- agement of a child's feet, much suffering wTould be spared in after life. Corns and tumours upon the toes are almost always the results of tight or ill-fitting shoes; and therefore it is highly desirable, that we should have these articles so constructed as to protect the foot equally, and not injure it by any undue pressure upon particular parts. x. SLEEP. For several weeks after birth, the infant is disposed to sleep con- tinuously, only awaking when pressed by the demands of hunger, and we should certainly not disturb its repose. As its senses become more capable of bearing external impressions ; and probably as its sensorium begins to elaborate these latter into ideas, the waking intervals become gradually longer, and after some time, the chief portion of sleep is taken during the night. Throughout the whole period of childhood, however, more sleep is required than in adult age ; and up to the third or fourth year, the child will be disposed, and ought to be. allowed, to sleep for an hour or two during the day. In regulating the periods for sleep, as in other matters, we should not forget the periodical plan almost universally adopted by nature ; and by a little training, or rather by permitting that plan to SLEEP. 43 operate undisturbedly, the nurse will be saved many a sleepless night. Matters should be arranged in the nursery, so as to have no obstacle opposed to the child's sleeping about the middle of theday,an hour or two before its time of dinner ; it will thus be again sufliciently tired in the evening to ensure its sleeping soundly from seven or eighto'clock, until the following morning. On the other hand, if we defer its daily rest, and keep it awake until later, by amusing it, its night's sleep will not commence so early, and (the child being less fatigued,) it will probably be interrupted before morning. A question is often, put to a physician : should the child sleep with its mother or nurse? For a month or two after birth, it is unquestionably desirable that it should ; for the infant, as we have seen, possessing a low temperature, and but a small power of generating heat, requires to be kept warm by contact with another being. In support of this conclusion, we may allude to the care which is taken by birds and other warm- blooded animals, to preserve heat in their young offspring by the almost continual application of their own bodies. In our care for the infant, however, we must not forget the mother : and as her health would be likely to suffer from the anxiety and disturbance occasioned by being obliged to attend to a child during the night, we need not prolong unnecessarily the period of its sleeping with her. At the expiration of a month or six weeks, especially when the weather is warm, the infant, if healthy, will, with due precau- tions, be able to maintain its own heat, and we may then allow it to sleep in a cradle or bed by itself. A sufficiency of bed-clothes should be employed, and the temperature of the room during the first few months, should not be allowed to fall below 60° F. While we are anxious to keep it warm, we must be equally careful to per- mit a free access of air to its mouth, which should also be strictly attended to while it sleeps with the mother or nurse. There has been at all times a considerable expenditure of words, and much learned trifling with regard to the question of the salubrity or in- salubrity of cradles. It appears to us that their employment or non- employment, is a matter very safely to be left to the fancy or con- venience of the parents. A cradle makes a clean, airy, and, from the facility of moving it about, a convenient bed, and, as such, has advantages over more ponderous pieces of furniture. As to the injury likely to be inflicted upon the cerebral system, by rocking, we have not the shadow of a proof of such a species of motion being ever injurious to the brain, of either infants or adults ; if it were so, how would the sensorium of the infant escape the effects of the thousand shocks to which it is exposed, and that too in an inverted position, before birth ; or, among adults, what sort of brains would the veteran sailor possess ? Throughout all our views respecting the management of children, we wish to avoid speculating or dogma- tising in the absence of any basis of facts, and to lean to popular opinions, whose antiquity, we are not ashamed to confess, is in our minds primd facie evidence of their having originated in observation, rather than to affect a pretension to science by abusing, upon a theory, practices which possess the sanction of long and general use. We 44 MANAGEMENT AND DISEASES OF CHILDREN. cannot therefore agree that u rocking must be utterly disallowed,'' or that the reason for its disallowance, viz. that : " Sleep here en- sues, because the motion promotes a congestive state of the vessels of the brain, inducing a degree of vertigo"* — is anything more than a very shadowy hypothesis. During the whole of the second period, a child should decidedly sleep alone, in a bed without any hangings which might impede the free access of air, and in a room as large,! as can conveniently be procured ; not cold, or admitting draughts of wind, but possessing the means of a free ventilation. As few persons as possible should be allowed to sleep in the nursery, and in winter, a fire is an essential requisite, both for the preservation of a sufficient temperature, which should be permitted to fall as little below 60° F. as possible ; and also for the promotion of a free circulation of air. With respect to early rising, we are ready to admit, to the fullest extent, the great advantages, physical and moral, of the habit, but still we must protest against a child being, under any circumstances, curtailed of the due proportion of sleep. The way to bring about early rising safely and usefully, is to train the child to habits of retiring early to bed, and then to encourage it to rise immediately upon its spontaneous awaking, but by no means to force it from its bed before the latter occurrence. No definite rules can or ought to be laid down as to the number of hours' sleep to be allowed : one child will require more or less than another ; and our only safe guide will be, to train it to go to bed shortly after its last meal in the evening, and then to permit it to sleep without disturb- ance until it awakes of its own accord upon the following morning. The composition of the infant's or child's bed is a matter of some moment — it should be firm and elastic, and of such material as can readily be dried, or changed altogether, when wet. To answer these ends, a small tick, stuffed with straw, forms the best bed for the infant and young child; the straw should be frequently changed, and the tick as often washed and well exposed to the air. For a more ad- vanced child, a hair-mattress answers all purposes. It should be exposed daily to a draught of air : and in summer, placed for an hour or two in the sunshine, when that is practicable. XI. EXERCISE. From the very earliest periods of infancy, some degree of muscu lar motion is necessary for the well-being of the child ; and as Dr. Barlow judiciously observes, " it is advisable to suffer them to ex- * Cyc. Pract. Med. art. Physical Education. | According to Dr. Edwards's views, the advantages of large rooms are not merely owing to the greater purity of the air, but he also thinks that the slight agitation of the atmosphere, caused by the space being extended, produces such a feeling of well-being, that the chest dilates in consequence, and admits a larger proportion of air. The agreeable sensation which is experienced on breathing in the country is, he says, principally due to that cause. Henke refers short- sightedness to the narrow circle of vision rendered customary in confined nurseries. — Zdolphe Henke Handbuch dtr Kinderkrankheiten, Fkt. a. m. 1813. EXERCISE. 45 ercise their limbs freely, by laying them frequently on a bed, sofa, or carpet, and allowing them to roll and kick at their good pleasure." This, and being carried about in the nurse's arms, is all the exer- cise a mere infant requires.* It may be well to advert to a hazard noticed by Dr. Barlow, as likely to attend the practice oUioisting, as it is termed ; it is the danger of the child's chest being compres- sed by the hand of the person holding it, being placed with the thumb and fingers on each side of the sternum. That some impres- sion is likely to be made in this way upon the chest of a young infant, appears to us extremely probable, and we should therefore caution the nurse against allowing it to be so grasped. The act of hoisting, itself, appears to be always attended with pleasure to a healthy child ; probably in consequence of that sense of well-being which is produced by agitation of the atmosphere; and if no risk of a fall be run, it need not be interdicted. With respect to the period of the child's walking, we conceive that it should be left entirely to nature. Spontaneous efforts will not be made to an extent likely to produce injury; but go-carts, &c. should be banished from the nursery, as by such contrivances, the child will be supported, and induced prematurely to walk, before its limbs have acquired suffi- cient firmness to enable them to support the weight of the body. By these attempts at anticipating the child's strength, its legs may be made crooked, but we need scarcely dread such a result, when the commencement of walking is a voluntary act. In early child- hood, the taking of exercise may in like manner be left altogether to nature ; all we have to do is to provide opportunity, by allowing the free and unrestrained use of a garden or field, in fine weather, or of a large nursery at other times. The active and restless spirits of the child will then prompt it to do all that is required for its health, and its own sense of fatigue will be the best monitor as to the proper duration of its exertions. When the child grows into the boy or girl, more consideration becomes due to the management of its muscular system, as the necessity for the dedication of definite por- tions of time to mental education then first arises. It then becomes an object to economise the hours of exercise, and for this purpose the gymnasium and dancing-school are sought by parents, and re- commended by physicians. The latter is generally considered rather as a place for acquiring an accomplishment than for exercise ; but under a judicious master, who avoids constrained positions and restrictive machinery, it may do excellent service, by giving vent to the buoyant spirits of youth, and exercising almost all the muscles. The gymnasium has certainly been an improvement in modern education, but it too has its evils and hazards. In it also a skilful teacher is required, whose knowledge of muscular anatomy will enable him to contrive means of generally exercising the frame, * Nurses are in the habit of rubbing the infant's body gently with their hand, during the time of dressing. This friction appears to be agreeable to the child, and is probably useful, by stimulating the surface, and promoting the cutaneous circulation. It may be considered as a species of exercise. March, 1S38.— // 6 46 MANAGEMENT AND DISEASES OF CHILDREN. and whose judgment will constantly interfere to prevent the youth from being carried on by spirit and emulation to an overtaxing of his own powers. When practised to too great an extent, gymnastic exercises certainly stop the growth,* by directing all the energy of the individual towards a development of the muscular system ^ if improperly directed, they also occasion ruptures and injuries to the joints ; but under a skilful teacher, such abuses may be certainly and safely prevented. Neither gymnastics nor dancing ought, however, to supersede the daily play in the green fields, and both parents and children are fortunate, when not called upon by cir- cumstances to sacrifice this, the most healthful and most invigo- rating of exercises. Our plan, restricting our observations to the management of childhood, does not warrant us in considering at any greater length the exercises of youth, — a full view of the merits, &c. of the different kinds of which, belong more to the province of the physiologist, than of the child's physician. With respect to the quantity of exercise to be permitted to the child, we can give no rules more definite than to allow the dictates of nature to be followed as to fatigue, and to adopt the views already put forward as to sleep and food; whereby, of course, will be provided, regular inter- ruptions to play, or continuance in the open air. It is much to be desired that public gardens should be established in our large towns, to which the inhabitants of all classes, and their children, could have access. They should be planted with shrubs and trees, so as to afford moderate shelter, — and be provided with a large shed, in which refuge might be taken from the vicissitudes of our variable climate. Most large continental towns have a pro- vision of the kind, as well as numerous private gardens, to which the poorest can resort at no greater expense than the price of a cup of coffee. We know that it will be objected, that in our country such places would become scenes of drunkenness and riot ; but we are sanguine enough to hope, that the opportunity of enjoying temperate amusements in the presence of their fellow-citizens of a better rank, would be appreciated by our artisans, and ultimately tend to restrain their ferocity, and elevate them in their own opinions. The lower classes of these countries are too much thrown upon the one brutal indulgence of drinking; and it is an absurdity to suppose that the strictest revenue laws will have any effect, ex- cept to aggravate the evil. Make spirits dearer, and the labourer will certainly diminish his allowance of food and clothing to pro- cure the only means within his reach of relieving his mind from the pressure of toil and want. Give him an opportunity of being amused, when his day's labour is ended, with music, and of en- joying the pleasures of a public garden in the presence of his supe- riors, and we hope (perhaps too sanguinely,) that he would be gradually led to lessen his allowance of spirits, in order to enable * Any person who recollects the stunted stature of a boy, servant in a gym- nasium in this city, will admit the truth of the above statement. MEDICINE. 47 him to procure dress sufficiently decent to admit of his partaking in those amusements without a sense of degradation. xn. MEDICINE. There is no subject connected with the management of children, in which such fatal errors have prevailed, as in the treatment of their bowels ; and unfortunately, the influence of certain medical theories has, of late years, tended rather to the increase than dimi- nution of those mistakes. The importance which has, in many re- spects very justly, been attached to the digestive system in disease, has attracted much attention to its state in health ; but, unhappily, the great majority of persons fall into the grievous fallacy of sup- posing that what is useful as a remedy, must also be useful as a pre- ventative : and as the multitude has, in the case of the system in question, but one idea cognate with either remedy or preventative, viz., the idea of purging, the propriety of adopting a regular system of purgation with healthy children, has been admitted almost with- out question. There cannot, however, be a more dangerous ab- surdity than such a system ; and in proof of our opinion, we shall ask a single question, and bring forward one fact. What is the mode of action and effect of every aperient drug in the pharma- copoeia ? Is it not irritation, direct or indirect, of the intestinal mucous membrane, in a greater or lesser degree ; and does it not produce, as a necessary effect, in every instance, a larger or smaller quantity of increased secretion ? So much for our question. We presume that no person, but a devoted disciple of St. John Long, will maintain that irritation producing increase of secretion, can ever be necessary in the healthy body. With respect to our fact — let any person with regular, or moderately regular bowels, take an aperient, and he will certainly find that after its immediate effects have passed away, a state of costiveness will remain. The ten- dency of nature to periodical movements, has been interrupted by the production of evacuations at irregular periods, and she requires some time to enable her to recur to the simplicity of her original design. We wish it to be distinctly understood, that what we are now advancing has no reference to the use of purgatives in disease, but solely to their abuse during health ; and we are the more par- ticular in endeavouring to convey our own views upon the subject, because we know that the impropriety of a needless resort to medi- cines of this kind, is not sufficiently thought of by medical men. We have, indeed, too often had occasion to lament over the display of drugs upon the mantel-piece of even a medical man's nursery, not to feel special interest in this matter. The least judicious would surely grieve, did he see an ointment of cantharides rubbed to a healthy skin with no other apparent intention than that it might be followed by a healing salve ; yet, what less absurd, is portended by the accumulation, in such a situation as we have 4S MANAGEMENT AND DISEASES OF CHILDREN. alluded to, of packets of aperient draughts, bundles of restraining powders, and bottles of carminative mixture — all designed for the same unlucky children. This is no imaginary description, we have but too often seen its original ; yet, better and more merciful would it be, towards many of the victims, to destroy them in the birth, than, by such a course, to provide for them the enduring miseries of an irritable intestinal mucous membrane. The bowels of a healthy infant, after the meconium has passed away, should be opened from two to four times in the twenty-four hours. The discharge should be fluid, of a lightish-yellow colour, free from any fetid or acid smell, and destitute of lumps, or white curdy matter : it should pass without pain, or any considerable quantity of wind. As long as these conditions exist, there is no occasion for medicine ; should they be materially deviated from, a state of disease must be present, and will be indicated by other symptoms, the nature and treatment of which will be considered in the proper place. The infant may, however, labour under a degree of costiveness which can scarcely be called disease, and yet requires medical interference. Having less than two stools, for example, in the twenty-four hours, calls for an aperient : and so also does a lumpy, or partially solid, condition of the discharge. The medicine, in such cases, should be of the mildest nature. For an infant, from half a drachm to a drachm of fresh castor oil, will generally answer every purpose ; or a dessert spoonful of a mix- ture formed of a couple of drachms of manna dissolved in an ounce of fennel or carraway water, may be given, and repeated every hour until the bowels are opened. These are probably the only safe nursery medicines. Calomel, which is but too commonly the first article in the list, should be banished from it altogether, and never given for the mere removal of, what we may perhaps call, healthy costiveness. Its use seldom fails to produce motions of a green colour, mixed with gelatinous mucus ; thereby showing that it is likely to do much more than what we want, when our object is merely to empty the bowels of their contents. During childhood, the bowels should be regularly freed once or twice a day (some difference existing in individuals as to the precise number of theirperiodical motions). The discharge should be rather of a darker yellow than in the infant, and more solid, but less so than in the adult ; it should have a feculent smell, and be free from mucus or lumps of indigested matter. When a healthy child has been treated upon the principles which we have indicated, — under the heads of food, exercise, and cleanliness, — it will seldom require any purgative medicine ; but occasionally, from some error of diet, or other accidental circumstance, costiveness will occur, and we must then be prepared to recommend a mild aperient. A couple of drachms of castor oil will usually answer very well ; or, if that should disagree with the stomach, a table-spoonful of the mixture directed below, may be given every second or third hour, until it LIGHT.— AIR. 49 operates.* In childhood, as in infancy, the domestic use of calomel cannot be too strongly interdicted. XIII. LIGHT. The influence of this physical agent, in the vegetable kingdom, is known to every one who has observed the bleached appearance of a plant growing in the dark, or has noticed the efforts made by flowers placed near a window ta turn towardsthe light, even though they may not be led to grow in that direction by the direct in- fluence of the solar rays. Dr. Edwards has made some ingenious experiments to show the influence of light upon the development of animals; in the course of which, he found that those which naturally change their form, as tadpoles, were prevented from doing so by the withdrawal of light. In man it is not easy to obtain any information as to the specific effect of light unaided by air and temperature ; but from the facts just alluded to, we are warranted in inferring analogically that light must materially influence deve- lopment of form. The infant, therefore, as soon as its eyes lose their extreme sensibility, should be freely exposed to light. The nursery should never be darkened during the day ; and at night, it is better that the shutters should be left unclosed, and no window curtains used. XIV. AIR. We hope that the stress which we have laid upon the propriety of keeping up a due degree of warmth in the nursery, will not be interpreted as warranting any measure likely to interfere with a free access of air. Both objects are perfectly compatible. The purity of the air in which, the child resides and sleeps should be secured, by providing means for ventilation, in a sufficient number of windows, and a chimney, which latter is absolutely essential to the establishment of a current of air ; and also by restricting the number of individuals residing in the apartment within the nar- rowest limits. It has been already stated, that a certain agitation in the atmosphere is healthful ; and, therefore, the nursery should be as large as possible, in order to favour motion of the air contained within it. But our attentions with regard to air, should not be confined to the nursery ; the vivifying influence which it has been shown to produce upon the system, by contact with the surface of the body, furnishes us with a reason for the advantages, shown by experience, to be derivable from an exposure of the child to the open air as freely as possible, consistently with an observance of * R Infusi Sennas Compositi, 517. Aquae Carui, 3 i i . Tartratis Potassoe, 5ii- Mannae Optima;, %i. M Fiat mistura. 50 MANAGEMENT AND DISEASES OF CHILDREN. the principles already inculcated under other heads. It is this vivifying influence which renders the play in the open fields so much more useful than the most carefully directed exercises of the gymnasium. XV. TEMPERATURE. We have already incidentally said so much upon this subject, that any thing farther would be merely repetition. We may, however, take the opportunity of controverting a very common fallacy, viz., that exposure to heat renders the body more sus- ceptible of the ill effects of cold. Dr. Edwards found, that ;< in ex- posing animals to successive applications of cold, their temperature will fall the more slowly, the longer they shall have been subjected to the influence of warmth. Hence, that those who are liable to frequent exposure to severe cold, are rendered more capable of supporting it, by subjecting themselves, in the intervals, to a high temperature." We find, in point of fact, that the Russians, and other northern nations, preserve, by means of stoves, and double doors and windows, a very high temperature in their dwellings during winter, and yet leave them with impunity to pursue their occupations in the open air.* This should make us hesitate in denying access to a fire to a cold and shivering child, under the idea that we should render him, by the prohibition, hardier, and less likely in future to suffer from cold. XVI. MENTAL AND MORAL EDUCATION. The connexion between these subjects and physical management is so close, and the action and re-action of one upon the other so constant and influential, that we cannot conclude this chapter with- out noticing them. In doing so, however, we feel considerable embarrassment, both from the difficulties incidental to the subject, and from the narrowness of the limits within which the nature of our present plan obliges us to confine ourselves in our observations. A moment's reflection will be sufficient to convince us, that the infant is scarcely born when it commences a process of learning. , Its senses first receive a knowledge of the agents which act speci- fically upon them ; the eye becomes acquainted with light, the ear with sound, &c; and subsequently the infant learns to compare the different sensations, and to derive inferences from this com- parison. Thus, the mother's nipple is soon recognized by the sense of sight ; but it is at a later period that the information conveyed by the eye is corrected by the touch, so far as to enable the mouth or hands to be directed with certainty towards the object in ques- tion. After a short period, the power of perceiving external ob- * The common winter temperature of houses in St. Petersburg, is 64° F. ; while out of doors, it is frequently so low as 20° Dr. Granville's Travels. MENTAL AND MORAL EDUCATION. 51 jects, and the memory, is so far educated, that the infant can deter- mine the differences between persons, and becomes capable of recog- nizing its mother or nurse. All this is really mental education, and that too of the most important kind: for what a small proportion does the learning of the schools bear to the knowledge of external agents, and of our own powers and relations, which we must acquire during the period of childhood, and without which we should be incapable of supporting our own existence. We cannot, however, materially aid id the communication of such knowledge ; the demands of the senses for their proper excitements will force it upon the young being ; and we refer to it, here, only to show that the young child who is permitted to use its eyes and ears, is always busily employed in learning, and that the hours of play are not to be considered as periods of intellectual idleness. At what time the business of formally instructing the intellect should be com- menced, becomes an interesting question, and one upon which much difference of opinion exists : if we begin too early, we shall certainly injure the health ; and if we delay too long, we shall often experience much difficulty in restraining the habits of bodily acti- vity, (which in such cases will generally be acquired,) within limits favourable to the necessary exertion of the mental powers. In this, as in most other matters, we shall probably find our best guide, if we carefully observe the plans of nature. She seldom fails to im- plant in the child a most restless and prying curiosity, which is in reality the appetite for knowledge, and should never be denied its gratification. Books and pictures never fail to attract the attention of very young children; and allowing them to apply it, at their own pleasure, to these, and especially to the latter, is precisely doing for the mind what we do for the body when we place it in the garden or field — it is giving it an opportunity of taking whole- some exercise, which it will cease from doing upon the first ap- proach of fatigue. In the one case the child will, itself, learn to walk and run with firmness ; and as its muscles and bones become stronger, it will usually desire to learn the more artificial exercises of riding and swimming. In the other case, an acquaintance will be imperceptibly acquired with the forms of letters, and of animals and other external objects ; and the uses of the one being gradually learned, and a curiosity respecting the others being excited, a growing desire for information will lead the child to devote more and more time to its acquirement, until at length we shall find it no difficult matter to include among our periodical arrangements, a daily allotment of a short portion of time for the purposes of in- struction. The precise age for adopting this latter arrangement cannot be exactly defined — it must differ a little, according to the strength of the child, but we conceive it should not be before the sixth year. The time to be allotted for instruction is also a matter of moment ; it should never be long enough to produce fatigue, and we think should not exceed two hours daily during any part of the period of childhood. By adopting such a plan as we have recom- 52 MANAGEMENT AND DISEASES OF CHILDREN. mended, we allow a child to learn to think, which in reality is superior to knowledge, and we also give it an opportunity of ob- taining materials for thought, by making an acquaintance, at its leisure, with the sensible properties of many objects. " We do not/' however, to borrow the words of an ingenious writer, " at- tempt to force their intellectual growth. Do not feed them with meat, until they have teeth to masticate it. There is a great deal which they ought to learn, can learn, and must learn, before they can or ought to understand it."* So much for intellectual education ; during the period to which our consideration is restricted, viz., the first eight years of life, it should scarcely^ in our opinion, be made a matter of formal business, but the foundation of it should rather be laid by such playful exer- cise of the faculties as we have sketched. — A more important sub- ject, however, is what we have designated as moral education. This commences at the earliest period of infancy, and wTe almost believe, is finished, for good or for evil, before the individual passes from the period of childhood. In moral qualities, the child is, in- deed, father to the man ; and the education of these requires the most anxious attention, even during the earliest periods of infancy. No one who is familiar with the habits of infants can avoid ob- serving, that from the moment of birth they display obvious marks of being endowed with active passions and affections, and that, too, in very varying proportions in different individuals. Anger is perhaps the first which is displayed to our notice, but shame and jealousy soon make their appearance, and also some of a more amiable character, as compassion and brotherly affection. Now, we must recollect that these, and all the other elements of our moral constitution, are originally implanted in us, and designed for good. " It is very true," says Dr. Chalmers/!" " that the anger, and the shame, and the emulation, and the parental affection, and the compassion, and the love of reputation, and the sense of pro- perty, and the conscience or moral sense, are so many forces of a mechanism, which, if not thus furnished, and that too within certain proportions, would run into a disorder that might have proved de- structive both of the individual and of the species." We shall give an example of our meaning, and again in the words of the ex- cellent writer just quoted: — "The more patent view of anger is, that it is an instrument of defence against the aggressions of violence or injustice, and by which they are kept in check from desolating, as they otherwise would, the face of society."^ In like manner, all the passions and affections are designed for good ; and we conceive, therefore, that our object in morally educating a child should be, not to obliterate those forcesof his moral mechanism, but to guide them into a system of harmonious operation with each * "The Doctor," generally (we believe,) attributed to the pen of Southey. f Bridgewater Treatise, vol. i. p. 196. j Op. citat. p. 208. MENTAL AND MORAL EDUCATION. 53 other. Now, how is this most likely to be accomplished ? Is it not by cultivating those affections which are obviously good, and by their influence lessening the violence of others, whose unre- strained indulgence would certainly lead to evil ? Thus, the anger of even a very young infant will be best restrained, not by B dis- play of anger upon the part of its parent, but by a steady exhibition of parental affection, and by showing it a practical example of calm- ness. Causes likely to excite irritability should be carefully re- moved from the infant, as a habit of indulgence in anger will readily be acquired before the counteracting affections can be cor- respondingly excited. As the child advances in age, new passions and affections call daily for our notice ; and as its mental education simultaneously progresses, and it is constantly acquiring an in- creased knowledge of external objects, we are furnished by this progress and knowledge with additional and powerful instruments for influencing its moral nature. He displays but a small ac- quaintance with the human heart, who hopes by an apothegm to ex- tinguish the passion of jealousy, or to repress the cravings of am- bition by a dry statement of the unquestionable truth that all is vanity. But still, the natural feeling of emulation, which is the commencement of jealousy, can be restrained within just and whole- some limits, by calling into play the family affection, and com- passion, which are equally original elements of the moral consti- tution ; and the love of reputation may be prevented from growing into a dangerous ambition, by encouraging, along with the affec- tions just mentioned, a development of the conscience or moral sense, and of the sense of property, both of which we conceive to be inherent in our nature.* The child may in this way be prac- tically shown, that while a generous rivalry in its sports and lessons is not forbidden, still that benevolence and natural affection for its brothers and playmates teach it to stop short, in every instance, of carrying this so far as to wound the persons or feelings of others ; and, again, that while it may be lawfully anxious to obtain credit and praise from its teachers, still that its sense of property forbid it to seek for either by making an unpermitted use of the labour of others, and its conscience peremptorily interdicts any advantage which might be attained by the assertion of an untruth. In this way we avoid overtaxing nature ; — we do not vainly denounce, or attempt to obliterate, forces which are as much part of our moral frame, as hunger is of our physical ; — we do not tell the hungry man he shall not eat, because gluttony is a vice, but we furnish him with a guide as to the quantity and quality of food which is whole- some and necessary. Above all the restraining principles (if one may be preferred to another), we would be inclined to endeavour with most care to bring into activity the sense of property, and conscience or the moral sense, as Dr. Chalmers terms it. Upeo these the well-being of society mainly depends : if not encouraged * See Chalmers in Bridgewater Treatise, passim. 54 MANAGEMENT AND DISEASES OF CHILDREN. in early childhood, they are of all others the most likely to remain dormant ; but if once well developed in the child, they require a long course of vice for their overthrow. The progress of mental knowledge may be brought into useful operation in our work, by directing the growing faculties of the child to such portions of the general plan of nature as may be within its comprehension. Admiration for the skill of Providence may, at a very early age, be excited, by calling attention to the more obvious adaptations of means to ends in the forms of animals, in the benefits conferred by the mode of distribution of water over the earth, &c. &c. ; and a perception of beauty can be called up in a very young mind, by the colours and fragrance of flowers, and the influence of music. From all these the watchful parent can derive practical lessons of humility and love, which would be sought in vain in the maxims of a dry morality. To work out in practice the principles which we have attempted to lay down,, we are well aware, would require qualifications, on the part of the parent or teacher, of no ordinary kind ; but the nearer we can approach to them, the more likely are we to produce the mens sana, which we feel con- fident is fully as certain of producing, as of inhabiting, the corpus sanum. Our limits forbid us to enter at greater length into this most interesting subject ; but one word we must add, to prevent miscon- ception. We have not yet spoken of religious instruction as a part of moral education, because we have been considering the manage- ment of the moral faculties as they exist in the natural man; we are deeply convinced, however, of its necessity and importance ; and we are firmly of opinion, that in no way can we promote the interests of an individual, both as regards himself and his relations with society, so effectually, as by encouraging in him early habits of religious observances ; in no way can we so surely call forth and strengthen his best affections, as by early setting before his view the living truths of revelation. As general conclusions from the views we have put forward, we would say, that during childhood (t. e. until the eighth year), education should have for its main object the cultivation of the moral qualities ; and that, during the same period, the intellect will be pretty fully occupied in obtaining such most necessary informa- tion as can be acquired by the use of the senses without much formal assistance, and therefore that schooling, properly so called, should not be commenced, at the very earliest, before the termina- tion of the sixth year. Until then, the confinement of a school is injurious to the bodily health, and not required for the mental im- provement of the child. In coming to these conclusions, we may appear to undervalue those useful inventions of late years, — infant schools. We conceive, however, that they have a specific purpose, and that, when well-regulated, they effect that purpose usefully — viz. to take charge of the children of the poor in large cities, when their parents are engaged in their daily labour, and unable to at- MENTAL AND MORAL EDUCATION. 55 tend to their wants. In this view, their value is inestimable ; but still they are but the substitution of a lesser for a greater evil: all the ties of social affection, of well-regulated obedience, and of mutual co-operation, which constitute the bonds of society, are learned by the infant in the domestic circle, and can be learned no where else; and if we can leave it in the care of an intelligent mother, and in the society of its brothers and sisters, we should not send it to an infant school, where it is governed by and associated with strangers, with none of whom it is likely to have natural sym- pathies. What the child may be expected to gain specifically in these schools, beyond mere protection, can only be regularity of habits, which certainly is of great importance, but not so great as to countervail the advantages of a well-regulated domestic circle. For the reasons we have advanced, we conceive that infant schools, though most serviceable in large cities for the poor, are totally un- fitted for children of more opulent parents. With the latter the system might be characterized, as Dr. Chalmers has done another artificial system, as " a taking to pieces of the actual framework of society, and re-constructing it in a new way or on new principles — which is altogether fruitless of good, and often fruitful of sorest evil, both to the happiness and virtue of the commonwealth." [Since writing the above, we have had the pleasure of reading an interesting little treatise on Infant Education, published in Chambers' Educational Course. Edinburgh, 1836. At the same time that we are most gratified to find that the principles which we have at- tempted to lay down for early education, are those sanctioned by the experience of Mr. Wilderspin and others, still we cannot change our opinion with respect to the class of society for which the infant school is really adapted; and we must be excused for pre- ferring the family circle, as a place of education for the very young, in all cases in which it can be made use of without important sacri- fices. We do not agree that the element of numbers, as Messrs. Chambers assert, is indispensable for exercising the social virtues of the child, particularly of the female child; but we acutely feel, that a tenderness, not less than parental, is required to keep unceasingly awake the sense of responsibility which ought to be felt by the in- fant's instructor: and we conceive that this responsibility is intended, by a wise Providence, not merely for the child's advantage, but also for a strong and wholesome check upon the morality of the parent, which it would not be beneficial to society to weaken by division, in any case admitting of its being left whole and undivided.] 56 MANAGEMENT AND DISEASES OF CHILDREN. CHAPTER III. PECULIARITIES OF DISEASE IN INFANCY AND CHILDHOOD. I. ETIOLOGY. The great activity which pervades the whole hody in the child, united in the peculiar susceptibility of the nervous system, and the abundant supply of blood-vessels, more especially arterial capilla- ries, predispose, in a particular manner, to the sudden occurrence of disease, its rapid progress, and frequently fatal termination, — organic change readily taking place. If one source of diseased action be zplus of vitality in any organ, as Broussais has taught, or an over-exercise of the natural function, in no subject is disease from such a source so likely to be found as in the child. This great activity of all organs and functions, however, while it predisposes parts so much to take on diseased action, con- fers at the same time a peculiar energy or power of reparation, in virtue of which the danger in infantile disease is in a particular man- ner diminished, when once the acute stage of the disorder has been subdued or has subsided. Thus the danger in infantile complaints is principally from the rapid occurrence of organic change, with fatal result, in the first instance, — the establishment of chronic disease being less liable to occur than in the adult, and more easily prevented; while, should such take place, the child has more chance of recovery, no matter to what extremity it may have been reduced. The great nervous sensibility of the infant, and consequent irrita- bility, is a prime source of disease, and gives a particular character to all disorders occurring in the child. Irritation is easily set up in any organ, directly or indirectly ; and indirect or sympathetic irri- tation is very liable to occur in the child, particularly in certain organs, and is often presented in a very severe form. The most common seat of direct irritation is in some part of the alimentary canal, and this generally arises from the ingestion of unwholesome aliment. The presence of any irritating matter there gives rise to symptoms often very formidable, particularly when it occasions sympathetic disturbance in the brain. The intestinal mucous mem- brane itself soon takes on the irritative action, and becomes the seat of disease ; the attendant symptoms generally assuming the type of remittent fever. The suffering caused by difficult dentition is a familiar example of direct irritation, which, though slight in itself, may lead to most serious results. The lungs may be directly irritated ; but often are sympathetically so, as when disease has existed in the abdomen, or occasionally in ETIOLOGY. 57 the head. The cough in the first case will be irritative, and may be violent ; it is in the second usually spasmodic. The brain is less liable to direct irritation, but often takes on this state, sympathetically, from disease in the digestive organs, or during the existence of protracted thoracic disease, especially if the cough be violent, as in pertussis. Thus we see that the head sympathises most directly with the digestive apparatus, less so with the chest. The lungs sympathise frequently with disordered states of the bowels, less frequently with disorders of the head. The digestive organs sympathise rea- dily with all the others, — remittent fever arising during almost all protracted diseases of childhood, as we see in most of the severe forms of pulmonary complaint: and the stomach and bowels are immediately affected on the occurrence of irritation or inflam- mation of the brain. The mucous membrane of the bowels, parti- cularly, sympathises with the cutaneous surface, many diseases of which arise from disorders of the digestive tube. In the child, irritation, which is of such frequent occurrence, readily passes into congestion or inflammation. In the brain, in particular, congestion often arises suddenly during states of irritation. Inflammation in the child is generally very severe, and runs its course rapidly, leading to organic change. Exudations of lymph, or other matters, are quickly thrown out, and occur in situations where they are not liable to be found in the adult — on the mucous membrane, for example, as we see in croup. Effusions readily occur in serous membranes, as the arachnoid ; and softening or ulcerations are frequent in the mucous membranes, as we find through- out the whole tract of the intestinal canal. Plethora is frequently present in the child, and is often the result of over-feeding ; but does not necessarily give rise to disease, as it does in the adult, the redundant material being consumed in the active processes of growth. The full fat child is a natural and wholesome object, and not so prone to disease as the pale, slender subject of misguided solicitude, that has been doctored into delicacy, and which, though not so violently affected by inflammatory disease when attacked, is more ex- posed to illness, and more liable to protracted affections and relapse. Metastasis, or transference of diseased action from one part to another, is particularly liable to occur in the child — hence the popular dread of the disappearance, or going in, as it is called, of eruptions, exanthems, &c, &c, — which apprehension, however, is commonly carried too far, and leads to very erroneous practice. The sudden suppression of inflammatory action going on in the skin, whether attended with fever or not, — as the eruption of mea- sles, scarlet fever, extensive itch or other cutaneous disease, — is often followed by morbid action set up in the alimentary canal, chest, or head. The first is perhaps most common ; but in mea- sles, the chest is often attacked under such circumstances, and at the close of scarlatina, the head. The suppression of an accus- March, 1838.—/ ' 7 58 MANAGEMENT AND DISEASES OF CHILDREN. tomed discharge, as chronic diarrhoea, may have the same effect ; and this appears natural, when we recollect the great susceptibility of the system, and the power of counter-irritation in the child. Disorders strictly to be called nervous do not occur in the child, though the nervous system is so susceptible and so subject to dis- turbance; but this usually displays itself in spasm or convulsion, and arises directly from morbid action going on in the brain or spinal marrow, or sympathetically, in consequence of disorder of the digestive organs. Convulsions occur in the infant, and epilepsy or chorea in the child ; but nervous affections such as hysteria or hypochondriasis are not to be seen at this age, neither do we often meet with neuralgic pains. Mental impressions, so fertile a source of disorders of the nervous system in the adult, scarcely if at all affect the child, with the exception of fear or anger, which, if sudden or violent, may pro- duce serious consequences. We have seen dangerous cerebral irri- tation thus excited; and fatal convulsions, or idiocy for life, have been caused in the child by a sudden fright. Some disorders are congenital, or may be born with the infant, as syphilis, and occasionally hydrocephalus. Some are peculiarly liable to occur immediately after birth, as purulent ophthalmia; while trismus nascentium is restricted in its period of invasion to the first nine days, never appearing after that period. There seems to be an hereditary predisposition to the occurrence of certain disorders, as croup, and hydrocephalus, among the children of some families ; all or most of whom are in succession attacked, and that often about the same age. The common causes of disease affect the child with more severity, in general, than the adult; but from some the infant is perhaps free. Irregularities of diet, or improper food, is one of the most fre- quent sources of illness in childhood; and derangement of the sto- mach and bowels, which are so liable to be thus induced, lead to serious results at this period of life. We have noticed the liability to dangerous sympathetic affections, particularly those of the head. Fever of an obstinate character, and generally of remittent form, is thus induced ; and inflammatory affections of the abdominal viscera have their frequent origin in this cause. A single indigestible meal will cause flatulency and acidity to an inordinate degree, soon to be followed by diarrhoea and more serious consequences. Such occur- rences take place frequently at the time of weaning; and we should always make inquiries on this point, when an infant suffering under such symptoms is brought to us. Indeed, so common a cause of infantile disease is disorder of the bowels, that many have regarded it as the sole source of children's disorders.* * Etmuller, in 'his " Valetudinarium Infantile," attributes the diseases of the first year to some peculiar alteration in the digestive system; Harris regarded acidity as the chief cause of infantile disease; and Sydenham attributed much to this cause, combined with debility. The increase of mucus consequent on intes- tinal irritation, we have already noticed; and this, Dr. Armstrong assigns as a prime source of infantile disease. ETIOLOGY. 59 Impressions of cold and damp, or vicissitudes of temperature, the most fertile source of disease at all periods of life, is particularly so with the child: this we were prepared to expect, having seen that the infant has hut low powers of generating heat, and so of resisting the injurious effects of cold, especially when associated with damp- ness. During sleep, in particular, there is a susceptibility of the injurious influence of sudden alternations of temperature; and to such the infant is especially exposed, much of its time being passed in sleep, frequently in the open air; and, when in bed, it often throws off the clothes, while warm or even perspiring. Here we have the origin of many inflammatory affections, particularly of the throat, chest, and abdomen. Some forms of disease are said to arise often, in certain situations, in consequence of the lowness and dampness of the place, as croup, or even hydrocephalus, which latter is looked upon as almost epi- demic in the Valais, where the best effects result from the removal of children from the district. Want of light and air is an abundant source of ill-health in children, and consequent delicacy of constitution in the adult. Thus is scrofula commonly generated or called forth, and all epi- demic diseases aggravated or spread. To such sources of malady, however, the children of the poor, especially in large cities, are sure to be exposed; and the detriment to the commonweal arising from this cause, though now little noticed, is such as well to deserve national consideration.* The influence of season, or states of the atmosphere, in generating or modifying particular forms of complaint, is most remarkable in the child, — so much so, as to cause an established uniformity in the variety of inflammatory affections prevailing at different periods of the year. This variety generally arises from a different tract of the mucous membrane being affected at different seasons; and a degree of order seems to be observed in the course of this morbid migra- tion, which may be seen to commence with the nose and mouth, coryza and catarrh prevailing generally among children at the be- ginning of winter. Bronchitis, and the severer forms of pulmonary inflammation, appear as the winter advances, and prevail during the spring, especially the earlier months. As summer approaches, dis- ease lessens, and pulmonary affections nearly disappear; but as the season advances, the seat of disorder again changes; and now the gastro-intestinal mucous membrane becomes engaged, and on the arrival of autumn, we have diarrhoea, dysentery, or cholera, con- stantly presented to us in the sick child. From attention to these particulars, we may derive some information as to the nature of a child's disease, when it is only complaining or out of order. Autumn and winter seem to be the most unhealthy seasons — sum- mer and spring, less so ; but this rule does not hold good alike in all towns, and occasionally much illness obtains during spring. At * See p. 46. 60 MANAGEMENT AND DISEASES OF CHILDREN. this season some epidemic usually prevails, and we most generally meet with one of the exanthematous disorders to which children are subject. It is a more favourable time for the occurrence of such, however, than the winter months, — the approach of summer facili- tating recovery during convalescence. It has been doubted whether the very young child is susceptible of contagion ; but infants have been born covered with small-pox, and are said to have come into the world affected with hooping-cough: and we have seen the youngest infants at the breast attacked by cholera. However this may be, certain diseases which spread epidemically if not by contagion, as measles, hooping-cough, &c, are particularly liable to occur during childhood, and generally prevail among many children at the same time. These complaints are sometimes repre- sented as peculiar to infancy and childhood, and the individual once affected is said never to have the disorder again. The same indi- vidual, however, may have any of these complaints a second time ; but this is rare, though it occasionally happens, as with scarlet fever. There is certainly less liability of their being taken by the adult than the child ; but we have seen a person of seventy in hooping- cough, and a mother will occasionally take measles from her own offspring. Hence it is desirable that such diseases should have been passed through ; and we may be consulted as to the prudence of leaving a child exposed to any of these complaints, or removing it for security. If the child be healthy, and the type of the prevailing epidemic mild, it will in general be best to allow it to take its chance ; but when the infant is delicate, or only recovering from a former illness, and under any circumstances, when the type of the prevail- ing disorder is severe or malignant, it will be advisable to take every precaution against the malady. Scrofula is much a disease of childhood, though not confined to that period of life. In the child it is particularly liable to display itself by attacking the glands of the neck. Glandular disease is fre- quent at this age ; mumps, an affection of the parotid gland, occurs usually in childhood ; and it is liable to be transferred by metastasis to the testicle. Enlargement of the mesenteric glands leading to disorganization, and the establishment of tabes mesenterica, usually commences during childhood. The bones are often engaged in disease at this period. The scrofulous diathesis, which then so often obtains, doubtless contributes to this ; but their great vascularity of structure, also acts its part. If this contributes to occurrence of dis- ease, it also aids materially in its reparation ; for recoveries may be looked for in early life, that could not be expected at a later period. In consequence of the great vitality of bone, fractures unite with certainty and rapidity : and the greater softness of the osseous mat- ter, also imparts the peculiarity, that partial fracture, or only bend- ing of the bone, may take place. * From anatomical peculiarities ♦See paper by Dr. Hart, in the Dub. Med. Jour. vol. i. DIAGNOSIS. 61 some fractures can scarcely occur e. g. of the neck of the femur. This power of yielding without being fractured, is remarkably ex- emplified in the hones of the head ; for a depression will occasion- ally be foqnd in the skull of the child from injury, which is in truth a mere bulging in, not fracture, — but which could not have taken place in the adult, without the bone giving way. The power of spontaneous rectification in cases of fracture, is also remarkable ; for however crookedly united, the bone has a tendency in the child to become straight, and will occasionally do so completely, even in bad cases. A similar power of reparation exists in the soft parts ; but great losses of blood are ill borne by the child ; and the peculiar suscep- tibility of the nervous system, makes the shock from operations and injuries always dangerous — it may be fatal. Hence, surgical opera- tions are generally objected to, until after the third month. ^ II. DIAGNOSIS. It is particularly necessary to be versed in the diagnosis of infan- tile disease, as our chief chance of success in acute cases, depends on an early discrimination, so as to be able promptly to apply the necessary remedies ; while the little patient cannot in general give any information itself, or only such as is likely to lead astray. This loss, however, will be the less felt, if we pay sufficient atten- tion to the information conveyed by the physical signs in infantile disease, — one look at the sick child often imparting more know- ledge to the experienced eye, than any account given by attendants could convey. We shall always have occasion, however, to inquire from them the history of the case. The healthy child is cool, plump, and lively, the flesh firm, and movements free. It likes to be played writh, and carried about. The abdomen is full and soft, and pressure upon it seems rather to please than annoy the child. It sleeps quietly on its side, with the limbs flexed, generally, going to rest at the same hour ; and awaking cheerfully, soon demands food. It is scarcely necessary to add, that the secretions are natural and regular. Not so with the child when ill : it is more or less peevish — dislikes being stirred/or even cries when handled ; its hour of sleep is uncertain, and it rests ill, or awakes startled or crying. The skin is hot and dry, particu- larly of the hands, feet, and head. The flesh is soft or wasted. There is thirst, with unnatural appetite and depraved secretions. ^ hen a sick child is brought to us, or we visit it, our attention should first be directed to the expression of the countenance, then to the attitude, state of the limbs, and skin. We next proceed to examine more minutely into the several symptoms, — to determine the seat of the disorder, whether in the head, chest, or abdomen, — and its nature, or the particular lesion on which it depends. When the brows are knit, the eves fixed and staring, or looking 7* 62 MANAGEMENT AND DISEASES OF CHILDREN. wild or vacant, our attention is at once directed to the head. We try whether it is unusually hot, the vessels full or in over-action, and examine the fontanelle, to see if it be depressed or in a state of distention. We now observe the attitude, and see whether the child's head hangs heavily on the nurse's arm, or rolls from side to side, sunk upon the pillow.* We examine the limbs, to see whether they be rigid or relaxed, — lying motionless, or tossed about, and affected with spasm — in particular, we try whether the hands are clenched, and the thumb turned in, or toes bent. According as the upper or lower extremities are affected,one or both, we judge of the seat and ex- tent of the disease. The state of the pupil next demands investigation. It may be found contracted, and the child will start, as if frightened, or scream out, on being touched ; or the pupil may be dilated and insensible to light, — the child being motionless or unconscious. We will hear that the child has had starting in its sleep, grinding of the teeth, or movements of the lips ; and when awakened, it started up affrighted or screamed out ; the bowels are obstinately costive, or the evacuations very foul and dark-coloured. The hands are usually hot, but the feet cold ; and one cheek is often deeply flushed. No doubt can now exist that the head is the seat of disease ; but what that particular disease may be, and whether a primary or secondary affection, is to be determined by symptoms hereafter to be detailed in their proper place. Occasionally we see a child lying completely prostrate, — the limbs relaxed and motionless, the belly sunk, and the eyes fixed, with the lids half-closed ; we are told that it is much better than it Avas, having been affected with convulsions; and no suspicion seems to exist that it is in the last stage of cerebral disease, — the attendants actually congratulating themselves on its quietness. It is not un- common to find one or more of the extremities quite paralytic in the young infant, without any notice having been taken of the circumstance. There is another expression of countenance, very different from that last described, but which denotes much suffering. The lips are retracted, or drawn, so as to show the teeth or gums ; the counte- nance is pale, or sallow and sunk ; the child seems to dread motion, lies on its back with the knees bent or drawn up, and is pained by pressure on the abdomen. Here neither the brow is knit, nor the pupil of the eye affected. The skin is very hot, shrivelled, and harsh; there is much wasting, great thirst, particularly for cold water, and a distinct diurnal exacerbation. The tongue is much loaded, or dry, red, and pointed ; aphthae may be present ; and di- arrhoea constantly attends, — the stools being generally thin, green or dark brown, and fetid. The abdomen is here obviously the seat of disease ; and such a state of things often occurs at the period of weaning, as the' state before depicted does during dentition. During the autumnal season, we often see an infant lying sunk in * Occasionally the neck is stiff or retracted. DIAGNOSIS. 63 the nurse's arms — the face is pale, the features sharp, the counte- nance betokens distress ; it may be that the eyes are sunk, and the skin around them, as also the lips, dark-coloured. On our first query, we will be told that the child lias vomiting and purging ; but a look was suilicient to tell us the nature of the case. When a child coughs, the eyes are red, and the nose runs, with sneezing or snullles, we know that it has a catarrh, but cannot say whether it may not be getting measles, or some epidemic then pre- vailing : we will therefore be cautious in our diagnosis, until the case has shown some more determinate symptoms. Cough is a usual attendant on affections of the chest, and cough in the child is often violent or spasmodic. In the young infant, we must recollect that pertussis may be present without any whoop. When the larynx is the seat of disease, the cough will be acute or hoarse, according as inflammation or ulceration be present, — but almost always spasmodic. The peculiar crowing cough of croup is well known, but cannot be too early recognized. The young child almost always swallows any matter expectorated, and therefore this can scarcely become an object of diagnosis. Some of the false membrane in croup, however, is occasionally coughed up. We should always recollect the influence which ex- pectoration swallowed may have on the stomach and bowels, and allow for the effect which it must produce on the appearance of the stools. The quantity of mucus thrown out, on even slight irritation of j. the mucous membranes, sufficiently accounts for the loud wheezing, Jj or rr//e, heard during the existence of pulmonary inflammation in /' the child ; and this circumstance alone need not cause the alarm it often does. Antecedent to the information to be derived from auscultation, we have intimation from the expression of the countenance, and at- titude of the child, as to the chest being the seat of disease. When acute or extensive inflammation is present, the respiration is hurried, the countenance discoloured, the eyes more or less staring, and the alae nasi in quick motion. Respiration is carried on more or less by the aid of the diaphragm and abdominal muscles; while the thorax remains comparatively quiescent. On the contrary, when the abdomen is the seat of the inflammation, it is by the thoracic muscles that respiration is carried on, the abdominal remaining quiet, and the alae nasi unaffected, though the breathing be hurried. The deep depression noticed at the scrobiculis cordis and the upper part of the sternum, when respiration is very difficult, indicate a severe degree of pleuro-pneumony; but our intention here is not to forestal the diagnostics of particular diseases of the chest, but to furnish a general sketch by which thoracic disease in the child may readily be recognized and distinguished from disease of the other cavities. It is very necessary, but often difficult, to determine the existence of pain and its seat in the child. Having ascertained that uneasi- 64 MANAGEMENT AND DISEASES OF CHILDREN. ness or crying does not originate in consequence of the child being hurt by any part of its dress, — we observe whether it puts its hand to the head, throat, or other place, as if indicating distress; and if this indication be corroborated by other symptoms, we may con- sider that part to be a seat of suffering. We have thus been led to detect otitis in the infant, when its cries could not otherwise be ac- counted for. Picking of the lips and nose is, however, a well- known indication of intestinal irritation. We must be cautious not to credit a child's statement of its having pain (or, as it generally expresses it, 'being sick,') in the head or stomach, without getting it to point to the part it complains of, but which it often misnames. The peculiar expression of the countenance also assists us: the brows being contracted, when the uneasiness has its seat in the head ; the lips drawn and apart, when in the abdomen ; and the alse nasi in motion, when the respiration is impeded and painful. The softness of the muscles or degree of emaciation to which a child is reduced, are important in diagnosis, but not to be judged of by merely regarding the face : this may appear full and firm, and yet the rest of the body be much reduced. In mesenteric disease, the emaciation proceeds steadily, but may be slow in progress. Derangement of the intestinal mucous mem- brane is soon attended with softness and wasting of the muscles ; and in protracted cases the emaciation becomes extreme — the skin being harsh, dry, and wrinkled — the countenance assuming an ap- pearance of old age that looks almost unearthly. We are often consulted respecting cutaneous disorders in children, which, from the delicacy of their skin, are very liable to occur, and often assume a very formidable aspect. It will be particularly necessary to be familiar with the forms in which itch or psora may be presented, as it appears often in a very severe form, and has been taken for a syphilitic eruption ; while syphilis is at times over- looked, and the child perishes before the true nature of the disease is discovered. III. PROGNOSIS. Determining the nature of a disease will often at once decide our prognosis. Thus trismus nascentium is almost necessarily fatal ; and a particular form of hydrocephalus generally so ; while syphilis, however severe in the infant, may almost certainly be cured : and so of other diseases. In no class of complaints is correct diagnosis of more importance than in children's, as so much of the danger arises from their not being distinguished in sufficient time to allow of a prompt employ- ment of remedies. Thus all acute inflammatory affections are highly- dangerous in themselves; but if seen sufficiently early and detected, our prognosis may be favourable — so influential is adequately active treatment. When the acute stage has passed by, or been subdued, we have PROGNOSIS. 65 again excuse for a hopeful prognosis, even though some organic change may have taken place ; so vigorous in general is the infant constitution, and such powers of reparation does it possess. In general we may say that, however severely a child may be affected in the first stage of an acute disorder, or to whatever extre- mity it may be reduced in the progress of a protracted one, it will be wise not absolutely to give it up, however guarded be our prog- nosis. Few who had not witnessed it, would credit the immediate benefit to be derived from sufficiently energetic means in the early stages of the severest forms of infantile disease, or the apparently moribund state from which a child may be restored by judicious management. One evil arises from early despairing of a child, which the practitioner should keep in mind and guard against. The attendants, who are always ready to give up administering medicines, which they often look on as only a source of annoyance, will from that time do nothing ; and thus children are allowed to perish for want of proper perseverance in the administration of the remedies prescribed. On the other hand, we should inquire carefully as to the plan of treatment that has been pursued with a child which has been long ill, and which may be brought to us in an apparently hopeless state, and, before we pronounce an opinion, see whether that state be not owing more to the remedies employed than the original disorder. Thus we often see children run down to the last extremity by incessant purging, which will almost of itself cease, if the little powders which it has been for so long taking be but discontinued : these powders almost invariably consisting of calomel, or some other highly irritating medicine. Or, a child which appears to be in the last stage of hydrocephalus, may be found, on examination, to have been brought into this state by the excessive evacuations to which it has been subjected : and of course, the mistake being dis- covered, our prognosis may be more favourable than it otherwise would be. Again, if we find our efforts to subdue inflammatory action inef- fectual, though apparently sufficient for the object proposed — that in fact the child, though relieved after each application, is again quickly thrown back, — we may suspect improper interference on the part of attendants, who are usually in dread of the little patient being too much weakened. By at once charging them with the delinquency, or expressing our opinion that now some stimulant would be beneficial, we shall in general obtain a confession, made either in contrition or exultation — the attendants owning their fault, or boasting of their sagacity in knowing that wine or spirits was required, and having administered it accordingly. Having thus discovered the source of failure in our remedies, our prognosis may improve accordinglv. W e have noticed the liability to the occurrence of sympathetic affections in the child. In them there is less danger than the same symptoms would indicate did they belong to a primary disease, 66 MANAGEMENT AND DISEASES OF CHILDREN. particularly when the true nature of the case is early detected, and the primary source of disease removable. We must keep in mind, however, that functional disorder, if con- tinued, will change into organic disease (particularly liable to occur in the child), and guard our prognosis accordingly. This tendency to sympathetic affection, or disease arising seconda- rily during the progress of any disorder, in the child, is itself a par- ticular source of uncertainty and danger ; and must make us always guarded in promising absolute recovery in any complaint that has to run a certain course, or shows a tendency to become protracted. Thus remittent fever, however slight at the commencement, is liable to be tedious in its course — and so time is allowed for the occurrence of sympathetic affections of the head or chest, which but too often supervene. In no disease is the necessity for this precaution better exemplified than in pertussis. We have already pointed out the greater liability of some of those sympathetic affections to occur than others. It now remains to no- tice the degree of danger with which these complications are liable to be attended. This will mainly depend on the facility with which the original disease may be removed, or the degree of inter- ference with treatment which the complication involves. Thus the combination of pulmonary inflammation with gastro-enteritis, or the occurrence of either during the existence of the other, is particularly dangerous from both sources. When the head becomes engaged during the existence of pertussis, the danger is augmented in con- sequence of the persistence of the primary disease, which has to run its course ; — and the occurrence of gastric, or intestinal irritation, during affections of the head, adds much to the danger by embar- rassing the treatment. The type of the prevailing epidemic will give us an early inti- mation as to the liability of danger, in many instances. There are times when measles and hooping-cough are comparatively mild complaints ; while, again, a most dangerous character, or malignant type, will prevail — and to be attacked, is to be in danger. When an hereditary disposition to the occurrence of particular diseases of childhood exists, such diseases when they occur must be looked on unfavourably, and all preventive means should be adopted to avert them. The same rule holds good with respect to disorders arising from particular situations. One peculiarity in the symptoms of disease, as it approaches a fatal termination, is often manifested in the child in so remarkable a degree, as in a special manner to call for precaution, to prevent our being signally misled in our prognosis. We allude to the remission, or at times total absence, of severe symptoms, which in truth ushers in death, but by the unwary will be taken as the harbinger of recovery. In no instance is this more striking, than in affections of the head in the child. Consciousness or even intelligence may be suddenly restored, just as death was expected — but they come only to mark the fatal moment. GENERAL OBSERVATIO.'n G7 CHAPTER IV. INFANTILE THERAPEUTICS. I. GENERAL OBSERVATIONS. In nothing are the peculiarities of infancy more remarkable than in the influence which they exercise over the action and uses of medicines. Most medicines act with great energy on the child, and some have a peculiarity of action differing from that on the adult ; while all require to be given in diminished doses, regulated by the age. If attention be not directed to these points, the practi- tioner can hardly fail to meet with embarrassment in treating infantile disease. An attempt was long since made by Gaubius to express with arithmetical precision the difference of dose according to the age ; and his table is useful, though not always implicitly to be followed. According to his arrangement, if the dose for an adult be 1, half the quantity will be the dose at fourteen years of age (or puberty), half this, or a fourth, at four years of age, and half this again, or an eighth, at two years. Expressed in a tabular form, with the inter- mediate ages from childhood, the table will stand thus : Dose for an adult, 1 say 1 drachm, For a child 7 years old, ... £ — 1 scruple, 4 years old, ... £ — 15 grains, 3 ... 1-6 — 10 grains, 2 ... i — 8 grains, 1 and under, 1-12 to 1-15 — 5 or 4 grains. We have here a useful general index; but to attain facility in prescribing, attention must be paid to the several medicines; and, as it may prove convenient, we shall subjoin formulae for them. The number of medicines given to the child is not great, and we are restricted in administering them to the liquid form or that of powder: when insoluble, the powder should be given in some ve- hicle sufficiently thick for its suspension, so as to ensure its being swallowed. Sugar is usually added to medicines for children, to render them more palatable ; and we should try to select such drugs as are free from strong taste or smell. — The dose should not be bulky: hence very light powders (as pulvis sennae) are inconvenient. The dose of liquid medicines varies from a tea-spoonful or drachm to a dessert-spoonful or two drachms, and a powder should not ex- ceed ten grains. Medicine is not required in all cases of illness in the child, alter- ation of diet or in the mode of management being often sufficient, 68 MANAGEMENT AND DISEASES OF CHILDRExN. and in many instances very mild remedies will suffice. This is no excuse, however, for giving nothing but ptisans or syrups to infants, and so letting them perish in acute disorders through fear of using adequate means. When obliged to employ active measures, it is necessary to be prompt in their application, and carefully to look for the earliest moment when their use may be suspended, and milder means resorted to, or the case left to the resources of nature, which in infancy are so powerful when the strength is not too much broken by the protracted use of depletion. We must be attentive to support the child by suitable nourish- ment during illness; at least, it must not be left too long without some kind of sustenance, as the infant cannot exist many hours without food. During febrile or inflammatory complaints, this must be restricted to barley-water, whey, or very thin gruel ; even the breast milk may be too stimulating, and will require to be mixed with water or exchanged for lighter drink; but this must be sup- plied at sufficiently short intervals. During depression or convalescence, change to a more nourishing food than usual will serve, to a certain degree, as a substitute for stimulant or tonic medicines: so susceptible of excitement is the child. Change of air exercises the most beneficial influence in infantile disease, often putting an end to protracted illness in a few days. With the child we can avail ourselves of this measure at an earlier stage of acute disorders than with the adult. Being brought abroad or changed to another room in the same house (if more elevated and airy), will always be useful ; and we cannot be too particular in insisting on the apartments of a sick child being kept cool and airy, at least sufficiently ventilated and of an equable temperature. II. mercury. Of the medicines which have a peculiar action, one of the most remarkable is mercury, which is often given in an empirical manner to the child. Mercury does not seem capable of salivating an infant. We have never seen it do so, nor do we know of any such case upon re- cord. Our experience agrees with that of Dr. J. Clarke, as we never succeeded in salivating a child under three years of age. The pushing of mercury, then, in inflammatory diseases, so as to induce salivation, as we do with the adult, cannot be practised with the young child ; and on this account we are impeded in the employ- ment of one of our most important agents in the treatment of acute inflammations — as croup, meningitis, hydrocephalus, &c. &c. This is the greater loss in consequence of the liability to gastric or intes- tinal irritation in the child, which, when occurring during the ex- istence of pulmonic inflammation, prevents our being able to employ tartar emetic. Some consider that mercury exerts a special influence in con- SEDATIVES. 69 trolling inflammatory action, independently of salivation ; and on some such ground, calomel is constantly administered to the sick child. It is more rational, however, to look to the influence which mercury is acknowledged to exercise upon the secretions, and which is particularly manifested in the child ; hut this, though hene- ficial, falls far short of a specific influence in arresting inflammation, and is liable to do mischief, if not cautiously resorted to. In connexion with this power, mercury has the character of quickening the action of other medicines, and so ensuring their effects; and hence it is often joined with diaphoretics, expectorants, cathartics, &c. It is its action on the intestinal canal, and particularly the biliary secretion, that is most manifest in the child ; and some give a pre- ference to calomel as a purgative for infants. No mistake can be greater: though occasionally useful, it is at all times liable to create intestinal irritation, and its continued use is certain to cause it, — producing griping, diarrhoea, and green stools. This irritation, however, is sometimes resorted to in the treat- ment of cerebral affections, as a source of counter-irritation. On the other hand, the occasional use of a mild mercurial is serviceable, by restoring the natural functions, when the stools are very foul and unnatural in appearance. Calomel is the preparation of mercury most frequently employed with the child. Blue pill is an inconvenient form, but might be given bruised down in some liquid. Hydrargyrum cum creta vel magnesia are mild mercurials — and from their mildness and combina- tion with an antacid, are peculiarly suited to the bowels of children, when acidity is present, with or without diarrhoea. Calomel may be given alone to act on the bowels, in doses of from one-fourth to one or two grains at most, and usually requires to be followed, in two or three hours, by a dose of castor oil, or other aperient. Calomel is more usually given in combination with other medi- cines, as purgatives, to quicken their operation; or with ipecacuan, as an expectorant or diaphoretic. The dose is usually i or \ a grain, or at most a grain, repeated every second or third hour. Its value in such combinations has been already alluded to. The hydrargyrum cum creta is particularly given when diarrhoea is present, and a mercurial indicated ; but in this case the dose must be small (not exceeding one grain), or combined with an opiate. Hydrargyrum cum creta alone is by no means to be taken as a cure for diarrhoea, as some seem to suppose; and even when guarded by an opiate, any mercurial is, in certain cases, injurious. III. SEDATIVES. Irritation is a usual attendant on infantile disease, which often arises directly from this source; and in all cases, nervous suscepti- March, 1S3S.— K S 70 MANAGEMENT AND DISEASES OF CHILDREN. bility to a greater or less degree is present. Hence we are prepared to expect much good from the employment of sedatives, which are often indicated, but concerning the use of which a very general apprehension appears to prevail. This has probably arisen from the injurious, or even fatal results, which have followed the admin- istration of soothing syrups, &c. to young children by ignorant at- tendants. The ingredients of such compounds, or at least the quan- tity of narcotic which they contain, are seldom known ; so that their employment, even by the regular practitioner, is dangerous, inde- pendently of the objection that recommending such fosters popular prejudice respecting the ignorance or indifference of medical men about infantile disease. Hence the physician should d\\\ ays formally prescribe them ; and from no class of medicines does more signal service arise, when judiciously administered to the child. Opium acts with much energy and rapidity, particularly within the first few months after birth, and due caution must be exercised in prescribing it. But when once the proper dose with which to begin is known, and we are aware of the quickness with which it acts, and the length of time during which its influence lasts, we can avoid the danger of an over-dose, or one too frequently repeated. Conditional orders should be always given to suspend the medicine while the child sleeps, or until the symptoms have returned. The in- fant frequently begins to slumber immediately on the administration of the first dose of the medicine, and continues to sleep for several hours,— the effect lasting from four to five hours or more at a time. Hence an opiate should not be renewed oftener than every third or fourth hour, — twice or thrice a day being in general sufficiently often. In some cases, however, it may be required so often as every hour or half-hour, until the desired result is attained, as in severe cholera, but its effects much in such cases be narrowly watched. The in- fluence of opium is more immediate and remarkable when the tinc- ture of opium, or the pulvis cretae comp. c. opio, are exhibited, than the syrup of white poppy, or Dover's powder, though the doses be equivalent. Syrup of poppy is generally preferred as the opiate for children ; but it is uncertain in its strength, being liable to spoil or be adulterated. When genuine and well-preserved, one ounce is considered equivalent to a grain of opium ; so that thirty drops, or half a tea-spoonful, would be equal to 1-16 of a grain of opium, or about a drop of laudanum : this would be the dose for a child two or three months old. During the first month, however, we would not advise more thon 5 or i of a drop of laudanum to be given at once until the effect was tried, — even this minute quantity occasion- ally producing more of a narcotic effect than a much larger dose of syrup of poppy. The best and safest form for exhibiting opium to the young infant is by diffusing a given quantity of laudanum in a mixture with simple syrup, so that the dose will be always definite, however minute, as in the following formula, which we name the simple sedative syrup. SEDATIVES. 71 No. 1. Syrupus Sedalivus Simplex. R Aqua; Distillata? ^i Mucil. Gum. ac. ,^ss Syrupi Simplicis ,^ss Tincture Opii gnttam. M. A tea-spoonful will be the dose, repeated every half hour till rest be procured ; but after the first month, double that quantity may be begun with. At the third month, half a drop of laudanum may be given for a dose, — one drop at six months old, — and two after the first year. The sedative influence of lettuce or orange-flower water would point them out as eligible vehicles, instead of the distilled water in this mixture ; but not being officinal in our Pharmacopoeias, they are not always to be obtained. Laurel water, however, can always be procured, and it is a seda- tive peculiarly serviceable in allaying pain, spasm, or convulsion, arising from intestinal irritation in the child. Hence we propose another sedative mixture to be called No. 2. Syrupus Sedativus Compositus. R. Mucil. Gum. ac. ^ss Aquae $i Aquae Lauro-cerasi gtts. iv. Syrupi Aurantii ^ss Tincturae Opii guttam. M. If we wish to obviate costiveness while using this mixture, syrup of violets may be used instead of simple syrup, or a drachm of rhu- barb wine added. If, on the contrary, we wish to check diarrhoea, allay pain, or remove flatulency, — arornatics, alkalies, or astringents, may be combined. Dover's powder is a mild and safe opiate for the child, and less liable to disagree than perhaps any other. From ^ to \ a grain may be given at a dose, during the first three months ; and from one grain to two, after a year old. The compound powder of chalk with opium acts more energetically, and must be used with greater caution. The very small quantity of opium present, however, enables us to give it apparently more freely: from half a grain to a grain will be borne during the first six months, and two grains after that period, three times a day, or four grains by a child two years old. Narcotics readily produce their effect when applied to the skin of the child, so delicate and susceptible is the cutaneous surface. In this manner, tincture of digitalis is often used in continental practice ; and an English practitioner, Dr. Bow, extols the use of opiate fric- tions in the inflammatory affections of children. The form he em- ploys is as follows ; and he relates many cures effected in this way. No. 3. Dr. Bow's Opiate Liniment. R Opii 31 Linim. Camph. comp. £i Digere per dies aliquot et effunde linimentum. 72 MANAGEMENT AND DISEASES OF CHILDREN. Sleep being almost as essential to the child as food, we can scarcely fail to benefit it by inducing a state of rest during illness, and this the use of opium seldom fails to do. Many alarming symptoms, as screaming, spasm, or convulsion, may be thus mitigated, or at once removed, if dependent on irritation alone. When using narcotics for such a purpose, however, we should examine into the cause of irritation, and try to remove it, while we palliate the symptoms, — as, for example, by dividing the gums, or freeing out the bowels, if required ; and in inflammatory cases, depletion should always pre- cede or accompany the use of sedatives. After blood-letting, opium appears to possess, in some instances, a distinct influence in con- trolling inflammatory action, more especially when seated in a serous membrane. In cerebral irritation, or in meningitis, after depletion, the beneficial effects of an opiate in procuring rest and tranquillity is often very remarkable; but in this case judgment and experience are particularly required, as cerebral irritation is very liable to pass into congestion in the child, and inflammation to end in effusion ; and the narcotic effects of an opiate would tend to obscure or aggravate the symptoms, and might increase the liability to congestion. The irritable or spasmodic character which often belongs to the cough or breathing, in the pulmonary affections of children, is generally miti- gated, and at times removed, by the use of an opiate; and some tincture of opium, or Dover's powder, is a useful adjunct to expec- torant medicines, which are also better borne by the stomach when thus combined. In all cases of gastric or intestinal irritation, whether sympathetic or not, opium is a chief resource, and must in severe cases be ad- ministered in a decisive manner. An injection containing one, two, or three drops of laudanum, according as the child is three, six, or twelve months old, will often at once check a diarrhoea which had lasted long, and been in vain treated otherwise. IV. ALKALIES AND ALKALINE EARTHS. These exert a decided sedative influence, especially upon the mu- cous membranes, when in a state of irritation or chronic inflamma- tory action ;. while they, at the same time, alter and improve their secretions. Their antacid properties, in addition, render them pe- culiarly eligible in the treatment of infantile disease; and we have often experienced their utility, more especially in controlling gastric or intestinal irritation. The stomach may be thus often quieted, and many of the more distressing attendants on diarrhoea or dysen- tery removed. They mitigate pain and spasm, appearing to restore or equalise the peristaltic motion. Tenesmus is often speedily re- moved by the use of one of these alkalies, and the character of the stools altered, their fetor being destroyed. In pertussis, or in spas- modic cough, they tend much to mitigate the severity of the symp- toms ; and in the advanced stages of bronchitis, &c, the alkalies, in addition, exercise an influence over the morbid action, causing the phlegm to be less viscid, and consequently more easily excreted. CARMINATIVES. 73 In prescribing these medicines, however, we must not employ them in the early Btagei of inflammation, and we must be careful to exhibit them sufficiently diluted or guarded by some mucilaginous men- struum. Combination with opium, or its alternate use, adds much to their efficacy, and is generally adopted. According to the object in view, will we combine, or select, the alkali we would employ. In general, the bi-carbonates are prefer- able to the carbonates, as being less caustic; and, for this reason, - carbonate of soda is preferable to carbonate of potash, as well as because it is not dilequescent, and therefore may be given in the ■ form of powder ; but these objections do not apply to the bi-carbo- , nate of potash, which should therefore be preferred to the carbonate. When the stomach is very irritable, the liquor of potash, or lime 1 water, will often answer best, or magnesia, if the bowels be confined. i When the bowels arc irritable, chalk in the form of pulvis cretae compositus, with or without opium, is usually selected ; or chalk mixture instead. Where the stomach is at the same time irritable, : however, carbonate of lime will not be borne ; and we choose car- bonate of soda, or better, bi-carbonate of soda or potash. If much flatulency be present, with acidity, any carbonate is objectionable : the additional extrication of gas, caused by its decomposition, adding to the distress and oppression. A few drops of liquor of ammonia, or of its aromatic or fetid spirits, will answer best in this case — often putting an end at once to the flatulency, as well as acidity, by its stimulant or alkaline properties. Should the action of a stimu- lant be objectionable, calcined magnesia should be preferred. V. CARMINATIVES. A stimulant action is often looked to as a principal agent in restoring the mucous membrane to a healthy tone. For this pur- pose, an aromatic stimulant is usually preferred, and some of the distilled waters, or a few drops of an aromatic oil, diffused through • the mixture selected. Indeed, with some, no medicine is prescribed for a child, without the intervention of dill or fennel water ; but this is objectionable, when unnecessary, as their strong odour is always offensive, and adds much to the disgust for medicine. To all these aromatic waters is attributed an anti-flatulent or anti-spasmodic action ; but to some, peculiar properties are ascribed. Thus mint water is selected when the stomach is irritable ; but in such cases the simple or compound infusion of mint, or fresh mint tea, is pre- ferable. Cinnamon water is chosen when the bowels are the seat of irritation. On such principles are constructed the carminative mixtures so commonly given to children when affected with gripings, acidity, flatulency, or convulsions ; and when these arise independ- ently of inflammatory action, those mixtures arc often of great uti- lity. But we must be careful to avoid stimulants when such symp- toms are connected with inflammation of the stomach, bowels, or any other organ. S* 74 MANAGEMENT AND DISEASES OF CHILDREN. The most celebrated compound of this description is Dalby's car- minative,* the prescription for which we give in a note ; but some of the following formulae, which are more simple, will be found convenient : No. 4. Mistura Jlnti-emetica. R Infusi Menthas ^i Mucil. Gum. ac. ^ss Liquor Potassas gtts. vi Syrupi Aurantii §ss Spir. Lavendulae c. ^ss Tinct. Opii gtts ij M. 3i — Jij nor^ quaque 2da sumat. In irritability of stomach with flatulency and acidity, or diarrhoea, when much griping or spasm is present without inflammatory action, the following mixture is to be employed — to which a drachm of tincture of rhubarb can be added, to ensure a purgative effect, if desired : No. 5. Mistura Carminaliva. R Aquae Carui §i Mncil. Gum. ac. Sjss Magnesias ustas gr. xxiv. Olei Cajeputi gtts. iv. Syrupi Croci ,^ss Spir. Ammonias Fcetid. Jss ]\f t 2jss — 5'J ter indies sumat. The stimulant effect of this mixture can be increased, when depression attends, by the addition of half a drachm of compound spirit of lavender, or one scruple of nitrous spirit of ether, or Hoff- man's anodyne liquor. Four drops of laudanum may be added to the foregoing mixture, when an anodyne effect is desired. VI. STIMULANTS. Much caution is required in administering stimulants to the child, as excitement is easily induced, and the depression often attendant on local disease increased, instead of being diminished. Great mis- chief is thus done by the improper administration of stimulants to infants, to whom they are commonly given to expel flatus, allay pain or spasm, and throw out eruptions, or stimulate the child when thought to be debilitated during the progress of inflammatory affec- * Dalby^s Carminative. R Aquas Mentha? Piperita? 51J Carbonatis Magnesias ^ij Olei Menthas guttam — Anisi guttas iii Tincturas Castorei $ss Cardam. Comp. 5ss Assafcetidae gtts. xv. Spiritus Pulegii gtts. xv. Tincturas Opii guttas v M. STIMULANTS. 75 tions, particularly of the alimentary canal. When exhibited in such . all the .symptoms become aggravated : and vet their use is often persevered in to the last. \\ e must not fall into the popular notion that the diseases of children arise from debility — an error of which even Sydenham seems to have partaken, often prescribing ammonia in infantile disease. When a stimulant is required, as in cases of sudden sinking or much depression, such as attends severe vomiting and purging, the volatile alkali is one of our best for children, being quick and tran- sient in its action — not likely to disturb the head, or give rise to continued excitement, as alcoholic preparations do. Hence aro- matic tinctures, wines, &c. should seldom be given to the child ; but the aromatic waters, volatile oils, or some of the milder aro- matic spirits, may be commonly employed as vehicles or adjuncts. During the course of the eruptive fevers, when the eruption has receded, or come but scantily out, some stimulant may be required ; and when these fevers assume the typhoid type, stimulants must be employed ; but their universal use in measles, small-pox, &c. &c. as practised by some, cannot be too strongly reprobated. When restlessness, spasm, or convulsions, arise from exhaustion, as in cases where depletion has been carried too far, or illness has been long protracted, a stimulant is most beneficial ; but if used as an anti-spasmodic where such symptoms arise from an opposite cause, as they generally do, an aggravation of every symptom will be induced. The following will be found a good general stimulant for the child : No. 6. Mistura Excitans. R Aquae Menthac 5iss Spir. Ammonia? Arom. 5s9 Spir. (Etheris nitrosi gtts. xij Spir. Lavendulae Comp. ^l Syrupi Caryophilloruin Jss M. 5i hora quaque secundd. Turpentine, as a stimulant and anti-spasmodic, is peculiarly adapted for children — one or two drops often at once removing flatulency or spasm. In protracted diarrhoea, its action is most serviceable : and it has also anthelmintic powers, which recom- mend it in particular cases. The following formula will be found convenient : No. 7. Mistura Tercbinihinata. R Aqua? Anisi 51 Mucil. Gum. ac. ^ss Olei Terebinth. Rect. $ss Olei Limon. volat. gtts. iv Syrupi Caryophill. 5iv M. 5* — 5'J hora quaque 3tid. 76 MANAGEMENT AND DISEASES OF CHILDREN. VII. TONICS. Children often require tonics during convalescence, or in" the advanced stages of inflammatory and febrile disorders ; but they must be tried with caution, and used very moderately, as they are much more liable to induce excitement than in the adult. A prin- cipal object in giving tonics to the child is to restore appetite, as when once that is established, strength will soon be renewed by the use of nutritious food. For this purpose any of the simple bitters, or sulphate of quinine, may be used. The infusions of columba, gentian, hop, or chamomile, given in doses of two drachms or half an ounce, twice or thrice daily, appear to be the bitters best adapted to the child ; but sulphate of quinine may be looked on as a substi- tute for all — and in sufficiently small doses can be given to the youngest infant, as in the following formula : No. 8. Mistura Corroborates* R Aquae Distillatss ^iss Snlphatis Quiniae gr. ij Acidi Sulphur, arom. gtts. xvi Syrupi Caryophillorum gss M. 5i — 3'J ter indies sumat. Iron and iodine are tonics of peculiar power, especially in the treatment of scrofula ; and hence often employed in infantile medi- cine. Their power in restoring appetite, when properly adminis- tered, is constant and remarkable, particularly so with iron. Iodine is liable to cause colicky pains, griping, or purging, with febrile excitement. It must be discontinued when such occur ; and so must all tonics, when excitement or fever attend their use. The tartrate of iron, which has little of the chalybeate taste and is very soluble, is the preparation generally given to children ; but the muriated or acetated tinctures will be found convenient, parti- cularly the latter. If the form of powder be preferred, the carbonate of iron can be exhibited ; but unless recently made, this preparation will probably be inert when given in the small quantity suited to a child. The black oxide or scales of iron are hence a better prepar- ation, though seldom prescribed. The tartrate is deliquescent ; but may be given in form of powder, (as follows) if not too long kept. No. 9. Fulvis Chalybeatus. R Tartratis Ferri et Potassae gr. ij Pulveris Aromatici gr. iss Sacchari duri gr. ij. M. Unum pulverem talem ter quaterve indies sumat. The tartrate will, however, be best given in solution : and we are provided in the Pharmacopoeia with such a preparation, in the vinum ferri, which may be given in doses of from five to twenty drops. In similar doses we may give the tinctura ferri acetatis, which, however, has a strong chalybeate taste, but this is somewhat con- cealed by giving it in whey or asses' milk. The tinctura muriatis ferri is still more styptic in taste, but a very powerful preparation, ANTIPHLOGISTIC PLAN OF TREATMENT. 77 and therefore to be given in but half the dose and well diluted. It may be combined with the muriate of lime of baryta ; and hence its utility in scrofula is enhanced. /ot/inr, HO the form of tincture or hydriodatcd solution, can be safely administered to the youngest child. From one to five drops of either preparation may be given at a dose, in some sweetened water ; but sugar should not be added until the dose is about being taken, as decomposition would otherwise occur ; and distilled water alone should be ordered for the solution of iodine. The tincture when recent, is precipitated on being added to water : but this does not occur when it has been some time kept ; and it is altogether one of our best preparations of iodine. No. 10. Solutio Iodinii Hydriodata. R Aquae Distillatce 51J Iodinii gr. v Hydriodatis Potassas gr. x. M In cachectic states of the system, such as we often see in children which have been neglected or mismanaged, iodine is most useful as a stimulating tonic, especially if unhealthy inflammation, or ulcera- tion, tending to sloughing, be present, as in pemphigus, &c. In glandular enlargements, which occur so generally at a young age, it is unnecessary to point out the utility of iodine. VIII. ANTIPHLOGISTIC PLAN OF TREATMENT. The class of remedies which we shall have most occasion to use in the treatment of infantile disease, is that which is employed to combat acute inflammation: and hence called antiphlogistic. These remedies act principally by depletion, or as evacuants ; but we must not forget that a certain part of their action is stimulant, — especially exciting some organ or tissue, as the kidneys or skin, and so produ- cing a diuretic or diaphoretic effect. This is most manifest in the case of cathartics, which often irritate the bowels, as well as purge, — thus acting more or less as counter-irritants, some of their reme- dial power arising from this source. This action may, however, be carried too far, so as to do injury by the special irritation thus pro- duced, which may also prevent the expected evacuation, and aggra- vate, or even create, locaL inflammation. Much mischief arises from overlooking these circumstances in the treatment of childrens' dis- eases ; for in consequence of the susceptibility of their organs, this irritative action is peculiarly liable to be carried to an injurious degree. Thus it is that we see intestinal irritation induced by pur- gatives given to children, until nothing but a little bloody mucus is evacuated ;. or stimulating expectorants employed, until expectora- tion has been suppressed, and a slight catarrh changed into a severe bronchitis. These, errors we shall avoid by recollecting that the use of evacu- ant medicines is not necessarily followed by evacuation, as their 78 MANAGEMENT AND DISEASES OF CHILDREN. names (purgatives, diaphoretics, &c. &c.) would imply, unless the necessary precautions be taken to ensure such results. These are, to employ only the least stimulating in the earlier stages of inflam- matory disease, and to premise direct depletion when required. IX. BLOOD-LETTING Is the first step in the antiphlogistic plan of treatment, and the most powerful, not only in subduing inflammation, but in ensuring the beneficial results of the other remedies — most evacuants acting with more speed and certainty when blood-letting has been premised. In the child, more particularly, bleeding is required in the first stage of all acute inflammations. It may be practised with safety in the youngest infant, provided we hold in view the relation between the necessities of the case and the strength of the patient — the only true rule applicable to depletion in old or young. Repetitions of blood-letting are not well borne by the child ; and hence an additional reason for its prompt employment when necessary. In the infant, or young child, we can seldom draw blood from the brachial veins, which are usually small and obscured by fat. We can generally, however, procure as much as we require from a vein on the dorsum of the foot, or back of the hand, or when these fail, from the jugular vein. The latter might be often opened in inflam- mations of the head or chest, with peculiar advantage, on account of the vicinity of the disease ; but it is sometimes difficult to stop the bleeding — and the employment of a bandage is here badly borne, especially when the respiration is affected. Leeches, however, can always be applied, and will take a sufficiency of blood to answer all the purposes of general bleeding. The safest place for their appli- cation is the hand or foot, as we can then ensure stoppage of the hemorrhage at any moment, by the use of a compress and bandage. When applied in other situations, as the chest, throat, &c, leeches have led to fatal results, by a continuance of hemorrhage. They may, however, in affections of the head, be safely placed over the mastoid process, as we then have a firm point of resistance upon which to make pressure, should they continue to bleed. When simple compression by means of the finger and a dossil of lint fails in restraining the hemorrhage from the bites of leeches, which have been placed in a situation forbidding the use of a bandage, we must dust the part with some dry powder, as starch or gum arabic, or, if this fails, press a fine pencil of lunar caustic into the wound. It may be even necessary to pass a needle through the lips of the bite, and wind a silk thread around it, in the mode adopted in securing the vein of a horse. The quantity of blood to be taken must, of course, be determined by the urgency of the symptoms. It should be always sufficient to make an impression upon the system — of which we judge best in the child by observing the colour of its lips and cheeks : the former BLISTERS. 79 especially quickly indicate the approach of faintncss hy the paleness which they assume, and arc a much hetter guide than the state of the pulse, which is very variahle. As a general estimate of the absolute quantity to be removed, we may say. that during the first year, from an ounce to three ounces, or two or three leeches, will be I sufficient bleeding ; and after the first year, we may usually take an additional ounce for each year of the child's age — seldom having occasion within the period of childhood to exceed eight ounces. The buffing of the blood is not a safe guide in the child, as we have diseases absolutely requiring bleeding, (e. g. croup, bronchitis, &c.) which seldom produce in the blood the appearance in question. X. BLISTERS Are much employed in the treatment of inflammatory affections in children, and, when judiciously used, are signally efficacious ; but, as they induce much local and constitutional excitement, very injurious consequences follow their improper application. Hence, blisters should never be used in the early stages of severe inflammations, as a substitute for bleeding; -nor should they even follow soon after the employment of this remedy, unless a decided impression is made on the local disease and fever — otherwise, both will be aggravated by the effects of a blister ; and we have had occasion to order repe- titions of bleeding, which would not have been requisite, had not acute symptoms been renewed in this way. Some attempt to obviate these effects by applying them at some distant part (as one of the extremities), in the first instance ; and such practice is common on the Continent, in the abdominal and cerebral inflammations of infants ; but the plan is not very efficacious, while it is accompanied by all the risks attendant on excess in the local irritation. We therefore prefer waiting until the proper time, and then applying the blister near the affected organ. The violent local irritation which often follows the application of a blister to the surface in childhood, — leading to sloughing, gangrene, and death, — is a serious objection to their use, and requires that particular care be taken to lessen the liability to such a disaster. To effect this, we guard against the too irritating action of the blistering plaster by using it of only half the ordinary strength ; or we protect the surface by the interposition of some thin substance, as fine muslin, or silver paper. In no instance is the blister to be left on more than a few hours (^from two to four) — not longer, in fact, than until the skin is reddened, when vesication will follow ; but it should not be waited for, as attendants always will do, unless the most express directions to the contrary be given. When the blister is removed, the part should be dressed with simple cerate, fresh, and spread on lint, in preference to linen, which does not lie so smoothly on the part. Should the blistered surface become irritable, looking very red, and showing a disposition to inflame, the dressing should be changed for the use of some fine powder, as flour, starch, or prepared 80 MANAGEMENT AND DISEASES OF CHILDREN. chalk. This should he industriously applied, so as to keep the parts constantly dry, when frequently all symptoms of irritation will dis- appear. Should this not occur, however, but inflammation of the surface set in with surrounding redness, a soft poultice will be the best application ; raw cotton is occasionally employed from the first, as with scalds; and we have seen excellent effects from its use in some cases. According to the character of the irritated surface, however, and the attendant constitutional symptoms, our treatment must be guided, as to whether we are to employ soothing or stimulating ap- plications,— or attempt the destruction of the surface altogether, as by nitrate of silver. When the constitutional symptoms run high, and the ulcer is very irritable, we use emollient applications ; and of these, the following ointment, thickly spread upon lint, is that which we have found answer best. Its consistence prevents the necessity for frequent renewals, as it does not dry so quickly as the Carron oil, of which it may be looked on as a modification. We have seen it produce ease, in irritable ulcerations, when no other application could be borne. No. 11. Unguentum Sedativum. R. Aquae Calcis Olei Amygdal. a. a. ^ss Bene admisce et adde Adipis Preparatae %i Ft. Unguentum M. When the ulcerated surface is pale, with ash-coloured spots, and surrounded by a dull or livid redness, some stimulant application must be used, particularly if the accompanying fever assume the typhoid type (as in such cases it usually does). A favourite one with the late Dr. Cheyne was a lotion of camphorated spirits of wine and infusion of chamomile flowers (3i to the §), applied fre- quently by linen cloths ; but we prefer the fermenting poultice, or lotions of chloride of soda, more particularly if gangrene have set in, accompanied by fetid odour. An excellent mode of treating the surface in such instances, when it begins to slough, is to alter the action going on, by brushing it over with a solution of nitrate of silver (gr. x — $\ to the §i), and then applying a soft warm poultice, as much pain often attends the application. In these cases, the full employment of tonics and stimulants is essential to support the constitution, so as to preserve life. The child will rapidly sink, unless supplied with nutritious diet — broth, jelly, or arrow-root, with a little wine ; and the quinine or ammonia mixture should be freely given, according to the circumstances of the case. No mat- ter how acute the original inflammation may have been, it usually all disappears when sloughing takes place. Such result is liable to occur, when blisters are applied (no matter how cautiously,) to chil- dren much debilitated, or living in very unhealthy situations ; and we should be slow to employ them, if any disposition to unhealthy EMETICS. 81 ulceration has been manifested, as when spreading aphthae, pemphi- gus, cVc. arc present. The other antiphlogistic remedies, like Mood-letting, act princi- pally as evacuants — yet not exclusively so, some special influence appertaining to most of them, while several act in more ways than one, being Emetic, Diaphoretic, or Expectorant, according to the circumstances under which they are administered. We shall briefly consider each class in reference to infantile medi- cine, the variety of drugs employed in which is not great. XI. EMETICS Are often given to the child, and are particularly serviceable in the first invasion of inflammatory and febrile complaints, which they occasionally cut short, and very generally mitigate. During the progress of remittent or other fever, an emetic may induce crisis, or give a favourable turn to the complaint. It is in bronchial inflam- mations, however, that emetics are so necessary with the child, for clearing out the overloaded bronchial tubes; and at times they af- ford the only chance of relief, when suffocation threatens in conse- quence of the quantity of mucus secreted. The power of an emetic in thus mechanically freeing the air passages is remarkably exhibited in cases of croup, where portions of false membrane have been thus ejected. Emetics are not to be employed when the head is much engaged, or any gastric affections present. We should as- certain the type of a prevailing epidemic, so as to avoid the use of emetics at the commencement of the attack, when gastritis is liable to occur. In some epidemics, we have seen the vomiting, caused by an emetic, persist until death took place. The milder emetics, only, should be given to children — of these ipecacuanha is the chief. Tartar emetic may be administered, but is not to be chosen without good reason. Squill, though commonly given to infants in the form of syrup, is objectionable, its operation being violent, though certain. Ipecacuanha may be given as an emetic to the youngest infant, in doses of half a grain or a grain, blended with sugar, and repeated every quarter of an hour until it vomits; or ipecacuan wine may be similarly given, in doses of twenty drops, half a tea-spoonful, or a tea-spoonful. After a year old, these doses may be doubled, and repeated at shorter intervals. On Hie Continent, a syrup of ipeca- cuan, (containing 16 grains to the Ji,) is used as we use ipecacuan wine; or an infusion made by digesting 3'j of the root in %iv. °f boiling water, which may be sweetened and given in tea-spoonsful. Ipecacuan is a very certain, as well as mild emetic, and will occa- sionally vomit a child when tartar emetic has failed. The following is a good general formula for its administration : March, 1 838.— L 9 82 MANAGEMENT AND DISEASES OF CHILDREN. No. 12. Misiura Emetica. R. Aquffi^i Vini Ipecac, ^ss Syrupi Simplicis ^ss 5i — 5'J saePe aa" emesem. M. Tartnrized Antimony is a poweiful, though not always certain emetic. Its action is accompanied by much depression, and evacua- tion by the skin or bowels constantly follows its use. Hence it is preferred in severe inflammatory affections of the chest, and its use is afterwards continued as a contra-stimulant. Tartar emetic may be given in minute doses — from one-eighth to one-sixteenth of a grain — to young infants; but when much depression is present, or the acute stage of the disorder passed, ipecacuan or squill is. pre- ferable. When gastric or intestinal irritation is present, tartar emetic is generally inadmissible. No. 13. Mistura Emetica Antimoniata. R Aquae Distilkta^ i Liquor. Antimon. Tart. ^ ss Syrupi Simplicis ^ ss M. ri contains 1-16 of a grain ; and from one to two or three tea-spoonsful can be given every quarter of an hour till vomiting occurs. §ss of ipecacuan wine, added to the foregoing, will make the action more certain, but less violent. The addition of squill still farther adds to the efficacy of the compound, as follows : — No. 14. Mistura Emetica Composita. R AquseDistillatae^i Vini Ipecacuanha? ^ss Liquor. Antimon. Tart. Jij* Syrupi Scillae 3u M. 3i — 5'J saePe a<* emesem. Squill, though so generally given to infants as an emetic, is too stimulating for common use, and should never be given at first, but I in the advanced stages of pulmonary inflammation, or when other j emetics have failed. Syrup of squill, in half drachm doses, will be | certain to evacuate the stomach, when repeated sufficiently often, ] particularly if combined as above. We have met a few children j that resisted the action of all emetics, and had never been known to vomit. XII. EXPECTORANTS. All the foregoing medicines act as expectorants, when given in small and repeated doses, or so combined as not to vomit. Ipecacuan is that most commonly employed with children, and alone often suffices to remove slight catarrh, given in doses of a quarter or half a grain, three or four times in the day. In severe EXPECTOKANTS. 83 attacks of bronchitis, ipecacuan alone cannot be relied on ; but after the use of blood-letting, or tartar emetic, when the more acute symptoms have subsided, and much mucus is secreted, it is particu- larly indicated. It may be added to the emetic tartar, and given in mixture ; or in powder, united with calomel. A minute quantity of opium in the form of laudanum, or Dover's powder, is usually added, to allay the irritability of the cough, and enable the stomach to bear the expectorant. If the proportion of opium be too great, its effect is injurious, by suppressing expectoration and checking the cough, so as to add to the embarrassment of the breathing. No. 15. Mistura Expectorant. II Aquae Distillate 31 Mucil. Gum. ac. 588 Vini Ipecacuanha? 3u Syrupi Limonum ^i Syrupi Papav. Somnif. 31 M. 3Ji hora quaque secunda. This may be continued at longer intervals, or given between the doses of the following powder. No. 16. Pubis Ipecacuanhx et Calomelanos. R Pulv. Ipecacuanhae Submur. Hydrargyri a. a. gr. x Sacchari Albi gr. xx M. gr. i — gr. ij hora qudque tertia. One grain of this compound contains J of a grain, each, of hippo and calomel, and constitutes the dose until twelve months old : when two grains are to be given, half a grain or a grain of Dover's powder may occasionally be added. Calomel is thus frequently combined with ipecacuan, and in Bevere cases its junction does good ; but in common it is an objec- tionable practice, being also liable to irritate the bowels ; and when this occurs to any extent, the calomel must be suspended. Nothing embarrasses the treatment, or adds more to the danger, of inflammatory affections of the lungs, than complication with gastric or intestinal irritation. Tartar emetic cannot then be em- ployed ; and if mercury be given, it must be in very minute doses, and well guarded by opium. Our chief reliance in such cases must be on ipecacuanha, which will check the irritability in the bowels, if we can get it borne by the stomach. This we will be assisted in doing by combination with carbonate of potash or soda, and the addition of an opiate. The following formulae will be found service- able in such cases, and also during pertussis, or spasmodic cough. No. 17. Mistura Ipecacuanhx Sedativa. B Infusi Menthae ^iss Vini Ipecacuanhae 3iss Bi-carbonatis Sodae gr. xij. Syrupi Aurantii 3U Tinct. Opii gtts. iv M. 5» — 5'J h°r^ °iuaque 2nda. S4 MANAGEMENT AND DISEASES OF CHILDREN. No. 18. Pulvis Ipecacuanh.se Sedativus. R Pulveris Ipecacuanha gr. £ Carbonatis Sodae siccatae gr. i Pulveris Doveri gr. £ Pulv. Cretae Comp. vel c. Opio gr. ij M. Unum Pulverem talem hora quaque 3tia vel 2nda sumat. Tartar Emetic is a more active agent in the treatment of acute inflammations, and in such cases is therefore to be preferred, particu- larly in pneumonia. Our object is to get a sufficient quantity of the medicine borne ; and the tolerance of tartar emetic can be at- tained with the child, as well as with the adult, though not perhaps so quickly. When much depression attends its use, the addition of a few drops of spirit of lavender, or tincture of cinnamon, will tend to obviate this. The following is the common form of ex- pectorant mixture containing tartar emetic : — No. 19. Jlfistura Expectorans Jlntimoniata. R Aqua Mentha? %i Mucil. Gum. ac. §ss Liquor Antimon. Tart. 3i-— 3'J Syrupi Limonura 5u Tinct. Opii gtts. ij M. 3i — 5*J nor^ quaque 2nda. Squill is employed as an expectorant in chronic bronchitis, &c, &c, particularly when the phlegm is viscid and difficult to get up, the febrile heat having subsided. Squill is seldom given alone — when it is, twenty drops of the syrup, or ten of the vinegar of squill, may be given every third hour. It may be added to either of the expectorating mixtures already given, in the proportion of 5i of the syrup, or 3ss of the vinegar or tincture, to each ounce of the mixture ; or from £ to £ of a grain of the powder of squill added to each dose of the powder of calomel and ipecacuan. By combining squill in this manner, we can sooner have recourse to its use, and longer continue that of the other expectorants. Combina- tion with an alkali lessens the acrid qualities of squill, without de- priving it of its expectorant power. The following mixture will be found very serviceable in pertussis, or spasmodic cough, with chronic bronchitis and secretion of viscid phlegm. No. 20. Mlstura Scillae Sedativa. R Aquae Fceniculi ^iss Tinturae Scillae Jiss Carbonatis Sodae gr. xij Syrupi Tolutani 3ij- Croci 3'j Tinct. Opii Camphor. 5SS M. 5i — 5iJ nor^ <luaque 3tia sumat. Poly gala Senega. This is a very stimulating expectorant, and used only in advanced stages of bronchial inflammation. It is very liable to cause purging and vomiting ; but the latter result is at times desired, when the air-tubes are much loaded, and the strength DIAPHORETICS. 85 inadequate to coughing up their contents. Ammonia is often added to the polygala in such cases, — the acetate, citrate, or carbonate being prescribed, as follows : — No. 21. Misturx Polygala: Ammoniatx. Ii Decocti Polygalae Seneg. ^i Aquas Ammonia; Acet. 53s Syrupi Scillae ^ij Syrupi Papav.Alb. Jij M. 3i — 3'J hora qudque 3tia. No. 22. R Decocti Polygalae ,$iss Carbonatis Ammoniae gr. iij Tinct. Cinnam. C. Syrupi Tolutani a. a. 3'j Syrupi Papav. Alb. Jij M. 3i — 3'J ^ora ^uaque 2d a. Polygala, in union with the other expectorants, makes a very powerful and celebrated compound. In free doses, it vomits strongly, and, as an expectorant, exercises a decided control over the more advanced stages of inflammation in bronchitis, croup, pertussis, &c. when other means have failed. Coxe's hive syrup, so famous in America in such cases, is a compound of this kind ; but we prefer the following formula (which resembles the anti- croup mixture of the Parisian hospitals), as being more easily pre- pared. No. 23. Mistura Polygalae Comp. R Decocti Polyopia? Seneg. ^iijss Oxymel. Scillae 3»j Vini Ipecacuanhas 3'j Antimonii Tartarizatae gr. i M. Ten minims to a scruple to be given every quarter of an hour, to vomit; or every hour or two, as an expectorant. A small tea- spoonful may be given to a child two years old. No. 24. Dr. Coxe'.i Hive Syrup. Mel Scillx Compositum of the Pharmacopoeia of the United States. R Scillae Polygalae Senegae a. a. 31 Aquae foi Mellis despum. ffoss. Ft. Syrupus — quaeque unciae cujus addatur Antimonii Tartarizati granum. This acts by vomiting, purging, and sweat, the dose being from ten drops to one or two tea-spoonsful. XIII. DIAPHORETICS Are not much employed in the treatment of children's disorders, nor do they seem to merit more extended use. Perspiration is not 9* 86 MANAGEMENT AND DISEASES OF CHILDREN. easily induced ; and the partial sweats which we witness over the head or abdomen, in affections of these regions, are not attended with benefit — rather the reverse. The intensely hot skin often attendant on the febrile diseases of childhood, will be best met by refrigerants and baths. Nitre exhibits its power in lessening febrile action remarkably in the child, and will be given with advantage in all such cases. Its combination with ipecacuanha is especially ser- viceable— (from quarter to half a grain of the latter, with from two to six grains of the former, every third hour) ; and is better calcu- lated to act on the skin than either alone — often lessening the febrile heat remarkably : in very acute cases, Antimonial, or better, James's powder may be substituted for the ipecacuanha. Nitre may be freely given, in wThey or barley-water, to the extent of ten grains or a scruple daily, even to young children. Should the bowels become irritable, the nitre must be discontinued, or guarded by combination with a little opium. When much heat of skin attends, this will be found very serviceable, even though diarrhoea be present. XIV. REFRIGERANTS. The vegetable acids are not often given to children as refrigerants in consequence of the tendency to acidity, so frequently present in infantile disease ; but drinks slightly acidulated with lemon juice or tartaric acid are often very serviceable. The latter is best given in the form of bi-tartrate of potash, as weak imperial — and has the advantage of increasing the flow of urine, while it tends to keep the bowels open ; if they are irritable, of course these acids are not ad- missible. To boracic acid in particular is attributed some sedative influence, which causes it to be much employed on the Continent in the cerebral affections of infants. A drachm dissolved in six ounces of water, sweetened, forms the ' Potion Calmante' of the Hopital de la Maternite : it is given in the dose of a tea-spoonful frequently — and maybe used in preference to other acids ; but is not to be relied on, as it seems to be, in the treatment of cerebral affections at that hospital. The mineral acids combine a well-known tonic and refrigerant power ; but are not as often had recourse to in the convalescence of infants as they deserve to be. The best of refrigerants, however, is cold water, — and it should be largely given to all children labouring under febrile disease, and desiring cold drinks, as they usually do ; even infants at the breast are much benefited by the occasional administration of a little cold water under such circumstances. If the stomach be very irritable the water may be iced ; and in no case should children desiring cold drinks be denied them, as is too commonly done. Occasionally warm drinks are preferred : this happens usually in some form of bowel complaint, and has been assigned as a symptom of inflammation of the ileum in particular. The influence produced upon the skin sympathetically from the BATHS. 87 use of cold drinks predisposes it to perspire, by lessening the action on the surface, and so diminishes the heat. This is an important part of the good thus done : but may be directly attempted by the use of tepid or cold sponging, or the employment of baths. Sponging the surface as we do in the febrile diseases of adults, is not practised at all so frequently with children as it deserves to be. Caution is requisite in the use of these means, particularly in the eruptive fevers, where the employment of cold sponging, or even dashing, is occasionally serviceable ; but much judgment is required before having recourse to this measure, which should never be em- ployed unless the febrile symptoms run very high and undoubted power of reaction be present. The local application of cold is one of our most frequent and powerful means of subduing increased action. Its mode of employment is important : to be effectual, we must use it steadily — but should try to avoid giving the child cold, as severe bronchitis not unfrequently follows the application of wet cloths to the head in young children. Ice inclosed in a bladder, or a refrigerating mixture put therein, is the safest and best mode in severe cases, as acute meningitis, when the cold should be kept incessantly applied. Pouring a stream of cold water on the head (held over a basin, so that the water shall flow backwards over the head, not down the face,) has been in particular recommended in severe cases. The em- ployment at the same time of the partial hot bath, as a derivative, the feet or hands being immersed therein, adds much to the effect of this remedy. The local application of cold is almost exclusively confined to the head — and hot stupes alone are applied to the abdomen ; but the order may be reversed with advantage under certain circum- stances. When the cerebral symptoms are those of compression, and have arisen in a child much debilitated, run down by very active depiction or severe vomiting and purging, the active application of hot stupes to the head will be found of signal service ; whereas cold which is so universally used, even under such circumstances, only adds to the severity of the symptoms. On the contrary, in cases of acute abdominal inflammations, with great heat of skin over this region, cold lotions have been recommended, and are said to have produced the best results ; but popular prejudice is strong against such practice as yet, — and though we have suggested their employ- ment, we have not seen them used. XV. BATHS. The general warm bath is constantly employed with the infant to soothe irritation, allay pain, induce rest, and subdue febrile action. To effect the latter object, however, its use must be cautiously had recourse to : no remedy, perhaps, is more abused than the hot bath with infants. A bath for a child should never be very hot, but warm, the temperature not exceeding 9S°; and in acute inflammatory affections, the general bath is altogether objec- 88 MANAGEMENT AND DISEASES OF CHILDREN. tionable, causing hurried breathing, and exciting the circulation, so as to aggravate the disease, particularly if seated in the respiratory organs. When the abdomen is the seat of the affection, it is less objectionable; but, in all acute cases, the bath should be local — and it may then be of higher temperature. When not too hot, we can leave the child for a longer period in the bath — from ten to fifteen minutes ; and its most beneficial effects may thus be ensured. Great care should be taken to dry the child perfectly, and keep it warm after being taken out. The use of the local hot bath, as the pedi- luvium, is one of our safest and best means for inducing derivation, or acting on the principle of counter-irritation, and is frequently adopted, especially in affections of the head. The cold bath is often resorted to as a tonic with children. Bathing in the open sea is its best form, and we should have said pleasantest, had we not often witnessed the mode in which it is commonly administered — the affrighted child being plunged under water in such sudden and quick successions as almost to deprive it of breath : this practice should certainly be amended. The use of cold bathing with the child is to be directed on the same principles as for the adult. We must be careful to ascertain that there is adequate power of reaction present, and not persevere unless the child become ruddy and animated on coming out of the water; and improve in strength and appetite. XVI. PURGATIVES. Children often require the administration of purgatives. By some, they are the only form of medicine given to the child; and much injury is done by their protracted use, or frequent repetition. Were children properly managed, however, especially as to matters of diet, the necessity for this class of medicines would be diminished, and an overloaded or deranged state of bowels be less common. A judicious variation of food would, in many instances, save the necessity for physic. When the bowels become overloaded in the child, or their secretions deranged, much disturbance of health usually attends, and often severe suffering. Acidity and flatulency seldom fail to occur — griping and purging follow, or the bowels become consti- pated, and the stomach unsettled — febrile symptoms attend, usually of the remittent type — sleep is disturbed, and the head is liable to become engaged — convulsions not unfrequently arising. The ju- dicious employment of purgatives will often remove all these symptoms ; and hence their frequent utility. But similar symptoms may be caused, and often are, by the abuse of purgatives, so com- monly witnessed in the treatment of children's disorders; the stomach and bowels being irritated to an injurious degree. Our first object generally is to empty out the intestinal canal; and in the young infant, we try to effect this by the mildest means. Haifa drachm to a drachm of fresh, cold-drawn castor oil, blended PURGATIVES. 39 with a little soft sugar, is the common dose ; but syrup of violets, though seldom given in this country, is, when genuine, * an effectual, as well as agreeable, laxative for infants, in doses of one or two tea-spoonsful ; or it may be combined with castor oil, instead of sugar. Syrup of roses, and syrup of senna, are likewise laxative svrups for children. Castor oil has the advantage of acting with expedition and certainty, fully freeing out the bowels. It has no effect, however, in altering the secretions; and as the infant grows older, other laxatives are required. Manna is that generally selected, being sweet to the taste, and mild in its action. The best flake manna should be selected ; and it is usually given in doses of half a drachm, or a drachm, in some aromatic water, to lessen its liability to cause flatulency and griping. In the following formulae, manna is prescribed alone and in com- bination with other purgatives, to quicken its action :t No. 25. Mistura Mannas. R Mannae gss Emulsionis Arabicae ^ss Syrupi Violae 3ij Bene admisce et adde Aquae Menthae ^i M. 5i — 3'J nor^ quaque 3tia ad effectum. No. 26. Mist. Mannx Comp. R Infusi Sennae %i Aquae Menthae ^ss Mannae ^ij Magnesiae J^i Tinct. Rhei ji Syrupi Rosae Jij M. 5i — 5'J nor* ^tia quaque ad effectum. Magnesia is often given to children, being a very mild aperient, and from its antacid properties peculiarly adapted for them. It is frequently added to other purgatives; and its combination with manna, as in the foregoing formula, constitutes an efficient purgative for general use. When more active purgatives are required, rhubarb is that gene- * Which may be known by its being changed to red by acids, and to green by alkalies. f The following is copied from Edwards and Vavasseur's Nouveau Formulair Pratique : Pastilles de Marine tartarisee. R Creme de Tartre ^ss Marine ^iv Eau ,5X M. Faites cuire jusqu' a consistance convenable, et faites des pastilles de 10 a 12 gr. Laxatif d'un usage commode your les enfans. 90 MANAGEMENT AND DISEASES OF CHILDREN. rally chosen, — being very mild and certain in its action, so that it may be given to the youngest ; and having a tonic and astringent influence, the stomach and bowels being strengthened by its use. From gr. iij. to gr. v. of rhubarb, every morning, tend to restore the tone of the stomach and bowels ; but it is seldom given alone. Its combinations constitute our best and most manageable purgatives in infantile practice. Rhubarb acts most powerfully when given in powder ; but the infusion* is sufficiently active for the child, and perhaps more con- venient, as the taste can be thus better disguised. Cinnamon has this tendency, and should therefore be selected as the aromatic with rhubarb. Bi-sulphate of potash, from its acidity, has also this effect; but cannot be given in powder, as it is deliquescent. Any of the neutral purgative salts may be combined with infusion of rhubarb. Rochelle salt, or soluble tartar, are preferred ; and magnesia is a favourite combination for children, either in this form or in powder: No. 27. Pulv. Rhei et Magnesias, R Pulv. Rhei £)i Magnesiae ^ij Pulv. Cinnamomi gr. x M. In doses of three or four grains, every third hour, to a child six months — six or ten grains will be required after twelve months old. No. 28. Infusum Rhei Salinum. R Infusi Rhei %<$s Bi-Sulphatis Potassae 5ss Tinct. Cinnam. >>ss Syrupi Sennee 3iv M. 2ji — 3*J h°r^ quaque 3tia. Rhubarb is the medicine generally selected as a purgative at the commencement of diarrhoea, or during its progress ; whenever, m fact, we wish to leave the bowels with a tendency to remain quiet, after having been acted upon. Some hydrargyrum cum creta is generally combined with it under these circumstances, especially if the biliary secretion be much deranged. The addition of half a grain, or a grain, of Dover's powder, or double the quantity of pulv. cretae comp. cum opio, renders the operation of the aperient milder ; and, indeed, may be often added with advantage to any purgative for the child, when we apprehend griping, or that the bowels are irritable. The astringent property of rhubarb is increased by toasting the root before pulverising it. No. 29. Pulvis Rhei Compositus. R Pulveris Rhei 9i Hydrargyri. c. cretae gr. x Pulveris Aromatici gr v. M. gr. iij — gr. v hora quaque 3tia. * That of the Edinburgh Pharmacopoeia. PURGATIVES. 91 Calomel may be used instead of hydrargyrum cum creta, but half the quantity will suffice ; and if an opiate be added, it should be Dover's powder, not powder of chalk and opium. The power which mercurials exercise in correcting the secretions is well known and valuable — but not confined to mercury ; other purgatives, as rhubarb and the aperient salts, act likewise on the small intestines, and influence the biliary secretion : so that mercu- rials are not necessary to produce these results, and therefore need not be so frequently prescribed. Some regard calomel as a purga- tive well suited to the child, and prefer it to all others. An occa- sional dose of one or two grains, followed in two hours by some castor oil or other mild aperient, is serviceable, particularly where the bowels are much confined, or the stools very foul ; but it is in general better to add half a grain or a grain of calomel to some other purgative to aid its action, as to the powder of rhubarb and magnesia, &c. &c. than to use it alone ; and even this should not be made a constant practice of. Where the stools are much disco- loured and fetid, minute doses of 5 or i of a grain of calomel, or hydrargyrum cum creta, given every night, or night and morning for some days, is at times of great service. In affections of the head, when it is desired to act decidedly on the alimentary canal, so as to make it a point of derivation, calomel in full doses is often preferred, particularly during the prevalence of dark green and fetid stools. Senna may be used instead of rhubarb, or in combination ; but the infusion should be given of only half strength to children. This is best effected by diluting it with an equal quantity of some aromatic water — that of pimento may be preferred, as best hiding the taste ; tincture of orange-peel has a similar effect, and may gene- rally be added. The powder of senna is inconvenient from its bulk ; but the compound powder, containing scammony, may be occasionally prescribed with advantage, in doses of gr. iij. to gr. vi. every third hour, when the bowels are difficult to move. Syrup of senna is a good laxative, and convenient adjunct in 3ss or ^i doses ; but the manna is liable to separate on its being kept, which could be avoided by ordering treacle, instead of sugar, in making it up. No. 30. Mistura Scnnae. R Infusi Senna; Aquae Pimentae a. a. 31 Tartrat. Potassae ^ij Tincture Corticis Aurant. $i M. 5i — 3'J l101"^ ^u^que 3tia. Jalap is an active purgative, but not very certain. When the liver or stomach is deranged, it is liable to disagree, causing vomit- ing, griping, &c. &c. ; but from its wide range of action along the middle tract of the intestinal canal, it is much used with children, as it well clears out the bowels when overloaded. It may be com- bined with any of the other purgatives ; but ipecacuan is a very 92 MANAGEMENT AND DISEASES OF CHILDREN. beneficial adjunct, as it adds to the purgative power of the jalap, without losing its own peculiar action. Such a combination is especially suitable when we want a purge during the existence of inflammation of the chest. Calomel quickens the action, and is often added. From gr. ij. to gr. v. of jalap may be added to each dose of the powder of ipecacuan and calomel, already prescribed ; or the following formula adopted :* No. 31. Pulvis Jalapae et Ipecacuanhx. R Pulvis Jalapas Jss Ipecacuanha gr. v Submur. Hydrarg. gr. v. Sacchari albi gr. x. M. gr. ij — v hora quaque 3tia. When our object is to produce serous discharges from the bowels, and so keep up depletion, jalap, in combination with some saline purge, is generally chosen ; and crystals of tartar, as in the com- pound powder of jalap, is one of the best, and is often required in the treatment of children's complaints. When in addition to serous discharges we wish to act energetically upon the bowels, so as to move them when constipated, or produce counter-irritation (the head being engaged), we generally have recourse to scammony. Scammony is a most energetic purgative, but liable to gripe and irritate the mucous membrane highly : hence care must be taken in the mode of prescribing and combining it. When given in powder, it must be reduced to the minutest state of division, and an aromatic always combined : the addition of a neutral salt, or alkali, is particularly advantageous. Scammony, though so liable to disagree, is often required in the treatment of children, when the bowels are difficult to move, or loaded with mucus, which prevents the action of other purgatives, but which scammony in particular seems to possess the power of removing ; hence its utility in obstinate constipation, the removal of worms, &c. &c. No. 32. Pulvis Scammonix cum Cretd. R Pulveris Scammoniae Jss Cretaeprepar. gr. xv Aromatici gr. v M ?r* U — ST- v hora quaque 3tia One of the most effectual and yet mild purgatives that we are * The Montpelier hospital has a convenient formula for purgative biscuits, containing jalap, which we subjoin, being anxious to contribute our mite towards lessening the miseries of the nursery, caused by physic-taking: "Take an ounce of flour, and an ounce of sugar, two eggs, and one drachm of powder of jalap — let three biscuits be made, a quarter of one of which will con- tain 5 gr. of jalap ; and may be taken once or twice a-day, according to the effect." PURGATIVES. 93 acquainted with, is a combination of rhubarb, scammony, and sulphate >f potash, in equal parts, and to which an aromatic may be added. No. 33. Pulvis Scammonix et Rhci. li Pulveria Rhei Scammoniac Chrystal. Salphatis Potassce ft. a. gr. x Bene tere simnl et adde Pulveris Aromatici gr. v M. gr. iij ad gr. vi hora quaque tenia ad efFectum. The li Iluile Purgative'' of Swi'diaur is a mild, yet active form or exhibiting scammony, and is conveniently given to children in jmulsion, as follows : — No. 34. I£ Scammoniae 9i Olei Amygdalarum ^i Solve caloris mitior. ope et adde Emulsionis Arabicae ^i M. 3i — 3" ^ora qu^116 tcrtiu Aloes is not often given to the young child, from the bitterness jf its taste, and its liability to gripe : however, there is no purgative [hat, if judiciously employed, is more useful. It combines a tonic, is well as purgative power, in virtue of its bitterness ; it has a ^articular relation to the liver, either as a substitute for bile, when Jeficient, or as passing through the liver, and so causing its flow ; ind it is well known, from its action on the rectum, to be peculiarly liostile to ascarides. The taste of aloes is well hidden by combina- tion with liquorice root, and perhaps there are few medicines to the taste of which children sooner become reconciled : of its various preparations, the compound decoction, and the vinum aloes, are those best fitted for administration to children. No. 35. Mist ura Aloclica. Ii Decocti Aloes Compositi £iss Extracti Glyeerrhizae3U Vini Aloes 3>j W« 3i — 5^ kis terve indies. In cases where the head threatens to be engaged, without inflam- matory action being present, this mixture, as a derivative purgative, is the best we can employ — as also when we wish to expel ascarides. Its anthelmintic powers will be much enhanced by the addition of half a drachm or a drachm of the muriated tincture of iron, which also corrects ihe tendency to regeneration of worms. Aloes, when used as an anthelmintic, may be employed in the form of supposi- tory or ointment. The following suppository is recommended by Swediaur ; and the ointment is used in the German hospitals, by rubbing a small portion round the naval, id cases of colic, connected with worms. March, 1S3S.— M 10 94 MANAGEMENT AND DISEASES OF CHILDREN. No. 36. Suppositorium dnthelminticum. R Pulveris Aloes £ss Muriatis Sodae 3iij Farinae 3ij Mellis q. s. ut ft. massa. M. Instar nucis, in forma suppositorii, utendum. No. 37. Unguentum Anthelminticum. R Pulveris Aloes %i Extracti Fellis Bovini 5'j Unguenti Simplicis %i Sf. t. unguentum. When the bowels are obstinately costive, purgative enemata must be had recourse to : care is required, however, in administering them to the child, as mechanical injury has been caused by their use. The following is a good general formula : — No. 38. Enema Purgans. R Decocti Hordei %v Muriatis Sodas ^m Olei Olivarum 3> M. A drachm or two of spirits of turpentine may be added, if much flatulency be present. CHAPTER V. ACCIDENTS AND DISEASES OCCURRING AT THE PERIOD OF BIRTH, OR SHORTLY AFTERWARDS. The infant at birth may labour under certain morbid conditions, or it may suffer from accidents or diseases either peculiar to the first mo- ments of existence, or materially modified by the circumstances be- longing to that period. These are usually first noticed by the accou- cheur, and require to be considered separately in a system of child's medicine, bothonaccountof the great danger attending many of them, and also of the peculiarities which remove them from under the rules applicable to diseases of the same name in the general practice of me- dicine and surgery. Of the importance of these affections of early infancy we may judge, from the great increase that takes place in the chances of existence after the season for their occurrence has gone by. According to the Northampton Tables, we find, that of 1000 persons born at the same time, the probability is, that 257, or more than one- fourth, will be dead at the close of the first year ; while of the STILL-BORN CHILDREN. 95 remaining 743, but 118, or less than one-sixth, will be dead at the close of the second year.* In the presentchaptcr we shall, therefore, notice a number of matters which are not susceptible of nosological arrangement, having no connexion with each other farther than their occurrence at the same period of life ; and we propose, in doing so, to limit our observations to peculiarities belonging to that period, and as far as possible to avoid occupying our pages with discussions upon general principles of medicine, when these require no variation to nuit them to the case in hand. I. STILL-BORN CHILDREN (ASPHYXIA NEONATORUM). Children are occasionally born in a state of asphyxia, and without active attention upon the part of their attendants, would be certainly lost. The causes of this state are either natural feebleness of con- stitution, existing to such an extent as to render the infant incapable of spontaneously making the muscular exertion necessarry for the commencement of respiration, — or similar incapacity produced by long continued pressure upon the brain, — or interruption of the foetal circulation by compression of the funis, before respiration has been established. To these causes, Dr. Ed. Jorg, in his ingenious Essay on the Foetal Lungs, has added the circumstance of a too rapid and easy delivery, which fails to produce such a degree of compression of the placenta, and obstruction to the foetal circulation, ashe supposes to be requisite for making the system feel the necessity of respira- tion.! This state of asphyxia may exist in a greater or less degree: the child may be completely still-born, with no indication of life except, perhaps, the pulsation of the funis, or a feeble action of the heart; or it may make ineffectual efforts at breathing, or even cry faintly, and yet subsequently perish, from want of strength to esta- blish perfectly the process of respiration. Under all these circum- stances, a good deal can often be effected by art ; and we are encou- raged to preserve in efforts at restoring animation, both by experience, and by reasoning upon the facts we have brought forward, showing that the less heat an animal produces, the longer it can exist under a condition of asphyxia. We have already seen,± that the heat of the new-born child is about 3° less than that of the adult ; and hence we have an explanation of what experience proves — viz. that it can exist longer without respiration. In every instance, therefore, in which we have not positive evidence of the child being dead, in the existence of putrefaction, or of such malformation as is incompatible with life, we should give a fair trial to the means of restoring sus- pended animation, presently to be spoken of. What length of time is sufficient for a fair trial cannot be exactly specified, as it must depend upon the degree of asphyxia, and upon the progressive success attend- • MacOulloch's Dictionary of Commerce. | Die Foetus' ungeim Gebornen Kinde, &c. von Ed. Jorg Grimma, 1835. X See p. 26. 96 MANAGEMENT AND DISEASES OF CHILDREN. ing our efforts. As long as the slightest attempt at motion of the respiratory organs is evinced, or the least pulsation of the heart continues, we have good grounds for persevering and hoping for ultimate success. Our first object, in the treatment of a still-born child, should be to remove every obstruction to the passage of air into its lungs. For this purpose, we place it with the mouth uncovered, and we pass our finger into the fauces, both for the purpose of removing any mucus or membrane which may obstruct the access of air, and also to tickle those parts, and thereby excite respiratory movements. With the latter object in view, we should also rub and gently slap the chest, and expose it to the stimulating operation of the cold air. If these means do not succeed, we must further stimulate the thorax, and soles of the feet, by friction with spirits, and irritate the nostrils and fauces with a feather dipped in the latter, or by holding harts- horn or carbonate of ammonia to the nose. The foregoing steps may be taken before dividing the funis, which should not be done as long as it continues to pulsate, unless respiration be fully established. Should the funicular circulation cease, or have been obstructed before birth, it is more convenient at once to divide the cord ; and it will be well, especially if the child's face be livid and swoln, indicating congestion within the head, to endeavour to excite circu- lation by allowing some drops of blood to escape from the umbilical vessels, by dividing them before applying a ligature. If the blood flows freely, it shows that circulation is still active, and is an addi- tional reason for perseverance. Two practices are invariably adopted with still-born children, after the separation of the funis — viz. inflation of the lungs, and the warm bath. These, when used with judgment, are unquestionably means of great power in excitingrespiratory action — but when injudiciously employed or persevered in, become, we have no doubt, frequent agents of destruction. It is now well ascertained that there is no more certain and speedy means of destroying animals, than a brisk inflation of air into the trachea ; and therefore it is positively wrong to use any powerful mechanical means, for this purpose, in the new- born child. The gentle filling of the lungs with air does, however, certainly excite respiratory movements, and also facilitatespulmonary circulation, and it should therefore be cautiously practised. In doing it, no trachea pipe or bellows should, we think, be employed, but air simply blown into the mouth, the operator applying his own lips, with a bit of silk or muslin intervening (for the sake of clean- liness), to those of the child. While doing this, the head is to be slightly extended, the nostrils must be held between the finger and thumb of one hand, and the fingers of the.other should be placed upon the pit of the stomach, so as to prevent the air from passing into that organ. When the chest has been distended, it may be compressed gently with the hand, so as again to empty it, and the inflation may be repeated three or four times, or until the commencement of natural respiration is announced by a sneeze or deep sigh. In addition to STILL-BORN CHILDREN. 97 the evil consequences due to the force that would be exerted by bel- lows or other apparatus for inflation, we may mention that insuffla- tion of cold air, in the event of resuscitation, seldom fails to produce dangerous bronchitis.* Willi respect to the warm bath, those who have frequently wit- nessed its employment with still-born children will recollect that when it does good it is at the first moment of its application: im- mediately upon plunging the child into it, respiration will be set agoing and a cry uttered — but if this does not occur at once, keep- ing the child immersed in the water will seldom be successful. This is explained by the discoveries of Dr. Ed\vards,t who found that the lower the natural or artificial temperature of an animal may be, the longer it can exist in a state of asphyxia; but that, at the 6ame time, the momentary application of heat, as well as of cold, acts as a stimulus, and produces more forcible motions. Conse- quently he says, " the immersion of a great part of the body in warm water, is frequently an efficacious means of re-animating a child just born without signs of life. As soon as motion is pro- duced, or if it be slow in manifesting itself, it will be right to aban- don a method the prolonged use of which would be fatal." The object, then, is to plunge the infant quickly into a bath hot enough to stimulate it (probably about 100°) ; and if motion be produced, to withdraw it, and continue the excitement of the surface by fric- tion with dry, warm flannel ; and when respiration is well esta- blished, to lay it in a warm bed. The researches of Dr. Edward Jorg, published in his work already quoted, show that our care for the establishment of perfect respiration is not to cease wThen we get the child to breathe so wrell as to enable it to live for days, or even weeks. It may survive so long, and yet die from the effects of an imperfect filling of the lungs with air — many cases of cyanosis, infan- tile bronchitis, atrophy, and even convulsions owing their origin to a partial continuance of the lungs in their foetal condition. Should the child, therefore, continue to breathe feebly, and show an ina- bility to suck, after animation has been restored, we must endeavour to promote more perfect respiration by friction on the surface, and stimulate the intestines by an aperient of castor oil ; or if there be much mucus obstructing the bronchi, it may be advisable to excite vomiting by administering half a drachm of ipecacuan wine. It is useless to speak of the employment of tobacco fumes, electricity, or enemata, as recommended by some writers in the treatment of still- born children : for the two latter there is no time, and the former is now deservedly expunged from the list of means of restoring sus- pended animation. * See Dublin Practice of Midwifery, p. 239. f Op. cit. p. 283. 101 98 MANAGEMENT AND DISEASES OF CHILDREN. II. DEFORMITIES IMPERFORATE ANUS. Several varieties of this morbid condition are to be met with. The anus may be simply closed by skin, or a membranous septum at the termination of the rectum ; or the rectum may terminate in a cul de sac, at a greater or lesser distance from the natural situa- tion of the anus ; or the anus may appear perfect, but an obstruc- tion exist in the gut at some distance within it. In other cases, we have known the rectum to terminate by opening into the vagina, or bladder in the male subject. When there is no anus, the case is usually discovered early, and time given for deciding upon the steps necessary to be taken ; but when the opening appears perfect, and the obstruction exists at some distance within it, we do not become aware of its nature until it is observed that no discharges can be procured from the bowels, or, perhaps, until a vomiting of meconium takes place. As soon as we ascertain, in any instance, that such is the case, we must institute a careful examination of the anus by means of a probe or flexible bougie, and be guided in fur- ther steps by the result of the investigation. The only relief that can be given will, of course, be by an operation ; and the exact na- ture of this must depend upon the particular circumstances. If the anus be merely closed by skin, or a membrane, all we have to do is to make a sufficient incision with a bistoury, and prevent closure of the opening by the use of tents. If there be no vestige of the rectum, an attempt must be made to reach it by incisions with the scalpel ; and if there be an obstruction in the gut at some distance from its external opening, its removal must be aimed at with the bistoury or trocar. By some it has been recommended to make an artificial anus in the groin in cases in which the gut cannot be found. The operation would be a very hopeless one ; but a consideration of its merits, and of the exact modes of performing the other opera- tions, belongs rather to the province of the surgeon than of the child's physician — who, in that capacity, has merely to ascertain the nature of the deformity, and must draw upon his own general knowledge of surgery, or apply to another practitioner, for the means of its removal.* III. IMPERFORATE VAGINA. The labia occasionally cohere at birth, and sometimes the vagina opens into the rectum, or terminates in a cul de sac. Unless the closure of the labia interferes with the opening of the urethra, * In a paper lately read before the French Academy of Sciences by M. Amus- sat, a successful. case of operation for imperforate rectum is detailed, in which the safe establishment of the artificial anus is attributed by M. A. to the draw- ing down of the intestine, and securing of its mucous membrane, by sutures, to the skin, so as to prevent the infiltration of fcetal matter between the extremity of the rectum and the wound in the integuments. In these almost hopeless cases, every hint is of value. — Gazette Medicalc, torn. 3. SPINA BIFIDA. 90 nothing is required, or proper to be done, during infancy, and the case belongs to the general practice of surgery. If the urethra be obstructed, which seldom happens, we must have the obstruction removed in whatever way may suit the individual case. IV. IMPERFORATE PENIS. Deformities of various kinds occur in the urinary organs of the male. The urethra may be altogether deficient, in which case there is usually concurrent deformity in the bladder — the anterior wall and corresponding portion of abdominal integuments being deficient, and the mucous membrane, with the mouths of the ure- ters protruded through the opening. Examples of this deformity are to be seen in every museum, and are, of course, beyond the reach of remedial art. In other cases, the urethra is not carried through the glans, but terminates by an opening behind that body, on the under surface of the penis. This variety, which receives the name of hypospadias, is also irremediable, and is seldom of any importance during childhood, as the urine will usually find its way through the irregular passage. Sometimes, but rarely, the orifice of the urethra, or of the prepuce, will be found imperforate, and will require treatment. In the latter case, the operation of circum- cision may as well be performed at once, and will remove all diffi- culty. In the former, the natural opening must be rendered per- vious, if necessary, by a cutting instrument, and kept so by the regular introduction of a small bougie. Retention, or rather suppression of urine, may, and often does, occur in infants, without the existence of any malformation or disease whatsoever. We arc often told, for example, twenty-four hours after birth, that no urine has been yet voided. In such cases, we should carefully examine the parts concerned to ascertain if any physical obstruction exists, and also feel the lower part of the ab- domen to learn if the bladder be distended. If it be, and that the external openings are free, we may introduce a probe or small bougie into the urethra for the purpose of removing any mucus, which might block up its canal. We do not recollect having ever found it necessary to introduce a catheter. Most usually the stop- page of urine is owing to its non-secretion; and this constantly obtains for many hours after birth, without any evil consequences. All we need do is to place the infant in a warm hip-bath, and leave the rest of the treatment to nature. Many deformities of the urinary and genital organs occur in both males and females, and are now and then dragged into a disgusting notoriety as instances of hermaphroditism. As these, however, have no practical bearings upon our subject, we shall not at present delay to notice them. V. SPINA BIFIDA. By this term is designated a mal-formation of some part of the vertebral column, in which the spinal processes are deficient, and MANAGEMENT AND DISEASES OF CHILDREN. the contents of the ipinal canal protruded in the form of a round, compressible tumor# containing fluid, and in some instances covered with integumentf in others, divested of this, and presenting a reddish, fungotfs appearance. The place of its occurrence is most commonly in the lumbar vertebrae ; but it may exist in any other part of the column, or in the sacrum. Its size varies from the bulk of a nut to that of the closed fist, or even larger r. at birth it is usually flat, but shortly afterwards is protruded by the passage of fluid from the spinal canal into its cavity, and is then in some in- stances semi-transparent. A paralytic or deformed state of the lower extremities frequently, but not constantly, co-exists with spina bifida. In some cases the fluid can be forced out of the tumor back into the canal, and the margin of the bony opening felt through the integuments; but pressure of this kind will usually produce convulsions. In a case which we saw lately the integuments ap- peared as if cut by a sharp instrument round the base of the tumor, which was quite uncovered by skin, and presented a reddish appear- ance, resembling the fungus which we occasionally see occupying the situation of the brain in an acephalous foetus. The prognosis in spina bifida is very unfavourable — the tumor commonly sloughing and bursting soon after birth, and occasioning immediate death ; or the child perishing early in convulsions. Instances, however, are upon record in which the patients have lived for months, and even years ; and Sir A. Cooper has published two cases, in which he effected what may be termed cures.* The plan which he adopt- ed was, in one case, the employment of pressure by a concave piece of plaster of Paris, lined with lint, and held on by a roller, until at length the tumor could be altogether reduced within the spinal canal, when the opening wras permanently protected by a suitable truss. In the other, repeated punctures with a needle were made at intervals in the tumor, and the fluid drawn off, pressure being at the same time applied by means of a piece of pasteboard and a roller. By these means adhesive inflammation was excited in the cover- ings, and the opening thereby permanently closed. Shortly after birth, our chief object should be to protect the tumor from any pressure or irritation, which might occasion inflammation and gangrene, as instant death is to be dreaded from bursting of the sac. At a subsequent period, we may cautiously try pressure ; or, if that cannot be borne without producing convulsions, repeated punctures with a needle, as just described, may be attempted, — and the bulk, perhaps, by that means reduced so much as to admit of a truss being applied. Spina bifida is occasionally complicated with hydrocephalus, and sometimes tumors of a precisely similar nature are met with upon the head — the fluid passing out, in a sac of dura-mater, through an opening in one of the cranial bones. The same principles of treat- ment apply to these affections as to actual spina bifida. * Med. Chir. Trail, vol. ii. DEFORMED FEET. ifjl VI. SHORT FRENUM LINGUiE (TONGUE-TIED). The frenuni linguae is sometimes so short, or its attachment to the tongue extended so near the tip, as to interfere with the motions of the organ in sucking or speaking. Nothing is more common than to have infants brought to us alleged to be tongue-tied, and yet the existence of the malformation to an extent requiring artificial aid is extremely rare. If the tip can be protruded beyond the lips, nothing need be done, as sufficient motion will then be permitted to allow of sucking, and the frcnum will gradually lengthen as the tongue becomes more employed. The division of the frcnum should, therefore, not be wantonly performed, especially as it is not altogether unattended with danger — instances having occurred of serious hemorrhage, and of suffocation from a turning back of the loosened tongue to such an extent as to impede the access of air into the glottis.' When interference is absolutely necessary, a very Might nick with a sharp scissors is all that will be required. The mode of operating is. to place the two fore fingers of the left hand under the tongue, on each side of the frcnum, and to raise it as much as possible from the floor of the mouth; then with the scis- sors in the right hand to divide the edge of the frenum, taking care to direct the points downwards, so as to avoid injuring the ranine arteries. The child must be watched for a little, lest hemorrhage should occur ; and it is to be recollected that the blood may pass down into the stomach, and a considerable quantity be lost without any issuing from the mouth. VII. HARE-LIP. The consideration and treatment of this deformity belongs to the surgeon — all that the child's physician has to do with it is to con- sider when the operation should be performed. If the child can suck, it is better not to submit it to the hazards of an operation in early infancy. But cases occasionally occur in which such a degree of deformity exists as to demand immediate assistance, in order to give the infant a chance of life. The nature of the operation, and modes of performing it, altogether belong to the province of surgery. We occasionally meet with a child born with one or more teeth, which may require to be extracted in order to prevent injury to the nipple. VIII. DEFORMED FEET. Three varieties of deformity of the feet are to be met with. These arc termed — valgi, when the foot is turned outwards : variy when it is turned inwards ; and pes equinus, when the toes are * Petit Mem. de l'Academie des Sciences. 102 MANAGEMENT AND DISEASES OF CHILDREN. pointed downwards, the foot being extended so as to cause it to approach a right line with the leg. The immediate cause of these deformities appears to exist not so much in the bones as in the muscles, which influence the motions of the foot — any alterations observable in the former, in old cases, being probably consecutive. Delpech found that, upon dividing the tendo-Achillis in young persons who had died subject to one of these deformities, it became easy to restore the foot to its natural position, no trace of deformity remaining. Accordingly, he inferred that the primary alteration was a shortening of the gastrocnemii and other extensor muscles, and that the distortion primarily produced was the pes equinus, or extended foot ; that subsequently the varus, or turning of the foot inwards, is easily induced, because the posterior extremity of the oscalcis is naturally inclined a little in that direction, and the dis- tortion is favoured by the ordinary action of the gastrocnemii upon that bone, tending to bring the foot somewhat inwards. As the turning inwards increases, the plantar muscles, ligaments, and aponeurosis, are gradually contracting; and the deformity becomes greater, until first the external margin, and subsequently the dorsum of the foot, comes to be the part resting upon the ground. The valgus, or turning of the foot outwards, so as to make a resting-place of the inner margin, is not so common as the other deformities. It is produced by a shortening or inordinate contrac- tion of the muscles situated on the anterior and external surface of the leg, whose office is to rotate the foot outwards. The remote cause of these deformities M. Delpech refers to an original defect in the nerves supplying the limb, in consequence of which there is a want of balance in the development and action of the antagonist muscles. His view is borne out by a fact which we have already stated, viz. : that spina bifida, which, of course, must often involve a lesion of those nerves while in the spinal canal, is frequently complicated with deformed feet. The treatment of deformed feet must be based in principle upon the view we have taken of the immediate cause. Our objects must 1 be gradually to extend the muscles, whose shortness or inordinate . contraction produces the distortion, and as far as possible to en- i courage the action of their antagonists. The first object is to be attained by mechanical contrivances, adapted to the foot in such a way as to tend gradually to bring it into its natural position. The |] form of shoe required will vary according to the kind and degree of distortion, and its construction must depend upon the ingenuity of the surgeon and the instrument-maker.* The principle of its application should be to make the extending force very gradual, and to apply it so as to act upon the shortened muscles ; and par- ticular care should be paid to the prevention of any injurious pressure upon the part which is made the point d'appui. The * For a description of an excellent form of shoe for vari, see Professor Colles's valuable paper in the first volume of the Dublin Hospital Reports. NiEVI MATERNL 103 action of the antagonist muscles should be encouraged by friction, and by daily moving the foot in the directions in which these muscles would naturally act. The period most favourable for the removal of all these deformities is early infancy, the parts being then most flexible and susceptible of alteration in position, and the patient most easily managed. In more advanced life the rigidity of the muscles is so great, as usually to frustrate any attempts at elongating them ; and under these circumstances, M. Delpcch has recommended and successfully practised a division of the tendo-Achillis. Our business, however, as child's physician, is to recommend the early employment of curative means ; and if these be properly adopted upon the princi- ples just suggested, there will, probably, be no occasion for any more violent expsdients.* Supernumerary toes and fingers will sometimes be met with in an infant, and perhaps so situated and attached as to make their removal desirable. We would not, however, recommend their removal in early infancy. The child is then little able to endure the shock of any operation, however slight ; and as this is not a necessary one, it will be better deferred for a few months. IX. N.EVI MATERNI. The new-born child is liable to have a variety of organic malfor- mations in the texture of the skin, all of which are classed under the name of nxvi, although they differ very materially from each other both in degree and nature. The most common forms of naevus are the brownish mole, and the claret stain. These are frequently met with upon all parts of the body, and vary very much in size. They appear to be simple discolourations in the skin, occasioned by an alteration in the structure of the rete mucosum. They are not much elevated above the rest of the surface ; and as they commonly remain stationary during life, without causing any injury except from their unsightliness, it is better not to meddle with them. We know of no means whereby they can be removed without the dan- ger of leaving a greater deformity in their stead, and therefore think it wiser not to interfere. All these marks are attributed, but with- out any good foundation, to effects produced upon the mother's imagination during pregnancy, and accordingly they are usually likened, by the aid of an active fancy, to objects for which she has longed, or by which she has been frightened, as fruits of various kinds, mice, spiders or other disgusting animals. Other nsevi exhibit a more important alteration of structure, being raised in granulated tumors above the skin, and consisting of * For full information respecting these deformities, we mny refer to L' Or- thomorphie par J. Delpech, Paris, 1828; to Professor Jorg's Uebcr Klumpfusse und eine leichte u. zweckmassige Heilart derselben, Leipzig, 1806 ; and also to Professor Scarpa's Memoire sur la torsion congenitale des pieds des enfans, &c. traduit par J. B. F. Leveille, Paris, 1804. 104 MANAGEMENT AND DISEASES OF CHILDREN. a congeries of vessels, sometimes venous and sometimes arterial, imbedded in a sort of parenchymatous tissue, and often identical in their nature with the disease termed 'aneurism by anastomosis.' The colour and external characters of these tumors vary considera- bly,— being sometimes dark blue, or livid ; in other instances of a vermilion hue — occasionally raised on a neck or pedicle, and again growing from a broad base. Their size and situation are also very various — not being always confined to the skin, but appearing at times in the tongue, lips, labia pudendi, &c. A particular disposi- tion to their formation appears to exist in some individuals, as we have seen so many as sixteen upon the body of a young child. Some naevi, like simple moles, remain stationary during life, and do no injury ; others show a constant tendency to enlarge, which is much stimulated by any trifling irritation, as a bruise, scratch, or slight pressure. Any circumstance which quickens the circulation, as anger, warm weather, or active exercise, may increase their bulk and heighten their colour, by producing a greater determination of blood to the surface ; and the skin covering them being usually very thin, they frequently burst, and occasion alarming, or even fatal, haemorrhages. When nsevi are small in size in situations unlikely to suffer from pressure, and show no tendency to enlarge, they call for no treatment ; but when opposite conditions exist, surgical aid is re- quired, and must often be had recourse to even in very young infants.* The principles upon which this aid is to be afforded are threefold. Their growth may be restrained by the continued appli- cation of cold washes, and the gentle pressure of a bandage ; or inflammation may be excited in them by various means ; or, lastly, they may be extirpated by the knife or ligature. The first named plan has the sanction of Mr. Abernethy's recommendation ; but still can scarcely be looked upon as more than palliative, and, so far as the bandage is concerned, is inapplicable to many cases of the disease, both on account of its situation, and of the likelihood of severe irritation being occasioned by pressure. For the production of inflammation, various means have been devised : caustics of dif- ferent kinds were applied by the old surgeons, and by producing ulceration, occasionally destroyed the disease. This practice was often followed by considerable irritation, and sometimes by danger- ous hemorrhages, and is now in a great degree laid aside. It was, however, in some measure consonant with the plans of nature, as we have seen many cases of large naevi in which ulceration set in spontaneously, and the whole disease was removed, leaving a healthy cicatrix. Latterly it has been recommended by Mr. Hodgson, of Birmingham, to vaccinate naevi ; and in some instances, this plan has been productive of good effects. Needles, also, have been passed into the tumor in various directions, and a seton has been drawn * For a case of extirpation of a naevus six hours after birth by Mr. Baldy, see Med. Chir. Review, vol. viii. p. 204. RUPTURES. 105 through it for the purpose of exciting inflammation.* Where every part of the disease can be removed by the knife, it is, perhaps, the least severe plan, and likely to be attended by the slightest mark ; but if it cannot all be taken away, there is considerable danger of hemorrhage, and of a further growth of the tumor. Ligatures have been employed in several ways, viz. : by applying a single ligature round the tumor, where that was practicable ; or by passing a double thread through its substance, and tying the tumor in two portions ; or, what we believe to be a very useful plan, to pass live or six common sewing needles through the skin surrounding the na2vus and bring out the points (also through the skin) on the opposite side, making the needles cross each so as to form a star, and then wind- ing a ligature tightly under them in the same manner as is done in hare-lip, or in securing the vein of a horse after bleeding. By these means an artificial pedicle is formed for the naevus, and sufficient pressure may be applied to cause it to slough away. X. RUPTURES (FIERNIiE). The new-born infant is liable to several forms of hernia, and in some individuals there appears to be a remarkable predispo- sition to the disease. We know a family of three children in each of whom there existed at birth an umbilical hernia — in one, combined with a single, and in the third, with a double scrotal rup- ture. The form of protrusion which we most commonly meet with is the omphalocele, or umbilical hernia. In the early foetus we are to recollect that there is naturally a pouch at the commencement of the umbilical cord, which contains convolutions of intestine, and that these are not retracted within the abdomen until some months of foetal life have elapsed. In the perfect state, the opening at the navel should gradually close, until at birth it should only be capable of admitting the passage of the vein and arteries: — but in many instances such perfect closure does not take place — a round, well-defined opening, is left in the linca alba, and through this a sac of peritoneum, containing a hernia, may protrude. The protru- sion may vary very much in size and contents, but commonly it ranges from the bulk of a hazel nut to that of a walnut, and contains intestine or omentum. The diagnosis is simple : we find a tumor at the navel, which increases when the infant cries or coughs, and Can be replaced when we relax the abdominal muscles, and use gentle pressure ; an empty pouch remaining, and an aperture, into which we can insert the point of the ringer, being perceptible in the wall of the abdomen. Instances are upon record, in which the liver and other viscera formed the contents of an omphalocele, but most com- monly there is merely a fold of intestine. When the aperture in * A modification of this latter plan, viz. — to pass twelve or fourteen threads through the tumor — has been recommended by Mr. Adams of this city, in an able paper road before the British Association in 1835. March, 1S38. — N 11 106 MANAGEMENT AND DISEASES OF CHILDREN. the linea alba is not very large, the prognosis is usually favourable; but much care and attention are required, both from the medical at- tendant and nurse. Until the funis has fallen off, and the navel healed, nothing should be done further than to apply a fold or two of old linen over the part, in the ordinary manner of dressing the child ; but as soon as cicatrization is perfected, a more effectual line of treatment must be commenced, and the earlier this can be done, the better will be the chances of success. Our object is to keep the protrusion permanently within the abdomen, so as to permit a free scope to the natural efforts at closure of the opening. The means of effecting this are various. Trusses have been invented for the purpose, but are in- applicable, from their strength, to the tender bodies of very young children; Sir A. Cooper recommends a section of an ivory ball to be applied over the umbilicus, and retained there by adhesive plaster and a belt; the plan which we ourselves usually adopt, and find successful, is to apply a graduated compress, made of white leather, spread with adhesive plaster, over the opening, and above this the common flannel roller or belly band. The apex of the com- press, which is to be placed next the navel, should be as nearly as possible of the size of the opening; the compress should consist of three or four pieces, — the largest, being about three inches in dia- meter,— and a double stitch should be passed through them, and knotted externally, so as to keep each piece in situ. We should always apply the compress with our own hands, as great care is necessary to ensure a complete return of the hernia. Unless the child exhibits marks of uneasiness, it should not be removed until the plaster loses its adhesive quality, and then a new one should im- mediately be applied. In conducting the case, patience will be greatly exercised, as many months will be required for the comple- tion of a cure, and this should be explained to the friends at the be- ginning. We have tried a plan, originally adopted, we believe, by Mr. Woodroffe, of Cork, and which answers well when there is a small opening with a considerably elongated sac, but cannot be em- ployed in broad flat herniae : it is, after reducing the contents, to hold the pouch firmly between the fingers, and then wind round it a narrow strip of adhesive plaster, commencing as close as possible to the abdomen, and continuing to the apex. This plan may suc- ceed, by causing adhesion of the walls of the sac, which will thus form a natural truss, and prevent protrusion through the opening in the linea alba. Inguinal hernia may also exist at one or both sides at the period of birth,. and then constitutes what has been denominated hernia congenita. The distinctive character of this form of rupture is, that the protrusion descends into the sac of the tunica vaginalis before the latter is closed, and thus comes to be in direct contact with the testicle. In many cases of congenital inguinal hernia, the testicle will not have descended from the abdomen; and into this circum- stance we must particularly inquire, by feeling for it in the scrotum, INJURIES RECEIVED DURING BIRTH. 107 as no truss should in any case be applied as long as the testicle re- mains within the belly. The diagnosis of inguinal rupture is less ensy than that of ompha- locele, as it may be confounded with hydrocele, which is not uncom- mon in infants; or, the testicle, while in the act of descending through the inguinal channel, may be mistaken for a hernia: after breoch presentations, also, considerable tumefaction of the scrotum may exist, which should not be confounded with rupture. Hydro- cele is to be distinguished from hernia by its transparency, and by our not being able to feel the cylinder of the intestine rolling under our fingers within the integument. The fluid may, however, be re- turnable into the abdomen as hernia is, and, in like manner, may be increased when the infant cries or coughs, so that caution is required in making our discrimination — the more so, as congenital hydro- cele requires little or no treatment, usually disappearing sponta- neously. The testicle is to be known by its solidity, and not being usually returnable into the abdomen. The enlargement of ihe scro- tum from pressure will be recognized from the history of the case, and will also, in general, rapidly subside. The principle of treatment in inguinal hernia is, of course, to keep the protrusion within the belly, and favour the closure of the ring. The accomplishment of this, however, is attended with im- mense difficulty in the young child : the smallness of the pelvis renders it next to impossible to get any truss to fit; and in early in- fancy, the constant wetting of the straps will cause chafing of the skin, notwithstanding the most careful attention. On these accounts we have, after repeated and patient trials, almost given up the idea of using a truss before the child is a year old ; and even at that age, we have been repeatedly foiled. A child subject to hernia should be kept in as tranquil a state as possible, and every means adopted to prevent it from crying, or using any exertion likely to increase the protrusion. When this has been carefully attended to, and the parts bathed daily with cold water, we have often observed a spon- taneous cure to be effected, without the employment of any artificial support whatsoever. All the forms of hernia in the child may be the subject of strangu- lation, and require the operation, the performance of which is strictly within the province of the surgeon, and requires no remarks from us. XI. INJURIES RECEIVED DURING BIRTH. When, in consequence of tedious labour, an extraordinary degree of pressure is exerted upon any part of the child, all the consequences of a contusion may result. Bloody tumors may be formed upon the head, face, or in the scrotum ; or inflammations may be excited, which will terminate in abscess, or even gangrene. To all these injuries, the ordinary rules of surgery apply; the bloody tumor should be left to itself, and never on any account opened, as un- healthy suppuration would be thereby induced; inflammation must 108 MANAGEMENT AND DISEASES OF CHILDREN. be treated by the moderate use of cold lotions, as spirits or vinegar and water, and by preventing any continuance of irritation from pressure of clothes, &c. ; when suppuration or sloughing ensues, we' must employ poultices. Considerable alteration is sometimes effected in the shape of the child's head ; and in face presentations, the fea- tures are often frightfully disfigured;, but neither of these cases re- quire or warrant any interference ; and it will be often a matter of surprise to ourselves, how very rapidly the parts will return to their natural state. Fractures of the bones of the extremities* are sometimes pro- duced during birth, especially in cases of preternatural presentation, when turning or other manual interference is required. They unite readily, and are to be treated upon common principles, only adapting our means to the delicate organization of the child — making our splints, for example, of Bristol board, instead of wood, and carefully preserving the skin from irritation. One thing we would recom- mend to the young practitioner in midwifery — viz. when such acci- dents unfortunately occur, never to think of concealing them, but at once to inform the friends, and explain the steps necessary for the occasion. This is the honestest plan, and we sincerely hope it will also be found to be the best. When pressure by means of a blunt hook or fillet, or in any other way, has been applied to the groin or axilla, such injuries may be done to the nerves in those situations, as will be followed by para- lysis of the limbs. Such an affection is probably altogether beyond the reach of remedial art, and it is unnecessary for us to consider it at any greater length. XII. BLUE DISEASE (CYANOSIS). This term applies to a morbid appearance of the skin, in which it assumes a blue, purple, or leaden colour, and which is occasion- ally observed in new-born infants. The change of colour is parti- cularly remarkable in the lips, cheeks, and nails, and. is generally accompanied with reduction of temperature, and paroxysms of diffi- cult respiration, during which the blueness becomes more pro- nounced, and is extended over the surface of the body — the pulse stops, the extremities become cold, and syncope resembling death often occurs. From these fits the child may recover, but usually to be again attacked, and ultimately to perish in one of them. Any thing which hurries the circulation, — as crying, or quick motion, — is likely to bring on a paroxysm. The cause of these symptoms was attributed by Senac, Morgagni, and others, solely to a con- tinuance of the fcetal condition of the heart ; or, in other words, to a permanent patency of the foramen ovale. Corvisart, however, observed the symptom of cyanosis in cases in which there was no * It is asserted by Schmidt, Jorg, Klein, and others, that in severe labours, with disproportioned pelvis, fractures of the cranial bones may be produced by the force of the pains alone. See Wendt, op. cit. NINE-DAY FITS. 109 communication between the ventricles ; and Dr. J. Crampton has met with others, in which there was no blue colour, and yet the Opening! between both auricles and ventricles must have been un- ! for many years.* Other causes, therefore, must exist ; and in new-born children, we conceive, it may often be accounted for by the imperfect filling of the lungs which we have already spoken of as having been noticed by Dr. Ed. Jorg. When the disease arises from organic imperfection, the prognosis is highly unfavour- able, and nothing can be done by art ; yet the unfortunate subjects sometimes drag on a wretched existence for years, as in Morgagni's well-known case of the girl who survived to her sixtcentli year with a foramen ovale so large as to admit of the passage of the little finger through it. When the symptom belongs to an imper- fect tilling of the lungs with air, we must have recourse to those means of exciting respiration indicated under the head of still-born children, and may sometimes be successful in our efforts. During a paroxysm, all we can do is to sprinkle the child's face with cold water, and expose it freely to cold air. XIII. NINE-DAY FITS (TRISMUS NASCENTIUM). This fatal affection, although occasionally to be met with in private practice, may be justly considered as a hospital disease in this country, but is stated to commit great ravages among infants of all classes in warm climates. t Its ordinary period of occurrence is within nine days from birth, — about the time of the falling off of the funis, — and it appears in two forms, distinguished by nurses as "black" and " white fits." The first of these is violent and rapid in its progress, terminating fatally in from eight to thirty hours ; the second may be protracted to three, five, or even nine days. Sometimes the disease sets in without any warning ; in other cases, there arc certain premonitory symptoms, as whining and starting during sleep, twisting of the upper extremities, the appearance of a livid circle about the lips, sudden changes in the countenance, and compression and puckering of the mouth, accompanied with a pecu- liar screeching : the child's appearing to smile during sleep is also commonly considered as an indication of the approach of fits. An extraordinary greediness for food or suck, as if occasioned by inward pain, is sometimes observed. The stools may be regular and natural, or they may exhibit considerable derangement, being greenish, slimy, and knotted. When the paroxysm actually comes on, the infant is seized with violent, irregular spasms of the muscles, particularly of those of the limbs and face, recurring at uncertain intervals. In the " black fits," the muscular contractions are very violent: there is foaming at the mouth; the thumbs are turned firmly into the palm of the hand ; the jaws are closed, and any * See Mad. Trans. Coll. of Physicians in Diblin, vol. i. new series. f It is also very fatal in the Westmann Islands, on the southern coast of Ice- land. See M'Kenzie's Iceland. 11* 110 MANAGEMENT AND DISEASES OF CHILDREN. attempt to separate them considerably aggravates the paroxysm ; the face, and often other parts of the body, are svvoln, and of a dark copper colour ; during the interval, the muscles retain a greater or lesser degree of rigidity. In the " white fits," there is not so much violence; the face is pale, and the body becomes quickly emaciated. Both are equally fatal. With respect to the pathology of trismus, nothing is certainly known; but the researches of Dr. Joseph Clarke* make it highly probable, that a powerfully predisposing cause exists in a vitiated state of the atmosphere of large hospitals; and Professor Collest has ingeniously put forward the suggestion, that this operates by inducing "an unhealthy or unkindly form of inflammation or ulceration" at the navel, and that the disease is in fact a species of traumatic tetanus, having its immediate cause in the wound occasioned by the separation of the cord. The views of Dr. Clarke led him to pay much attention to the prevention of trismus in the Dublin Lying-in-Hospital, by establish- ing a free ventilation and perfect cleanliness in the wards ; and his numerical statements, certainly, appear strongly to corroborate his opinions. They are also further borne out by the facts contained in Dr. Collins's book,J to which we may refer the student and statistician for much valuable numerical information upon this and other subjects connected with midwifery. Whether we can fully assent to the exact number of lives (16,371) said to have been saved by Dr. Clarke's suggestions, is a matter of very trifling importance ; but we would strongly recommend that his principle with respect to ventilation, &c. should be carried into effect, as perfectly as pos- sible, in every lying-in institution. Professor Colles suggests the propriety of constantly dressing the umbilicus with spirits of turpen- tine, from the birth of the infant, as a preventive measure ; but the small average occurrence of the disease, especially in private prac- tice, scarcely appears to demand such a step. With respect to the treatment of trismus nascentium, when it has once set in, we believe that every thing is empiricism, and that little is to be expected from any plan. We have tried, or seen tried, every variety of treatment — mercury, leeching, blistering, opium, tobacco, &c. &c. — without any impression being made upon the affection ; and we must candidly confess it is not in our power to propose any measure with confi- dence. Dr. Breen,§ of this city, speaks encouragingly of the ad- ministration of an eighth of a drop of laudanum every second hour until narcotic effects are produced, together with "a grain and half of calomel every fifth or sixth hour up to the third time ; afterwards not more frequently than twice or three times in twenty-four hours, with intermediate doses of castor oil, in the quantity of a large sized tea-spoonful, sometimes joined with a third part of spirits of * Trans. R. I. Acad. vol. iii. f Dub. Hosp. Reports, vol. i. X Practical Treatise on Midwifery, by Robert Collins, M. D. London, 1835. Published in the Select Medical Library, January and Febrnary, 1838. — Ed. § See Dub. Med. Journal, vol. viii. INFANTILE ERYSIPELAS. HI terpentine." Dr. B. has not found the warm bath productive of advantage. XIV. INFANTILE ERYSIPELAS. Inflammation of an erysipelatous nature sometimes attacks infants, especially those born in lying-in-hospitals. The disease in its worst form appears about the navel, or lower part of the belly, (from which latter situation it has sometimes been denominated erysi- pelas pubis) ; but it also frequently attacks the limbs, and particu- larly in the vicinity of joints, as the ancle and wrist. It is a very dangerous affection, running quickly into suppuration or gangrene, and usually occurs at periods when the existence of other malignant diseases, as diffuse inflammation, puerperal fever, scarlatina, &c, prove the constitutio mini to be of a typhoid character. Its affinity with such affections is also further shown by the morbid appearances observable in fatal cases of the disease — the different cavities con- taining effusions of curdy gelatinous lymph and serum, and the organs often exhibiting softening and infiltrations of sero-purulent matter. It first appears in the form of a dark red, shining spot, which quickly extends in size, and becomes of a purplish colour ; there is not a great deal of swelling, but the skin is tense and very hard. When it commences on the belly, vesications, destruction of the cellular tissue, and gangrene of the skin, quickly follow. The genital parts are not unfrequently destroyed altogether ; and we have sometimes seen the scrotum become black and slough away, leaving the testicles bare and hanging loosely by the cords. In such cases, the fever is of a typhoid kind and very severe, usually carrying off the child in a very few days. The erysipelas which attacks the limbs, in the first instance is milder in its nature ; and although suppuration often follows, the prognosis is not so un- favourable as in that which commences upon the abdomen, as it less frequently runs into gangrene. Before the setting in of erysi- pelas, the bowels are generally deranged, the stools being offensive, slimy, and knotted. It often, however, makes its attack so speedily after birth, that we have not time to recognize any premonitory symptoms. The general symptoms during the existence of the disease are great restlessness and peevishness, diarrhoea, with ill- conditioned motions, very rapid, feeble pulse, and towards the termination a state of coma. The prognosis is very unfavourable, and yet (so little are we warranted in despairing of children under the most doubtful circumstances,) we have seen a case recover in which the whole scrotum and skin about the pubes had sloughed sway, the bare testicles being again covered up by an extension and cicatrisation of the neighbouring integuments. In treating infantile erysipelas, we must hold in view the circum- stances under which it occurs and its usual course. It is commonly a disease of hospitals, and must therefore be presumed to have its predisposing cause in some impurity of the atmosphere; accord- 112 MANAGEMENT AND DISEASES OF CHILDREN. ingly we should lose no time in transferring the child, if it be practicable, to a different and well-ventilated apartment : this we conceive to be an essential step in the treatment. From the usual course of the disease, its quickly running into gangrene, and the fever being typhoid, we learn the necessity of supporting the child's strength, at the same time that the gastric derangement demands from us a careful attention to its bowels. Should the mother not have sufficient milk, or not be free from disease, we must at once procure a wet-nurse ; and if the child be unable, or disinclined to suck, a tea-spoonful of white wine whey must be administered every hour or half hour. An alterative aperient should at once be given ; and when it has operated, small doses of quinine (one-third to one- fourth of a grain), every three or four hours, in conjunction with one-fourth of a grain of aromatic powder. Ammonia has been re- commended by some ; but we think the wine whey a better stimu- lant, as combining also nutritive matter. With respect to local treatment, in the first instance we probably cannot do better than dust the part with starch-powder or common flour ; and subsequently, when suppuration or gangrene is approaching, more relief will be given by warm fomentation and light poultices, as of bran or chamo- mile flowers, or the fermenting poultice. When matter is formed, incisions will be required in order to give exit to the sloughing cellular membrane, and prevent as far as possible further destruction. Underwood and Burns recommend, as local treatment, compresses of linen wrung out of camphorated spirit; but we rather think we have seen more benefit result from the use of warm applications. Perhaps, when the disease attacks the limbs, it would be advisable to try a modification of Mr. Higginbottom's plan in erysipelas, by drawing, with a pencil of lunar caustic, a sort of cordon round the diseased part. We cannot speak from experience of this suggestion ; but it appears worth trying, especially as the erysipelas, when it attacks the limbs, is frequently of an erratic nature. XV. ABSCESSES. We have frequently had occasion to treat large collections of matter in very young children, which, if the short course of life already permitted to the little patient did not forbid, we should be almost tempted to call chronic abscesses. These formations of matter we do not recollect to have seen noticed by any author; 3-et they are of very frequent occurrence. Their usual situation is in. the axilla, neck, or lower part of the leg ; but we have observed them in almost every part of the body. They set in and increase with little appearance of inflammation, and often attain a very con- siderable size. .We have sometimes given exit to a wine-glassful of matter from one existing in a child of a few weeks old. The dis- ease consists at first of a tumor, apparently not very painful to the touch, until it approaches the surface, when the skin becomes in- flamed, and a process of pointing commences. We can then satisfy INDURATION OF THE CELLULAR TISSUE. 113 ourselves, by the feel, of the presence of a fluid — and the sooner we give vent to it, by a small opening with a lancet, the better. The pus is sometimes fetid ; at others, healthy. After being opened, the abscess commonly gets well without any treatment, beyond the use of a poultice, being required. XVI. INDURATION OF THE CELLULAR TISSUE ((EDEME DU TISSU CELLULAIRE DES NOUVEAUX-NES ; SKIN-BOUND DISEASE). This appears to be a very common disease of the French hospi- tals, and extremely fatal, so much so, that in the years between 180S and 1811 there died, in the Hospice des Enfans frouvte, 576 out of 643 who were attacked. In this country, however, it is not by any means so common. It occurs during the first few days after birth, and in some instances the infant has been born with it. It usually attacks premature, or feeble children, in whom respiration has not been fully established, and commences in the extremities — most commonly in the feet. These parts become somewhat swollen, dry, hard, and cold. The skin is sometimes of the natural colour; at others, livid or purple. It appears as if stretched tightly over the subjacent parts, and is cold and hard, pitting slightly upon pressure. From the extremities the disease commonly proceeds, with rapidity, to the trunk of the body, the whole or parts of which it affects in like manner. The diminution in temperature is remarkable, and the body often appears to be acted upon by external heat merely as so much dead matter. No febrile condition accompanies this affection, thus differing from infantile erysipelas, which in other respects it resembles. The child will not suck, is restless, and continually whines in a manner compared by Dorfmuller to the crying of young mice. Respiration becomes gradually more difficult, until death ensues, usually within the fourth day, but sometimes so late as the second or third wreek. The prognosis is very unfavourable; but in mild cases, the respira- tion sometimes improves, heat begins to be evolved, and recovery slowly takes places. Post mortem examinations prove this disease to consist in an effusion of yellowish or greenish sero-albuminous fluid into the cells of the cellular membrane, both the subcutaneous tissue and that which lies between the muscles. The peculiar hard- ness has been attributed by some to the coagulable quality of the effused fluid, which was analysed by Chevreul ; but we have the authority of Dr. Carswell* for stating that this quality does not exist in a greater degree in the serum in question than in that which constitutes the oedema of adults, and that further, it is not found in a coagulated state in the cellular tissue of children subject to this disease. It is probable that the peculiar hardness and tight- ness of the skin depends upon the condensation of the fat produced by the mechanical pressure of the effused fluid. All observers are * Cyc. of Pract. Med. art. Induration. 114 MANAGEMENT AND DISEASES OF CHILDREN. agreed upon the constant existence of congestion in the large veins, and accumulation of black blood in all the viscera as concomitants of this disease; which stale, however it may be produced, suffi- ciently explains the diminution of temperature, serous effusion, and other phenomena. Other lesions, which are only occasionally ob- served, as open foramen ovale, inflamed state of organs, &c, must be merely considered as accidental coincidences. With respect to the remote cause, much difference of opinion exists. By Dr. Andry, who first* accurately described the disease, and subsequently by M. Duges it was attributed to cold ; M. Breschet conceived it to depend upon an open state of the foramen ovale ; M. Denis con* sidered it as an inflammatory affection of the cellular membrane ; M. Billard assigns several predisposing causes, the most prominent being a natural debility of the child, which, of course, is merely an asylum ignorantise. It appears to us highly probable, that a fre- quent cause may be the imperfect filling of the lungs at the time of birth, of which we have already spoken. Treatment in so fatal a disease is, of course, the subject of much difference of opinion. The earlier plans had for their object the application of heat by means of the warm and vapour bath, and wrapping the child in wool or cotton. The lowness of temperature, however, is merely a symptom of the state of commencing asphyxia ; and we have already observed that that state is not likely to be re- moved by the application of external heat alone. We must endea* vour to lessen the venous congestion, and if we succeed in doing so, the production of heat will proceed naturally. For'this purpose, we would recommend friction with warm flannel; the administra- tion of an emetic of ipecacuan, for the purpose of removing mucus and exciting respiration ; and the internal use of stimulants, as warm wine whey. We cannot put forward this plan as the result of ex- perience ; but we conceive it to be based upon a rational view of the pathology of the disease. Palletta recommends leeches to be applied to the cedematous parts, as a means of promoting circula- tion ; but his plan has not succeeded in other hands. XVII. JAUNDICE (ICTERUS NEONATORUM, OR YELLOW GUM). A more or less marked yellowness of the skin and tunica con- junctiva of the eye is a very common occurrence with infants o two or three days old. This, in ordinary cases, appears to depend merely upon the active commencement of the secretion of bile, more being formed than is required for the uses of the digestive function, and then disposed of by means of the skin and other ex- creting organs. Viewed in this light, it can scarcely be called a disease, commonly disappearing spontaneously, and requiring no medical treatment. W~hen it does not go off in two or three days, we may set matters to right by the administration of a drachm of * It was previously noticed by Drs. Denman and Underwood. , PURULENT OPHTHALMIA OF INFANTS. 115 castor oil, or two or three grains of rhubarb with one of hydrargyrum cum crctii. Jaundice may occur in a young child as the result of malforma- tion, or obstruction of the biliary ducts ; but under such circum- stances it is permanent, and if there be an organic defect, cannot be removed, and will probably be fatal. XVIII. PURULENT OPHTHALMIA OF INFANTS. An inflammation not unfrcquently attacks the eyes of new-born children, which is speedily followed by a copious secretion of pus from the conjunctiva, and, when neglected, often terminates in sloughing of the cornea, or permanent opacity. This disease com- monly sets in the second or third day after birth, and commences with increased vascularity of the conjunctiva, lining the eye-lids, which latter becomes swollen and permanently closed. The inflam- mation soon extends to the conjunctiva of the eye-ball— the swell- ing of the lids increases very much, and a copious discharge of thick, white, purulent matter ensues. If we attempt to open the eye at this period, a gush of matter takes place, and frequently the lower lid is everted, exhibiting its interior surface highly inflamed and of a bright red colour. In some severe instances, the tumefac- tion of the lids is so great as to cause eversion without its being the result of an attempt at opening the eye. We can seldom get a view of the cornea, as the intolerance of light is so great as to cause a turning upwards of the eye-ball upon every attempt at open- ing the lids. Some difference of opinion prevails as to the cause of purulent ophthalmia. It is attributed by many solely to a specific infection communicated during the birth of the child: while by others it is supposed to be a species of epidemic : and others, again, attribute it to cold, or the stimulus of too much light. It is probable that any one of these causes may occasionally produce it ; but our own ex- perience certainly goes in support of its usually being the result of infection, as we have in a large majority of instances traced it to a gonorrhfeal or leucorrhceal discharge existing in the mother before parturition. The prognosis is usually favourable, if the case be seen in time and carefully attended to ; but it has too often happened us to be first called when sloughing or opacity had already taken place. The treatment of purulent ophthalmia has been conducted upon very different principles by diflcrent practitioners. The violence of the inflammation has induced some to apply a leech to the lid or temple, in almost every instance, and to repeat the application as often as three or four times. We have, however, but seldom found it necessary to draw blood at all ; and the most protracted examples of the disease, we have seen, have been those in which leeching was repeatedly employed. It has frequently appeared to us that the loss of blood by two or three leeches — (it is to be remembered 116 MANAGEMENT AND DISEASES OF CHILDREN. that we are treating an infant of two or three days old) — produces such general and local debility as favours very much a protracted continuance of the discharge, merely by causing relaxation of the inflamed vessels. It is only, then, in an extreme case, when the in- flammation is very rapid and violent, and the child strong, that we would venture upon the application of a leech. Our common plan is to employ astringent or stimulant collyria from the commence- ment ; and by the use of these, and the most scrupulous attention to cleanliness, we have generally been successful in saving the eyes. The kind of collyriuin to be used is not of great consequence. A very good formula is six grains of alum to an ounce of rose water; or three grains of sulphate of zinc to the same quantity of rose water. We generally prefer collyria of this description to those composed of nitrate of silver. Much benefit has, however, been derived from a strong solution (say ten grains to the ounce) of the latter substance in distilled water. A drop or two of the collyrium should be introduced into the eye three or four times a day ; but at least every hour (oftener, if necessary,) the discharge should be carefully removed by dropping from a sponge, or injecting between the lids, lukewarm water or chamomile tea. Without attention to cleanliness, and constant removal of the discharge in this way, any treatment we can adopt, whether energetic or mild, will be quite inadequate to the safe management of the disease. When the inflam- mation is severe, and the lids adhere together strongly, a poultice of bread and cold water enclosed in a muslin bag, and applied be- tween the periods of washing, will be found of great service. The application of the solid nitrate of silver to the inflamed eye has been tried by some, and no doubt often with benefit ; but we are never desirous in our practice of trying what can be done with im- punity, but rather of safely removing a disease with the least possi- ble artificial interference. In conjunction with the local treatment, we must attend to the condition of the child's bowels — and will generally perceive a necessity for aperients, and if the discharges be unnatural, for small doses of hydrargyrum cum creta as an alter- ative. Should the discharge begin to decrease, we must continue our attentions to cleanliness, and persevere in the use of the astrin- gent collyria, as the disease is liable to relapse. Even when con- siderable opacities of the cornea remain in severe or improperly treated cases, so active are the absorbents of the child, that we shall frequently find the speck gradually to disappear. XIX. RED GUM (STROPHULUS INTERTINCTUs). Almost every infant is affected three or four days after birth with an eruption of. papulae, which has received the foregoing appella- tions. In its ordinary form this consists of a few red pimples, ap- pearing in greatest number upon the face, neck, and hands, and in- terspersed with diffused red patches. When there is a slight degree of redness, a distinction has been made, and the eruption DENTITION. 117 termed stroj)hulus albidus ; and a rash of the same nature which occurs during dentition in larger quantity and with more irritation, has been termed strophulus confer t us. The ordinary red gum of infancy can scarcely be called a disease. It arises, probably, from the slight irritation attendant upon the new circumstances under which the skin and mucous membranes are placed, — and requires no treatment. The nurse constantly looks for its appearance as a favourable occurrence ; and we believe it merely indicates a healthy state of sensibility of the integuments and mucous membrane. XX. SWELLING OF THE BREASTS. The breasts of infants, both male and female, contain at birth a secretion somewhat resembling milk, and which is generally sup- posed by the attendants to require speedy removal. Accordingly they frequently set about pressing the part until inflammation, and occasionally an abscess is produced. This notion, however, is alto- gether erroneous. No measure for getting rid of the secretion is necessary; and we should forbid any attempt at adopting one. We have repeatedly had to open an abscess produced by pressure in the way alluded to, but which was always attributed by the nurse to the want of sufficient removal of the fluid in question. CHAPTER VI. DENTITION. Absence of teeth has already been remarked as a character be- longing to the mouth at birth. Infants, however, have been born with teeth ;* while in a few instances none have ever grown. The first appearance of teeth usually begins about the sixth or seventh month. It may be much earlier, as the third or fourth month : but oftener is delayed to a later period. The process is commonly com- plete during the first year, or year and a half ; but may be protracted beyond the second year. * When teeth are in the gums at birth (usually the central incisors of the under jaw), they occasionally cause distress by irritating the tongue during the act of sucking. In such cases, their edges, when sharp, may be filed down ; or the teeth themselves extracted. But unless inconvenience arise, it is well to leave them undisturbed ; for they are not always, as stated by Mr. Fox, merely the upper parts or crowns of teeth, without fangs. March, 1838.— 0 12 118 MANAGEMENT AND DISEASES OF CHILDREN. The number of the first set, or milk teeth, is 20 ;* and they make their appearance usually in pairs, — those of the lower jaw coming out before the corresponding pairs of the upper; and a degree of uniformity is to be observed in the order and times of their appear- ing. The middle incisors are those that first come out ; then come the lateral incisors, and after these the anterior molars ; but not uniformly (as M. Serres asserts), for the canine teeth occasionally precede. The posterior molars are the last to appear, at a period varying from the 20th to the 30th month. In the foetus the rudiments of the teeth are observable about the second or third month; and are found (as they advance in size) to consist of a double membranous sac. From the bottom of this arises a pulp, which is composed of nervous and vascular matter, and around which is found a colourless consistent fluid, which is gradually absorbed as the pulp increases in size. On the summit of this pulp (upon which the future tooth is moulded) ossification becomes visible about the end of the third month. The enamel is not formed until afterwards, which it most probably is by secretion from the vascular membrane lining the sac. The groove or channel which had run uninterruptedly along the edge of the jaw-bone, now becomes divided by osseous septa, which grow across ; and thus the alveoli are formed. At birth, ossification is already advanced in most of the first set of teeth; much of the crowns of the molars are formed, and those of the incisors are in general completed. Subsequent to the ossifi- cation of the crowns of the teeth, that of their roots takes place ; and the tooth is thus pushed upwards, the development of the alveoli aiding in the process. The consequent absorption of the surface of the gum, and the apex of the enveloping sac, at length makes way for the appearance of the tooth, which is then said to be cut. This process is a natural one, and does not necessarily lead to diseased action ; but such is liable to occur in consequence of the irritability of the infant constitution, which is at this time particu- larly remarkable, as well as the proneness to sympathetic disturbance. Some irritation must attend the passage of the tooth through the gum ; and this is caused both by the pressure of the crown of the tooth on the parts above, and of the root on the dental nerves below. Hence arises pain ; and to this we are to attribute, as a chief cause, the morbid sympathies that accompany dentition. The degree to which these may amount, however, depends more upon the state of * 4 Incisors in each jaw, 8 2 Canines 4 4 Molars 8 20 In the second set there are — 4 Grinders additional in each jaw, 8 2 Dentes Sapiential do 4 32 DENTITION. 119 the infant at the time, than the extent of local irritation caused by the tooth ; for we see what little suffering attends upon cutting the large double-teeth compared with the small ones, which preceded them at a time when the susceptibility of the infant constitution was at its height. Certain symptoms must naturally accompany dentition, however favourably it may proceed ; and the attendant determination of blood to the parts contributes to these. Saliva flows in increased quantity from the mouth when a child is teething, and the gums are more or less swollen, hard, and hot. Thirst appears to be felt ; for the child takes the breast more frequently, though for shorter periods than usual, dropping it, as if from the tender state of the gums — but the fingers, or whatever it can grasp, are often thrust into the mouth. The child is frequently fretful or peevish, and gets sudden fits of crying or starts in its sleep, which is liable to be disturbed. The cheeks are occasionally flushed ; and increased heat, or pulsation, may be felt about the head. A tendency often exists to disturbance of the stomach, or bowels, the food being rejected; or slight diar- rhoea attends. These symptoms are not to be looked upon as con- stituting disease ; and some of them are obviously but indications of an increased activity in the process of ossification, as they often pre- cede the appearance of the tooth by many weeks, and subside in some days (eight or ten to fourteen). This may be looked upon as the first stage of dentition ; and is called, in popular phraseology, " Breeding the teeth. " The symptoms again occur, but in a some- what modified form, when the tooth begins to approach the surface of the gum. The relation which subsists between dentition and disease, as arising directly therefrom, or merely complicated therewith, is most important; and, upon a right understanding of this, will de- pend our success in the management of children while teething. On no subject does more misapprehension, in common, prevail. All complaints occurring about this time are attributed to dentition as their cause, and hence are frequently mismanaged, being altogether neglected as salutary efforts of nature, or attention paid only to the state of the gums: yet the just medium seems sufficiently obvious. Whenever a child is ill about the time at which the teeth may ap- pear, we should carefully examine the gums, to ascertain how far the symptoms may be connected with their state ; and act accord- ingly. But attention is not to be confined exclusively to the gums, nor are we to rest satisfied with remedial means directed thereto. The illness may be merely an accidental complication, or, even if connected with teething, may require active treatment on its own account In a word, neglect of the state of the gums may render our other treatment unavailing, or attention to this alone, prove in- adequate. The morbid phenomena so often witnessed during dentition are influenced, first, by the degree of irritation caused directly by the teeth ; secondly, by the degree of susceptibility of constitution existing at the time : — the age and condition of the child affect both. 120 MANAGEMENT AND DISEASES OF CHILDREN. The more suddenly the teeth are developed, and the greater the number coming out together, the more will be the iocal irritation, particularly should any obstacle be presented, as a disproportion between the rate of development of the teeth and the jaw, &c. &c. The earlier the age at which dentition commences, the severer is likely to be the constitutional disturbance, from the greater suscep- tibility of the system ; for the natural susceptibility is heightened by the rapid evolution which the brain is undergoing at this early period, in addition to which, there is local determination of blood, caused by the process going on : so that the nervous system is in the highest state of irritability : hence is symptomatic disturbance of all parts, but more particularly of the brain, so liable to be induced at the time of teething. The proneness to this will be increased by any thing that tends to deteriorate the general health, as the injurious effects of improper food, bad air, &c. &c. Delicate children suffer more constantly than the robust, their dentition being tedious ; and in them, bowel complaints, with wasting, frequently attend. Any complaint, in short, to which a predisposition may have existed, is likely to be developed ; and any disease contracted at this time (as measles, pertussis, &c.) is attended with unusual danger. Dentition is, however, no longer regarded as a universal source of infantile disease ; and we shall treat only of such complaints as are to be traced distinctly to this source, resting satisfied with a general notice of its incidental relation to other maladies. Many of the symptoms caused by dentition are truly nervous ; but inflammatory affections do often arise from, or are complicated with it. The local symptoms of irritation in the gums are at times severe ; and here, in truth, lies the origin of all the others. There ma^ be much swelling, heat, redness, and pain in the gums, which will be so tender as not to tolerate the slightest pressure. This most usually occurs on the first irritation, during the " breeding of the teeth ;" and the redness of the whole gum is then often very intense. At a later period, when the tooth is coming forward, the sensibility undergoes a modification, and pressure gives ease rather than un- easiness, the redness being now confined to the base of the gum, the surface being white, or looking like a vesicle stretched over the tooth. Aphthae or ulceration may be present, and the cervical, or more usually the salivary glands, enlarged and tender, accompanied by a very profuse flow of saliva. The determination of blood may extend further, and engage the head, which will be hot and heavy ; the cheeks red and swollen ; and the eyes suffused and watery. Great thirst, heat of skin, restlessness and alternate heaviness, with disturbed sleep, or sudden startings therefrom, now attend. This symptomatic fever is remarkable for its suddenness and variableness, often recurring and remitting within a few hours. Distant organs soon become implicated in a marked manner, and suffer sympathetically, either from inflammatory disease, or mere nervous disturbance. DENTITION. 121 Acute inflammatory affections, wholly independent of dentition, may occur during this process, which predisposes to them; but no doubt can exist that many such affections are directly connected therewith, as they rapidly subside when the irritation in the gums is mitigated, but are little relieved by any means, so long as this subsists undiminished. The treatment of such cases requires no modification beyond the necessity for paying primary attention to the state of the gums. Nervous disturbance of various organs still more frequently arises in connection with dentition ; and upon a correct diagnosis between these and the inflammatory affections, will depend much of our success in practice. Some of these secondary affections appear to be rather of a salu- tary character, as if efforts of nature to aid by counter-irritation or derivation, as we see in the abundant flow of saliva, and lax state of bowels, so constantly attendant upon teething. Suddenly suppress- ing these is certainly dangerous ; and so long as they retain their mere sympathetic character, little should be done to interfere ; but we are by no means to fall into the popular error, that treatment for such is never to be adopted, and so allow children to die of purging or vomiting, because they are getting their teeth. The mucous membrane is the tract most liable to suffer from these secondary aflections, and the gastro-intestinal mucous mem- brane is that most frequently affected. The brain and nerves, how- ever ; the lungs, the skin, and the lymphatic glands, are all subject to this irritative disturbance ; and we remark, that occasionally the urine becomes pale and copious, as it is observed to do in the ner- vous affections of adults. Symptomatic disturbance of the brain or nerves often induces sleeplessness, or very uneasy slumbers, with startings and sudden awakenings out of sleep, the child screaming and looking frightened. If there be grinding of the teeth, with tremor or rapid motions of the lips, convulsions are likely to follow, particularly if the fever be high, and bowels costive. These may depend on mere nervous excitement, or arise from congestion, or be connected with derange- ment of the digestive organs. The convulsive movements are often confined to mere twitchings or spasmodic motions of the face, eyes, and arms, and in such case are not so dangerous as is commonly thought. In no case, however, are they to be neglected ; for great danger attends when they become general, violent, and frequent. Death may take place suddenly, as if by apoplexy ; or an incurable paralysis be the result, as we have more than once witnessed. A particular affection of the hands and feet has been described by Dr. Kellie, of Leith, as connected with dentition, in which a spastic contraction of the flexors of the thumbs and toes is a prin- cipal character; but a peculiar swelling of the hands and feet shows it to be an affection before described by Underwood. This swelling arises suddenly, is of a mottled or purplish hue, very round and elevated, and cooler than the surrounding skin. It may last some 12* 122 MANAGEMENT AND DISEASES OF CHILDREN. weeks, but usually terminates favourably in a few days, ceasing spontaneously when the tooth appears. — Of the spasmodic affections connected with dentition, those of the respiratory organs are especially formidable, as spasm of the glottis, &c. &c. The most frequent of these, however, is the dry, nervous, irritative cough, that so often attends dentition, and is sure to be aggravated by any derangement of the bowels. This, like all the other symptoms dependent on irritation in the gums, will be mitigated, or at once removed, by the liberation of the tooth. Diseases of the skin often occur during dentition, but cannot be said to arise directly therefrom, unless they appear or disappear in relation to the condition of the tooth, which they do occasionally in a remarkable manner. Affections of the lymphatic glands appear to arise rather in con- sequence of the debility induced by teething, than directly from the irritation caused thereby. Guersent, however, appears to look upon the early and rapid development of the teeth as occasionally the cause of tubercle and such affections ; contrary to Gardien, who considered very early dentition as caused by a scrofulous diathesis. By far the most frequent of the symptomatic affections attendant upon teething are those of the stomach and bowels, which therefore we have reserved for last. Purging or vomiting often attends dentition. The purging is characterised by being unaccompanied by pain on pressure ; the tongue is moist and white, not red or dry ; the appetite remains unimpaired, nor does the child lose flesh. Acidity, however, and flatulency, with griping, frequently attend, when the stools are green, and smell sour, as does also the breath. Vomiting is often conjoined with purging during dentition, and may be, like it, merely symptomatic ; but when they are carried to a great degree, this combination is a most formidable one, and often proves fatal. M. Cruveilhier has described a disease of this kind, as also M. Guersent (though with some difference) ; but we cannot agree with them in regarding it as necessarily connected with dentition, though often appearing at this period, as we have seen it prevail at times quite as an epidemic, and must regard it, with Dr. Joy,* as a species of cholera morbus. This disease requires very decisive treatment, and will be noticed in the proper place ; but the slight purging and vomiting that so often attend dentition should be cautiously interfered with, so long as the child's strength remains unimpaired, and no signs of inflammation make their appearance. Treatment. — The management of the morbid conditions con- nected with dentition is in nothing peculiar, beyond what concerns the local treatment of the teeth and gums, which we now proceed to consider, — leaving the diseases in question to be treated of, each under its proper head. * See "Dentition," Cyclopedia of Practical Medicine — one of many excellent articles by Dr. Joy, to which we shall have occasion to refer. DENTITION— TREATMENT. 123 When dentition proceeds favourably, as a natural process, little interference is required. Generally speaking, the child should he kept calm and cool (more especially the head), and much in the open air ; the bowels rather free ; and great care taken to avoid overloading the stomach, or giving stimulating food. It is as im- portant to attend to this with respect to the nurse, as the infant. Exposure to cold air should be avoided, inflammatory affections being particularly liable to occur at this period. As dentition advances, or on its completion, the child usually suffers somewhat in its general strength, and will require improvement of diet, as the occasional use of a little weak chicken broth, &c. &c. : the object is, to keep the system at a just medium. Dr. John Clarke especially recommends sponging the head daily with cold water. So long as no particular irritation or suffering exists in the gums, the less they are interfered with, the better. Something, however, will always be done, and it is well to understand what that should be. One of the first symptoms of teething is tenderness of the gums, which are often so sensitive as not to tolerate any pressure : the child attempts to put things into its mouth, but appears to be hurt; and, at this time, such should not be supplied. Gentle friction with the nurse's finger soothes the gums most; and if they are very hot, the finger may be previously dipped in cold water, or other fluid, that has been sweetened. At a more advanced stage, as the tooth is coming forward, the mode of sensibility seems altered, and pressure on the gums gives satisfaction, so that the presence of hard substances is enjoyed. This is the period for corals, ivory rings, &c. &c. The latter, from their shape, are less liable to hurt than the former, and should therefore be preferred. Some particular virtues have long been ascribed to a ring of gold ; but, even, if not too expensive for common use (it should be large, to be safe,) the reasons assigned for its utility are unfounded ; as we cannot agree with Mason Good, that because ptyalism followed friction of the gums with powder of gold, in the experiments of Dr. Chrestein, of Montpelier, such effects are to ensue from the use of the metal in form of a ring. The produc- tion of an increased flow of saliva is attempted, in some parts of Germany, by the use of little bags of spice and sugar ; while in France they dip any substance used, in honey, or sweet decoction of barley, as being relaxant to the gums. Such practices succeed in occupying or soothing the child ; but mischief arises from stimu- lating or overloading the stomach and bowels with sweets or spices. A good and simple plan is, to allow a child the use of a small wax candle, or occasionally a stick of liquorice root; but, in truth, a crust of bread answers all useful purposes. When much local irri- tation prevails,.and the gums become very hot, tender, and swollen, the tooth may be obviously on its way to protrude. The local treatment is now the most important point, often removing the ne- cessity for any other : and without it, all other means may prove ineffectual. To relieve the tension, and remove the irritation, is 124 MANAGEMENT AND DISEASES OF CHILDREN. our object, and the gums should be scarified ; but there are two purposes for which this may be done, and according to which the operation will vary. We may wish merely to draw blood, which will be done by scarifying the gum freely, but not deeply : this may be advisable in the first stage of irritation, and before the tooth appears to be coming forwards. Such practice, however, is not often required ; and we should never omit to explain our object, as a tooth is always expected to appear soon after the gums are sca- rified, and in this instance, only disappointment would follow. When our object is to open the gum so as to free the tooth, our incision must be made freely and firmly through the gum and cap- sule, until we feel the instrument grate upon the teeth. If it be a molar tooth, the incision should be crucial, or double, so as to enclose a small flap, which some advise to be cut out, but this is seldom re- quired. The child's head should be held firmly by an assistant, while the operator stands before or behind, according, as the tooth is in the under or upper jaw, and with the fore-fingers of his left hand keeps the tongue and cheeks out of the way, while he makes his incision longitudinally with a gum-fleam.* The instrument should be sharp and clean, and no fear need be entertained of ulcera- tion. The bleeding that follows always does good, nor need appre- hension be entertained about hemorrhage. The operation is scarcely attended with pain, and is followed by quick relief; but the tooth will not always immediately appear, even though the capsule be opened. A repetition of the operation is not unfrequently required ; but when the local distress is relieved, the mere absence of the tooth is not a sufficient reason for its renewal. No one need sup- pose, that if a cicatrix be formed, it tends to retard the progress of the tooth, by its callosity, — the fact being, that newly cicatrised parts are those most easily absorbed. This operation should never be omitted when the local irritation runs high ; and its prompt em- ployment will always mitigate, and often remove, any attendant symptoms, particularly if merely sympathetic, or of the nervous class : even when inflammatory, relief is afforded, and the usual treatment will seldom require to be pushed so far afterwards as in ordinary cases of like inflammation. II. SECOND SET, OR PERMANENT TEETH. The first set of teeth begin to fall or be shed at about seven years of age, and are replaced by the second or permanent set, — this process i occupying five or six years in its completion. * It is often difficult to make a child open its mouth, and it may be well to < mention the plan we have found most convenient: by pressing firmly with the finger and thumb upon each cheek, we never fail to separate the jaws ; and, in children who have already cut the front teeth, we can keep the mouth open, and prevent our fingers being bitten, by turning a portion of the under lip into the mouth, between their teeth and our own thumb. Dr. Blake recommends the incision to be made towards the external plate of the alveolar processes, so as to avoid injuring the connecting membranes and sacs of the permanent teeth. See Blake's Essay on the Teeth, p. 177. DISEASES OF THE DIGESTIVE ORGANS. I05 The immediate cause of this change in the milk teeth seems to be (according to M. Serres), the obliteration of the artery of these teeth, and its canal, which takes place about the seventh year, more or less completely, when the fangs and sockets become absorbed. The ascent of the second set contributes somewhat to the general process, by destroying the nerves and vessels, but does notso directly, as might be supposed ; for the permanent teeth have separate sockets of their own, and, in consequence of the prolongation of the jaw- bones, which takes place at this age, do not lie immediately under the shedding teeth that correspond. In the foetus, we see the germs of the greater number of the second set lying behind or below the first. The cutting of the second set is seldom attended with distress ; and when local irritation does occur, it is little felt by the constitu- tion, which has lost by this time its excessive sensibility : but occa- sionally much local suffering, and consequent constitutional distress, does attend, and the free use of the gum lancet is required. When the teeth come up very irregularly, and press against those before them, or protrude by their side, so that some of the same teeth of both sets are apparent together, extraction of some of the first set will become necessary ; but this belongs to the province of dental surgery, — as also the use of dentrifices, &c, which, however, chil- dren should be early taught to employ — at least, they should be instructed to brush their teeth once or twice each day, with a soft tooth-brush and water. CHAPTER VII. DISEASES OF THE DIGESTIVE ORGANS. I. GENERAL OBSERVATIONS. The gastro-intestinal mucous membrane is, in particular, subject to disease, even in the youngest infant. It may be affected through its whole tract ; or, what is more usual, in one part only ; — but fre- quently two or more portions are at the same time the seat of dis- ease ; and of these, some are much more liable to be attacked than others. Again, different structures may be separately engaged ; and hence will vary the name of the disease, according to its seat, or the nature of the affection. Inflammatory affections are the most common ; and according as they are seated in the mouth, stomach, or different parts of the intestinal canal, will the disease be called stomatitis, gastritis, ileitis, 126 MANAGEMENT AND DISEASES OF CHILDREN. &c. The inflammation may be simply erythematous, or may lead to ulceration, exudation, or gangrene. The ulceration may be of a common kind, or, what is more usual, of an aphthous character ; and exudation may take place as a conse- quence of this ulceration, or independently of it. Exudations upon the mucous membrane are of two distinct characters : either white and soft, being made up of the crusts of aphthous ulceration ; or of a peculiar secretion resembling milk or curd, and said to result from a particular form of inflammation (independently of ulceration,) called by the French muguet ; or the exudation may be firm and tenacious, truly consisting of an effusion of lymph. Any of these forms of disease may end in gangrene, or from the commencement show a disposition thereto. In the mouth of children we may witness every one of these affections of the mucous membrane ; and most of them may be seen in any tract of the intestinal canal. But some are much more liable to occur in certain regions than others ; while a few are very rare in any. The mucous membrane of the mouth in children shows a dispo- sition to disease from the earliest age, and may be seen in a state of congestion at birth, or of inflammation almost immediately after. Exudation, or ulceration, are common consequences ; and are always attended with a degree of danger, even in the mildest cases, from their liability to spread, and so pass into the digestive tube, or encroach on the air passages. So long as the disease is confined to the mouth, even in severe cases, little constitutional disturbance is perceived, if the infant be young. But these affections are seldom merely local, being usually complicated with gastric or intestinal disease, or symptomatic thereof. Hence constitutional treatment, particularly as regards the state of the bowels, is never to be neglected ; but attention must not be confined to this alone. Not less important is the local treatment ; a prime source of danger in such affections being (as already noticed) their tendency to spread. Hence no time is to be lost in trying to arrest their progress by topical applications. IT. AFFECTIONS OF THE MOUTH, PHAKYNX, ETC. Inflammation of the mucous membrane of the mouth — Stomatitis — is a frequent source of disease with children ; and may be brought on by cold, stimulating or improper food, the too frequent use of the sucking-bottle, &c. &c. It is often symptomatic of a similar condition of the stomach, or other part of the intestinal canal. M. Billard considers that a congested state of the mucous membrane, to which newly-born infants are subject, predisposes to this disease. • The symptoms are, heat and redness of the lining membrane of the mouth, to a greater or less extent. The tongue and mouth are often dry ; the lips may be swelled and excoriated, or surrounded AFFECTIONS OF THE MOUTH, ETC. 127 by an eruption ; and when the disease is protracted, and the infant but a few months old, a profuse flow of saliva may attend. But there is seldom any appreciable fever, unless the infant has reached the fifth or sixth month, when such is usually present. Inflammation of the mouth, when slight and uncomplicated, is attended with little danger, and usually yields to mild emollient applications, such as mucilage of gum, decoction of barley, &c. ; attention being at the same time paid to the state of the bowels, and care taken to remove any source of irritation, as in the nature of the food, the mode of feeding, &c. &c. When complicated with intestinal disease, or symptomatic thereof, the case becomes serious, — and the principal attention must be paid to the more dangerous disorder. In all cases, the tendency to run into ulceration, or sloughing, and to spread, must be taken into account ; and on the first symptom of such disposition, local appli- cations, calculated to alter the morbid action, or arrest its progress, be at once adopted. These will be particularised, when speaking generally of the treatment of these affections. Inflammation of the mouthy with ulceration — Ulcerous Sto- matitis.— When intense or protracted, inflammation soon leads to ulceration, especially in children who are mismanaged, or placed in unfavourable situations, and whose general health is in consequence deteriorated. These ulcerations may be of a common character, or, what is more usual, of that peculiar form denominated aphthous, and long known under the general appellation of thrush. The common ulcer is usually large and irregular in shape. It is covered with a white or yellowish slough, and surrounded by much redness. These ulcers are seldom numerous — ofton single, and are situated on the inside of the cheek, the roof of the mouth, or may be found on the tongue. They appear to arise directly in consequence of the inflam- mation of the mucous membrane, or of a state of ramollissement caused thereby. In infants at the breast, or until after a year old, an ulceration of the gums may be observed of a very acute character. The gum appears spongy, vascular, or of a purplish hue ; and the ulceration often runs deep, being disposed to bleed, and of a greenish or ash colour ; but it is not liable to slough. It occurs usually about the period of first dentition. Much local irritation attends these ulcerations of the mouth, with fever, which occasionally runs high, and is accompanied by great restlessness, — the digestive organs being in particular deranged. •Aphthous Ulceration. — The form of ulceration most frequently met with in the mouths of children is the small circular white ulcer, called aphtha, and seen so frequently on the inside of the lower lip, the cheeks, gums, or on the tongue, especially at the time of teething. A degree of obscurity, however, appears to prevail respecting the true nature and character of these ulcers ; and some varieties do certainly exist, which it is necessary to distinguish. Aphthae are commonly described as originating in an eruption of 128 MANAGEMENT AND DISEASES OF CHILDREN. small white vesicles, which are superficial, and filled with a gela- tinous or puriform fluid. Ulceration succeeds, or a crust is formed of a whitish pultaceous matter, which becomes detached, and is thrown off in the saliva. Aphthae may be single or confluent. When few, they are usually found on the inside of the lower lip, on the gums, or on the tongue. When confluent, the inside of the cheek is often quite covered with them, and they extend backwards to the fauces. The colour may be dark or yellowish, according as the ulcers are tinged with blood or bile. We must be careful to distinguish such discolouration from that indicative of sloughing or gangrene. The mouth is usually hot, and the child fretful and uneasy. Dif-i ficulty of mastication, or deglutition, may attend ; but there is seldom much accompanying fever ; nor are aphthae dangerous in1 themselves, unless they show a disposition to spread along the; pharynx, or become gangrenous. When symptomatic of disease of; the digestive organs, the case assumes a new character. The con- stitutional disorder claims our chief attention, especially if the aphthae occur during its progress, as after protracted diarrhoea, when their- supervention is to be looked upon in a more serious light than if- they had been antecedent in their appearance. M. Billard attempts to determine the true nature of aphthae, and to distinguish them from other affections of the mouth, by assigning to them a different character, and anatomical origin. Aphthae, ac- cording to him, are truly an ulceration of the muciparous glands or1 follicles, which, becoming inflamed, soften in the centre and ulcerate.. They retain their primitive round form, and become covered withj a white or puriform matter, being usually surrounded by a red; circle. Previous to the stage of ulceration, M. Billard states that the inflamed and tumid follicles may be felt by the finger, before, they can be distinctly seen ; or, when visible, they may appear as! small white specks, a little prominent, and surrounded by a red' edge. These are situated on the inside of the lips or cheeks, on1 the vault or pillar of the palate, or on the inferior and lateral parts of the base of the tongue. When numerous and near to each other.; aphthae may become confluent, and be covered with a continuous5 crust or coating of a whitish hue. Muguet, a white exudation, covering the mucous membrane of the mouth in children, has been long observed. This was denomiH nated white thrush, and ranked as a species of aphthae ; but is] probably the same disease as that called more recently by French authors muguet or millet — to which infants at the breast, in par-, ticular, are subject. In this disease, the mucous membrane appears covered, to a! greater or less extent, with a white milky, or curd-like concretion — at times covering the whole surface, as if the child's mouth were lined with cream or curd. We have seen it to such extent, that' the white fluid exuded from the nostrils. It may occur in infants only a few days old ; and appears to be AFFECTIONS OF THE MOUTH, ETC. 129 frequent in France, at least among the infants crowded together, at the Foundling Hospital. Like aphthous ulceration, this disease may spread into the bowels or lungs ; or it may be found in other situations besides the mouth. According to M. Billard, muguet and aphthae differ essentially ; the morbid excretion in the former not arising from ulceration, as in aphthae, but in consequence of a peculiar form of inflammation, affecting in particular the papillae of the mucous membrane, and i causing this white secretion to be thrown out by them. This will i vary in appearance according to the part on which it occurs, being disposed in white specks or dots on the tip of the tongue, and in .patches on the internal surface of the lips and checks ; or assuming .the membranous form on the palate and base of the tongue. This difference appears to depend on the degree of development of the ^papillae in these several situations. The early period at which imuguet is liable to occur also distinguishes it from aphthae ; which, .according to M. Billard, never appear until about the period of dentition, when the muciparous glands, which can scarcely be traced iat birth, become highly developed, and hence liable to that inflam- mation and ulceration which, according to him, constitute aphthae. That there is an affection of the mucous membrane of the mouth, ■in which a white, exudation is present independently of ulceration, ■we have no doubt, having seen the disease in very young infants, and found the membrane unbroken beneath, this secretion being iexternal to the epithelium ; and to this disease the term muguet may be restricted. But that aphthous ulceration never is the cause I of such an affection in early infancy, is an opinion contrary to our • experience, and we find is also opposed to that of Dr. Ryan, as stated •by him in his Lectures. M The exudation in muguet, and the crusts covering the ulcerations Hn aphtha:, become from time to time detached, being thrown off j;nthe saliva, or passing into the stomach, and mixing with the x -»tools. So long, however, as the inflammatory or ulcerative process continues unchanged, the excretion is renewed, and this process continued. Our object, therefore, must be not merely to remove j >his, but to prevent its renewal. When much local irritation prevails, emollient applications will be required, as a linctus made of equal 5 oarts of mucilage of gum, white of egg, and simple syrup, as recom- jj nended by Boerhaave. But to alter the morbid action, and so | check the disease, decisive local measures must be adopted : while ,j It the same time attention is paid to the state of the constitution, J ic. &c, as will be stated when speaking of the treatment of the norbid conditions of the mouth, which we shall do in a connected 0 panner. Diphtheritc. — Another form of exudation, differing in its character j ind seat, is to be observed in children affected with inflammation jjj ,f the pharynx, tonsils, or soft palate. Children are subject to ommon inflammation of these parts, like adults — not differing in II *ature or mode of treatment, except so far as danger arises from March, 1S38.— P 13 130 MANAGEMENT AND DISEASES OF CHILDREN. the greater narrowness of the passage, and proximity of the rima glottidis, — and so the greater risk of suffocation. Hence, however, much promptness in the application of antiphlogistic means is ne- cessary. But in children, in particular, we are liable to find inflam- mation of these parts throwing out a false membrane ; and this, whether the inflammation show a tendency to sloughing or not. The presence of this membrane, which appears to be an exudation of true lymph, is always a source of danger from its tendency to spread into the larynx, and constitutes the disease known by the name of diphtherite, as described by Bretonneau, and spoken of by him as croup.* This use of the term is, however, objectionable, as will be hereafter noticed. Diphtherite, according to its etymological signification, is a pellicular inflammation, or one attended with exudation. In this sense, strictly, the disease is not common ; but we have seen it, and removed from the velum or back of the pharynx a thick pellicle of lymph — the mucous membrane beneath being inflamed, but free from ulcer or slough. On the contrary, we have found from the first the inflamed surface beneath converted wholly into an ash-coloured slough, or studded with patches of such. Again, the exuded lymph seems of itself capable of undergoing putrefaction, without the surface beneath becoming gangrenous, but appearing simply inflamed. This peculiarity has been represented as the general state of the case ; but such is far from being correct All these forms of inflammatory exudation at the back of the mouth are attended with much danger, and this is doubled when a ten- dency to sloughing is added. The inflammatory affection may pre- 1 sent this character from the commencement, or only assume it during the progress of the disease. Diphtherite is a very formidable form of disease, but by no means so common as some would lead us to suppose, who apply this term to any spreading ulceration at the back of the throat. Some very instructive cases of true diphtherite, in both its forms, are given by Mr. Bewley in the eighth volume of the Dublin Journal of Medical Science. He notices the dangerous insidiousness of this form of inflammation, which may have made extensive progress without any uneasiness in the throat, pain in swallowing, or other symptom to indicate the disease going on ; and concludes by pointing out some peculiarities of the disorder, as seen by him, which are well worthy of attention : but to which our limited space allows us only to refer. Sloughing or gangrene may be the result of any of the morbid conditions of the mouth, or fauces, of which we have spoken ; and it is a danger attendant upon every one of them, when occurring in weakly children of an unhealthy aspect, or living crowded togethej in unwholesome situations. It is most liable to occur, however, ir * Des inflammations speciales du tissu muqueux, et en particulier de 1: diphtherite, ou inflammation pelliculaire, connu sous le nom de croup, &c. &c Par P. Bretonneau, &c. &c. AFFECTIONS OF THE MOUTH, ETC. 131 affections of the tonsils, soft palate, or back of the throat — perhaps more particularly when attended by false membranes. When aphthae become gangrenous, the surface of the aphtha; grows brown, being covered by a hard eschar, or one soft and pul- taceous ; and when detached, the surface beneath is highly red, or granulated. The surrounding parts are soft and easily depressed, being swollen and of a violet hue. The edges of the ulcer assume a torn, soft, or burned appearance, and a fetid odour usually attends. The mouth hangs open, and allows the saliva to escape. Aphtha; situated at the back of the fauces seem more liable to become gan- grenous than those found elsewhere; and this appears to constitute that form of the complaint known by the name of black thrush. Muguet may become gangrenous in a similar manner. When inflammation of the tonsils or pharynx is very intense, accompanied by false membranes, or occurring during scarla- tina or any livid-coloured eruption, we may apprehend gangrene, particularly if the child be very delicate, ill-nourished, or exposed to contagion, (as when gangrenous sore throat prevails,) or if gan- grene of other parts of the body be present. We judge of the approach of gangrene by the local appearances and general symp- toms, as when much or sudden prostration attends, or is induced by a disproportionate degree of depletion ; while the colour of the inflamed part changes from a lively red to pale, or appears from the first of a livid or dusky red hue. Soon small white or ash-coloured specks appear, rapidly spreading one into the other, and becoming grey, or even black, towards the conclusion. A fetid odour attends; hut when the sloughs are completely developed, the breath often loses its fetor, the pain in the throat ceases, and the deglutition becomes easy, — the general prostration, however, growing more intense. If the gangrene spreads to the nasal parts, breathing through the nostrils becomes difficult, and the voice nasal ; while an acrid discharge, flowing through the nares, irritates the surround- ing skin. When the isthmus of the fauces is affected, the appear- ance of the parts betrays this state, accompanied by a sense of suf- focation, and difficulty of deglutition — this becomes impossible, if the gangrene extend to the oesophagus ; and when passing into the air tubes, there is remarkable alteration in the cry or voice, which becomes hoarse or inaudible, with a peculiar cough, or wheezing respiration. Pustular inflammation of the mucous membrane of the mouth attends small-pox ; or a malignant pustule, commencing on the inside of the cheek, and extending outwards to the skin, may suc- ceed to small-pox, measles, or scarlatina, at the time when the face and extremities are oedematous. Huxham notices, in his Reports for July, 1745, mortification of the mouth and fauces as occurring after measles. Dr. Marshall Hall, in a paper given in the fifteenth volume of the Edinburgh Medical and Surgical Journal, states that all the cases that he observed occurred after antecedent disorders of the digestive organs, typhus fever, or some inflammatory disease. 132 MANAGEMENT AND DISEASES OF CHILDREN. The exanthemata appear to be the acute disorders most frequently followed by gangrene of the mouth in children. A particular form of gangrene of the mouth, without any pre- ceding inflammation, occasionally attacks infants, especially such as are very feeble at birth, or broken down by disease. An cede- matous circumscribed swelling appears on the cheek, with a central point more or less hard, over which occurs a dark red spot This spot may appear on the inside or outside of the cheek ; and the skin over the cedematous part is characterised by an oily appear- ance. An eschar forms from within outwards on the central point; and the soft parts mortify, often extensively, down to the bone, so that the parietes of the cheeks and gums are destroyed, — falling off in shreds, mixed with a dark sanguineous fluid, and accompanied by a very fetid odour. No-disease can be more frightful or formidable, than sloughing of the mouth in children. Recovery seems impossible, when once the disease has set severely in, the child sinking beneath the constitu- tional disturbance, independently of the local ravages of the dis- order,— which, however, are often such as to render recovery not to be desired, so frightful is the deformity necessarily entailed. The fever, which may be at first high, soon sinks into low typhus; the bowels become greatly deranged, and diarrhoea often attends at the close.* Cancrum Oris. — An ulceration of the mouth occurring in chil- dren, and often ending in mortification, has been described by authors under this appellation, and is noticed by Dr. Cuming, (formerly assistant physician to the Dublin Institution for the Dis- eases of Children,) in an excellent paper on this subject, printed in the fourth volume of the Dublin Hospital Reports. He confines this appellation to a form of ulceration, generally commencing in the gums, and thence extending to the lips and cheeks. It may be acute or chronic; and is more liable to be attended by sloughing, the more acute it is; but the ulcerative process still predominates, and by it, principally, is the destruction effected. This variety of the disease, according to Dr. Cuming, does not attack infants at the breast, nor under a year and: a half old ; but is met with in children between twenty months and seven years of age. A very important point, in the class of disorders which we have been just considering, is to determine the question, how far any of them may be contagious, or not. The common forms of inflamma- tion or ulceration are obviously not so. Inflammation attended with aphthous ulceration appears capable of being communicated by close contact; but, unless applied to a similar structure, the same disease * Mr. Dease the elder describes a disease of this description, under the name of" gangrenous erosion of the cheek;" and by Mr. Burns, a similar disorder is described as Noma. The subject has been fully treated of by Continental writers. See Isnard's Dissertation sur une Affection Gangreneuse particuliere aux Enfans ; and Baron's Memoir sur une Affection de la Bouche. — Bullet, de la Faculty 1816. AFFECTIONS OF THE MOUTH, ETC. 133 will not arise. Thus the nurse's nipple often becomes inflamed, or excoriated, from the contact of a child's mouth affected with aphthae ormuguet; hut the disease of the nipple is not the same as that , which gave rise to it. True aphthae are said to have been commu- nicated directly by contact, from kissing the lips of an infant | labouring under the disease. Muguet docs not appear to be thus , communicated, as healthy infants have deen observed drinking from the same vessels with those labouring under the complaint, without contracting it. Such a practice, however, should be guarded against, and children separated as much as possible, when affected with these disorders. At the Hospice des Enfans Trouves, the disease, accord- ■ ing to M. Billard, seems to prevail at all times with nearly equal intensity, but is not looked upon as contagious. No doubt, however, can be entertained as to the contagious character of diphtherite, and i that, whether tending to gangrene, or not. No time should be lost in separating a child affected with pellicular inflammation of the pharynx or fauces ; and when once this disease has appeared, the occurrence of any redness or soreness of the throat in a child should be sufficient to induce us to separate it from others, — as the disease, however severe in its progress, often commences in a mild and in- sidious manner. Neglect of this precaution has led to sad results, as we have witnessed in families where several children in succes- sion were lost, before attention was paid to this point. When sloughing or gangrene are present, or a disposition to such is mani- fested, all agree upon the necessity of separating children not affected, from those that are ill. In the foregoing account, our object has been, to give a general and connected sketch of the principal morbid affections to which the mouth and fauces are subject in the child, so as to present at a view their relations one to another. To avoid, as much as possible, interruption to a continuous account of these diseases, as presented lo the eye, we touched but slightly on the constitutional symptoms; some peculiarities in which, however, we now mean to sketch in the same general and connected manner. One of the first of these peculiarities is, the very slight constitutional disturbance, or febrile action, that usually attends any of these affections of the mouth in very young infants ; and that, even though the disorder may have extended farther, or have been complicated with intestinal disease. Until the infant has reached the third or fourth month, or until the time of teething has commenced, little change is observed in the state of the skin, pulse, or appetite, and even the bowels are at times scarcely deranged. The infant will probably be peevish, and may be restless, with some heat of skin, the bowels ultimately becoming disordered ; but the pulse is remarkable for partaking little of the general disturbance, and altogether is a very uncertain guide in affections of the gastro-intestinal mucous membrane in the young infant. "When the child is older, particularly about the period of dentition, the constitutional disturbance becomes very manifest, and 13* 134 MANAGEMENT AND DISEASES OF CHILDREN. often amounts to a great degree. Restlessness, crying, disturbed sleep, intense heat of skin, with shiverings and very rapid pulse, at- tend, if the inflammation be acute, and attack especially the tonsils or pharynx: such symptoms usually usher in an attack of diphtherite. The bowels- soon become remarkably deranged, the stools being thin, watery and fetid, — the bile being absent, or much disordered, and white flakes appearing in the stools. Great thirst attends, and the head becomes more or less engaged, there being startings in sleep, head-ache, or stupor, particularly when respiration is impeded. In noticing the constitutional symptoms, we must specially mark those that indicate the approach or presence of gangrene, as a total change of treatment becomes then necessary. Treatment. — Local applications are particularly important in affections of the mouth and fauces, and will vary according to the nature of the case, or stage of the. disorder. When much irritation is present, as there often is in the early stages of aphthae or muguet, attended by sharp inflammatory action, soothing applications, as already specified, will answer best. When inflammation runs high, leeches will be necessary ; and in cases of acute inflammation of the tonsils or pharynx, they should be early applied. We must be care- ful, however, to observe the character of the inflammation, and pro- ceed with caution ; for whert sloughing sore throat prevails, malig- nant diphtherite, or a bad form of scarlatina, local depletion should be used with great reserve, or altogether interdicted. The same caution is necessary when a child is much broken down in health, or resident in a confined unwholesome situation, even though the inflammation set in with severity. In some instances, however, gangrene appears to result from excess of inflammation ; and in such cases leeches are essential, especially when the child is strong, and the fever runs high. In diphtherite, leeching is little available, and, from the tendency to slough, is in most instances to be avoided. The enlargement of the submaxillary or cervical glands, which so often attends on affections of the throat or fauces, requires occasion- ally the application of a few leeches, to lessen the obstruction thus caused. Having allayed or removed the inflammatory action, we are pre- pared to employ some of those stimulating or escharotic applications used to alter or destroy the morbid action going on. Much judg- ment is required, efficiently to employ these ; and we must first determine, from the nature of the case, the object in view — whether merely to alter the action going on, or actually to destroy the parts. The same substance may answer for either purpose, but will of course be used in a different manner. In simple cases of ulceration, aphthae, or muguet, some astringent lotion is generally applied, for the purpose of gently stimulating the surface, and so disposing it to heal. Borax is the substance usually employed, and in many instances it is very serviceable, when notfapplied too soon or too strong. It should be prescribed in combination with honey, or some saccharine matter, as borax has not otherwise the same AFFECTIONS OF THE MOUTH, ETC. 135 astringent action. A linctus, consisting of one drachm of honey of borax, in an ounce of water, may be used three or four times in the day, and should be applied with a camel's hair pencil, feather, or piece of soft sponge, — not rubbed on with the finger enveloped in muslin, as it often is, so that the mouth becomes excoriated. Altogether, we have not found borax so serviceable as its popular employment would seem to indicate; and often prefer alum, as a milder and more astringent application. When aphthae are few, the surface of each may be touched with a bit of alum ; when numerous, we use a solution of alum in sweetened barley water, in the proportion of ten grains to the ounce. The remedy, how- ever, from which we have derived most benefit, and have found applicable in the greatest number of cases, is a solution of sulphate of copper, either in water or in honey. Saccharine matter soon decomposes the salts of copper, and hence the mel aeruginis of the Pharmacopoeia is seldom found good ; and we never prescribe it, but order, instead, a linctus containing ten grains of sulphate of copper in an ounce of honey, and employ it only when recently prepared. A stronger solution, containing twenty or thirty grains, may be necessary; or the sulphate of copper may itself be employed, in more obstinate cases. From no other application have we derived equal benefit, in the treatment of aphthae, muguet, cancrum oris, ulcerated sore throat, &c. &c. According to its strength, the solution of copper acts as a stimulant or escharotic, while its astringent power is of a high order. Hence its applicability to a great variety of cases; while it is remarkable, that under its use the surrounding inflammation is lessened, as well as the ulceration improved. In cases of muguet, M. Guersent recommends the solution of chloride of soda, which he uses rather strong: we never employ more than a drachm of the solution to a pint, or at least half a pint of barley water. When a fetid odour is present, or sloughing threatens or has commenced, the preparations of chlorine are of service; but in the latter case, much more decisive means are required. If ulceration or inflammation show a disposition to spread down the pharynx, to throw out a false membrane, or to form sloughs, we are called upon immediately to try and arrest the progress of the disease, by direct local applications, for constitutional means cannot be relied upon. Nitrate of silver is the remedy most generally employed, and it may be used in the solid form, or in solution, strong or weak. The pencil of lunar caustic is employed to touch single aphthae, and one or two applications often cause them to heal ; but its use in confluent aphthae, occupying the back of the throat, is more important, as the means chiefly relied upon to arrest this dangerous disease. It should be employed in the manner recommended by Mr. Higginbottom, being rubbed freely over the part, so as to cover it with a continuous eschar, beneath which the surface is disposed to heal. It is applied in a similar manner in diphtherite, or a strong 136 MANAGEMENT AND DISEASES OF CHILDREN. solution (a scruple to half a drachm to the ounce,) employed, and often repeated, so as to alter the morbid action, and, if possible, arrest the development of the false membrane. Such result, how- ever, by no means necessarily follows from its use ; but it should get an early and fair trial. Powdered alum, blown into the back of the throat, has been recommended in these cases by Bretonneau, and had been used before him by Dr. Pommier. Its good effects are spoken highly of; but we have not seen it used. When sloughing has actually taken place, the most decided escharotics may be required to destroy the sloughing parts, and arrest the progress of the disease. For this purpose the muriate or butter of antimony is perhaps the most effectual and manageable of the escharotics, as its action does not extend beyond the part to which it is applied, nor is its use attended by inflammation of the surrounding parts. The mineral acids are often used as escharotics ; but their action is very violent, and not easily regulated. Of these, the muriatic acid is to be pre- ferred, and may be applied undiluted in very urgent instances; but is more safely employed diluted with half, or a third, of its weight of honey. When the sloughs are small or superficial, the nitrate of silver should be first tried ; but in extensive sloughing it is of no avail. The mineral acids, sufficiently diluted, make good detersive gargles in cases of protracted ulceration ; but their use for this purpose is quite different from their employment as escharotics. In some cases of unhealthy ulceration of the gums, we have seen black wash of service ; but as a common application,, we know of none so generally serviceable as the salts of copper. While em- ploying any of those stimulating applications, we must observe their effect, and suspend their use, or alternate it with emollients, when- ever much irritation is induced. General Treatment. — One of the first indications is to support the child's strength, and to improve the health, by attention to the diet, which should be mild and nutritive; and by removal to good air, when the child is unfavourably situated. Change of air is, in all cases, a measure of paramount importance. When the infant is at the breast, we must see that the nurse is in good health, and that her milk agrees with it. Should the febrile symptoms run high, the diet must, of course, be reduced ; but more frequently the opposite is required — most of these affections of the mouth occurring in children ill-nourished, or in ill-health. Attention to the state of the bowels next demands our care. Mild aperients, or alteratives, are required to keep the bowels open, or improve the secretions : a single dose of castor-oil, or rhubarb and magnesia, occasionally removes an attack of aphthae. Before employing any active purga- tive, however, we must examine, lest the affection of the mouth be complicated with disease of the digestive organs, which might be aggravated by any medicine liable to irritate the bowels. Emetics, as well as purgatives, have been advised for the purpose of freeing the intestinal canal from the morbid matters liable to be swallowed in AFFECTIONS OF THE STOMACH AND BOWELS. 137 cases of aphthae or muguet. When not contra-indicated by the state of the mucous membrane, their employment for this purpose is advisable. In acute inflammations of the throat, the early and free use of tartar emetic is as valuable in the child as in the adult ; often of itself cutting short the attack. When much restlessness, heat of skin, &c. &c, is present, the use of the warm bath, and the cautious administration of anodynes, are very serviceable. The employment of mercury, so as to pro- duce a constitutional effect, has been proposed in some of the more acute of those forms of inflammation; and Mr. Bewlcy seems to think that good was thus done in one of the cases of diphtherite recorded by him ; at least no harm resulted from the trial. In cases accompanied by ulceration, or disposed to slough, however, we should fear the effect of mercury, were the child old enough to allow of the gums being made sore. When prostration of strength attends, and sloughing threatens, or has taken place, we must imme- diately have recourse to tonics or stimulants, with a generous sup- ply of broth, jelly, or even wine. But we must be careful not to mistake the absence of fever in very young infants, or the dark colour accidentally acquired in aphthae, &c. &c. (from being tinged with blood,) for indications of sinking or gangrene; and so be led to the improper use of stimulants, which might induce the very state we wished to avoid. Of stimulants ammonia is to be preferred ; and its free use will be found often signally serviceable, even after gangrene has com- menced. Cinchona is the best tonic ; and should be largely given in the form of sulphate of quinine, or the tannate of quinine, which has been lately recommended, in a special manner, in cases of gangrene. Steady perseverance in these means will recover children, that must otherwise have perished. The internal administration of chlorine (from two to six drops of the solution of chloride of soda, given in mixture three or four times a day,) is often serviceable, but not so much to be relied on as the ammonia. In some protracted cases, we have seen the adminis- tration of iodine decidedly attended with benefit. III. AFFECTIONS OF THE STOMACH AND BOWELS. The stomach and bowels are peculiarly liable to be disordered in the child ; and these disorders may arise from mere functional de- rangement, or from inflammatory action, leading to organic change of structure. The functional derangements are most commonly induced in consequence of the administration of improper food; or they may be purely symptomatic, arising from sympathy with some other organ, which is in a state of disease. However originating, these derangements of the digestive organs soon tend to the production of diseased action in the parts affected — irritation frequently giving rise to inflammation and its conse- 138 MANAGEMENT AND DISEASES OF CHILDREN. quences. This, however, is not always the case ; and mere func- tional derangement may be sufficiently severe, or protracted, to destroy life, and yet no trace of organic change be found after death.* To distinguish such cases from those which are truly inflammatory, is often a difficult, but always an important task. We shall endea- vour to draw the line of distinction, being careful to set down the symptoms which indicate inflammatory action, and those which may exist independently of it ; while we candidly point out those cases respecting which doubts must unavoidably exist. It is only by attention to the whole group of symptoms, not to any particular one, that the true distinction is to be attained. Inflammatory affections of the stomach and bowels are of fre- quent occurrence in the child ; and may arise directly from impres- sions of cold, or the effects of damp, particularly when associated with a peculiar influence exercised by the season, as we see in the frequent bowel-complaints of children observed during autumn ; or inflammation may be the result of a severe or continued irritation of the mucous membrane, induced by improper food ; or sympto- matic of some existing disorder. Congestion is a frequent precur- sor of inflammation in the very young child. The stomach alone may be inflamed ; but much more frequently the inflammation ex- tends farther, involving the mucous membrane of the small intes- tines to a greater or less extent, and constituting a case of gastro-' enteritis. The lower portion of the ileum, in particular, is a fre- quent seat of inflammation ; or the large intestines may be affected, and give rise to dysentery. The inflammatory action, going on in the mucous membrane, soon tends to its disorganization ; ramollissement is induced, or ulceration set up ; but death may ensue before either of these states occur, the mucous membrane being found merely reddened, or injected. In ramollissement, the membrane becomes friable, easily peeling off in soft reddish masses, when the disorganization is caused by inflammation ; but there is another form of this affection, in which the softened membrane is white, and does not owe its origin to inflammation. When ulceration ensues, it is found to have its seat in the muciparous glands or follicles, being analogous to the aphthous ulceration of the mouth, with which it is often combined. Excitement of the muciparous glands, however, may give rise to severe or serious symptoms, without their being actually inflamed or ulcerated. An alteration or secretion, identical with that observed in the mouth, and called muguet, may occur in the intestinal canal, but is seldom seen. Gangrene has, in some instances, resulted from in- tense inflammation of the mucous membrane of the stomach ; but more particularly of the ileum. The intestines have been thus per- forated, and peritonitis induced on the escape of their contents ; but this is more frequently caused by follicular ulceration. The peritonitis thus induced is the most dangerous with which we can have to contend. Peritonitis, independently of this cause, occurs in the infant as well as the adult. AFFECTIONS OF THE STOMACH AND BOWELS. 139 When the mucous memhrane of the lower portion of the canal is much irritated or inflamed, pain or straining attends the passage of the stools, or prolapsus ani is induced. Hemorrhage of rather a severe character may attend, or he in- duced in consequence of congestion, or inflammation of the mucous membrane. The fever attending inflammatory affections of the bowels is often severe, and the local symptoms well marked, particularly if the child be grown, and the attack recent ; so that in many instances no doubt need be entertained as to the nature of the case. In others, however, where the infant is very young, the invasion of the disorder and its progress may be so insidious, as to tend to extensive organic alteration, before the true nature of the case is suspected. The fever attendant on disorders of the digestive organs in the child, usually assumes the remittent form ; infantile remittent fever being now well understood to be indicative of intestinal irri- tation, whether caused by extraneous matters, as worms, or undi- gested food ; or by actual disease of the mucous membrane. We must recollect both these sources of the disorder, and learn to dis^ tinguish them, if we wish to understand or treat this disease aright. The sympathetic disturbances of the head, chest, or skin, caused by disease of the digestive organs, whether acute or chronic, in a particular manner demand attention, and shall be specially noticed. We now proceed to consider separately the several disorders of the stomach and bowels, to which the child in particular is so sub- ject— beginning with those which are merely functional. Functional Disorders of the Digestive Organs — Infantile In- digestion.— The infant, as well as the adult, is subject to a train of symptoms arising in consequence of disagreement of the food, which, being unfit for the process of digestion, deranges the func- tions of the stomach, and is inadequate to supply nourishment. This may result from the quality of the food being such as to be inadequate to furnish the necessary supply of nutriment, or being unfit to undergo the digestive process — the infant perishing for want of sustenance, or in consequence of the disorder of the stomach and bowels, induced by improper food. The first form occurs with infants at the breast, who are not pro- vided with wholesome milk ; the other with children who are im- properly or too soon fed : this usually occurs at the time of weaning. Hence we would divide infantile indigestion into two varieties : the indigestion of suckling, and the indigestion of weaning. Indigestion during Suckling. — Infants at the breast are often observed to look pale, lose the firmness of their flesh, and become emaciated. They are peevish and fretful, and constantly cry until they receive the breast, for which they show great avidity, seizing the nipple with force, and sucking eagerly ; but this seems to avail them little, either in appeasing their hunger, or affording them nourishment. The more they suck, the more does their food dis- agree with them, being soon rejected from the stomach, or passed 140 MANAGEMENT AND DISEASES OF CHILDREN. by the bowels in a curdled state. Griping, flatulency, and acidity soon attend ; and a protracted diarrhoea sets in, which carries off the infant in a period varying from two to four weeks. Such a state of things is often witnessed in infants suckled by nurses who are out of health, whose milk is too old for the infant, or who do not observe the rules already laid down for the manage- ment of infants at the breast. It is at foundling hospitals, or among the