*^. ' 'J ' I Mi -M m t 1,^ ,JI .V '■;^ 1 '■ir i« -" - r^ ife ^gH r^' '''^f>^ y^i."' ''^' ■ V ■ ■i^'">.V7"' •^.■f^_ ^1 1 .£/ ^ -f / /Vw.< /^// ^4, ON THE WASTING DISEASES INFANTS AND CHILDREN. BY EUSTACE SMITH, M. D. Lo^d. MEMBER OF THE ROYAL COLLEGE OP PHYSICIANS; PHYSICIAN TO HIS MAJESTY THE KINtt OP THE BELGIANS; PHYSICIAN TO THE NORTHWEST LONDON PREE DISPENSARY FOR SICK CHILDREN; AND TO THE METROPOLITAN DISPENSARY. SECOND AMERICAN, FROM THE SECOND REVISED AND ENLARGED ENGLISH EDITION. PHILADELPHIA: nEI>^"EY C. LEA 1871. PHILADELPHIA : COLLINS, PKINTEK, 705 JAYNE STREET. 10 TO SIR WILLIAM JENNER, Bart., M.D., D.C.L., F.R.S. £ljxs J^'olttmc is |n6cribtb AVITH RESPECT AND GRATITUDE BY THE AUTHOR. ADVERTISEMENT TO THE SECOND EDITION. In preparing a Second Edition of this Work for the Press, the text of the First Edition has been carefully revised, inaccuracies have been corrected, and additions suggested by increased ex- perience have been freely introduced. Two new Chapters have been added. In one (Chapter VI.) will be found the description of a disease, very comraoa amongst children, which in severe cases causes great disturb- ance and emaciation, and is often mistaken for tuberculosis. The other (Chapter XI.) contains special directions upon the feeding of children, and presents a series of carefully-arranged dietaries suitable to infants and children of various ages, both in health and disease. A few illustrative cases have been added where illustration seemed advisable, but the Author has avoided overburdening the text with the narration of cases, as he was unwilling needlessly to increase the size of the volume. George Street, Hanover Square. September 30, 1870. PREFACE TO THE FIRST EDITIOK The extensive use of such terms as "marasmus," "tabes," "atrophy," as denoting vaguely some slow disease fatal to children, affords a strong presumption that diseases of which wasting is a prominent symptom are but little understood, and that much loss of life is due to insufficient knowledge of their nature. The Author had not long begun the study of children's diseases before he found that even the best systematic treatises dealt but imperfectly with the clinical condition of chronic wasting, and did not consider together — in the way required for every-day use in practice — the various disorders to which it may be due. He was, accordingly, induced to devote considerable attention to this subject, with the view of forming some practical classifi- cation, by means of which the diseases giving rise to this slow wasting might be more readily recognized and controlled. As a result of the experience thus acquired, he offers the present volume as a contribution to the literature of the diseases of children, in the hope that it may be found of practical value in the treatment of this exceedingly common and fatal condition. In the chapter on pulmonary phthisis the Author has endea- vored to utilize recent views on the nature of the phthisical process ; but as his aim has been primarily to make his little book clinically useful, he has limited himself to matters of direct practical significance, and has indulged little in considerations of a purely speculative kind. George Street, Hanover Square. September, 1868. CONTENTS. INTRODUCTION. Wasting a sign of defective nutrition Importance of detecting the cause of malnutrition Wasting not always the first sign, and may even be absent in slight cases ...... Defective nutrition may be the result of acute disease Liability of badly-nourished children to secondary acute diseases Peculiarities of these secondary diseases . Insensibility of the nervous system in cachectic children Infrequency of reflex convulsions . Importance of diagnosing the secondary diseases Information to be derived from examining the face of the infant M. Jadelot's traits ..... Color of face ..... Breathing ....... Cry ....... Causes of large belly in infants Infrequency of mesenteric disease . Mode of examining liver and spleen General treatment of wasting Uselessness of tonics so long as there remains any derangement of the stomach and bowels .... Importance of minuteness in giving directions about diet External applications .... Frictions ...... Anointing with warm olive oil . Counter-irritants ..... Baths — Hot bath ..... Mustard bath . . . . Cold bath ..... Internal remedies ..... Cod-liver oil must not be given in too large doses Stimulants i . . . . .' PAGE 17 18 18 18 19 19 20 20 20 20 21 21 22 22 22 23 23 24 24 24 24 24 25 26 26 26 27 27 28 28 CHAPTER I. Simple Atrophy from insufficient Nourishment. Causes ...... Insufficient supply of food Yaiieties of breast milk . Effect of preponderance of butter in milk Test of a good nurse 29 29 30 30 30 Vlll CONTENTS, Unsuitable food Dependence of nutrition upon powers of digestion Over-feeding .... Varieties of food required for perfect nutrition Differences between woman's and cow's milk Cow's milk cannot always be digested Symptoms .... Two classes according to cause Food suitable, but insufficient Food unsuitable . Wasting Constipation . Cause of inactivity of bowels Flatulence Colic . Ravenous appetite . Eruptions on skin Strophulus Urticaria . Thrush, its importance in prognosis Inward fits . Attacks of vomiting and diarrhoea Convulsions . Aphthie Danger of secondary diseases Mode of death Treatment .... Suckling, by mother . by nurse Rules for choosing nurse Directions for efficient suckling Advantages of putting child early to breast after birth Time? of suckling Artificial feeding Directions Feeding bottle . Importance of cleanliness of bottle Farinaceous foods Their relative value Boiled flour Quantity of farinaceous food . Cow's milk may disagree Isinglass Liebig's food for infants Weaning Usual time Must sometimes be anticipated Method of weaning Reasons why a child may refuse breast Diet after weaning General management of infants Treatment of constipation Flatulence and acidity Convulsions and colic Thrush . Aphtha? . Diarrhffia and vomitinjr CONTENTS. IX CHAPTER II. Chronic Diarrh(ea. May be secondary to acute disease Or may be primary Mode of commencement when primary Increased peristaltic action of bowels When disease established Character of the stools Other symptoms Complications .... Serous effusions . Pneumonia Exanthemata Convulsions rarely except towards commencement Thrombosis of cerebral sinuses . Death without complication . Diarrhoea may cease before death Influence of the disease upon dentition Causes — In infants, bad hygiene . Cold Previous acute disease . In older children, worms . Tubercular ulcerations of bowels Anatomical characters Simple ulceration of mucous membrane Tubercular ulceration . Diagnosis ..... Prognosis — Unfavorable signs Favorable signs Prevention . Attention to diet Avoidance of cold Influence of dentition Treatment . General management Diet External applications Internal remedies Antacids Astringents Enemata Opium . Nitrate of silver Raw meat plan Tonics . CHAPTER I II. Chronic Vomiting. Frequency of slight attacks of gastric disturbance Such attacks easily remedied Chronic vomiting non-febrile Symptoms . Character of vomited matters Constipation Interference with nutrition CONTENTS. After a time vomiting almost constant Exhaustion Spurious hydrocephalus Causes Diagnosis . From tubercular meningitis Of spurious hydrocephalus Treatment . Attention to diet Eeturn to breast Substitute for wet nurse Warmth External applications Baths . Medicines Bismuth and magnesia Calomel Dilute hydrocyanic acid Enemata Vinum ipecacuanhas . Illustrative case Liquor arsenicalis Emetics Stimulants CHAPTER IV. Rickets. Preliminary symptoms those of general malnutrition Symptoms of commencement Deformities of bone Enlargement of ends of bone Softening- Thickening of flat bones Mechanical deformities Bones of skull and face Distinction between rickety and hydrocephalic skull Cranio tabes . Dentition Teeth sometimes unaffected . Illustrative case Spine .... Thorax Deformities of long bones and of pelv Arrest of growth of bones Articulations . Relaxation of ligaments Other symptoms; Enlargement of liver and spleen Intellect General behavior of a rickety child Complications Catarrh and bronchitis . Diarrhoea . Laryngismus stridulus Convulsions Chronic hydrocephalus . Death from intensity of the general disease CONTENTS. xi PAGE Pathology .113 Eickets a general disease 113 Anatomical characters of bone changes 114 Kolliker's views .... 115 Virchow's views .... 115 Keconsolidation of rickety bone 116 Analysis of rickety bone 117 Ephysema and collapse 118 Alterations iu lymphatic glands 119 in liver .... 119 in spleen .... 119 in other organs . 120 Urine ...... 120 Diagnosis ...... 120 Prognosis ...... 122 Importance of complications . 122 Causes . . . ... 123 Rickets not a diathetic disease 125 Bad feeding and hygiene 125 Connection between rickets and syphilis 126 Prevention ...... 126 Treatment ...... 127 Diet ..... 127 Attention to digestive organs 127 Dry bracing air . . . 128 Tonics .... 129 Yalue of mechanical supports 1.30 Treatment of complications . 130 Catarrh .... 130 Diarrhoea .... 131 Convulsions 132 Laryngismus stridulus 132 CHAPTER y. Inherited Syphilis. Appearance of first symptoms . 133 Before birth 133 At birth .... 133 After birth . 134 Fretfulness at night . 134 Snuffling .... . 135 Necrosis of nasal bones 135 Eruptions .... 135 Seat ..... 136 Yarieties .... 136 Ecthymatous pustules 136 Mucous patches 137 Cracks and fissures . . . 137 Complexion .... . 137 Cry . 138 Openness of fontanelle 138 Influence of the disease on general nutrition . 138 Affections of internal organs . . 139 Liver .... 139 Local peritonitis . 140 Spleen 140 Delayed symptoms . 140 XI 1 CONTENTS. Syphilitic teeth Relapses .... Diagnosis ..... By general symptoms . By history .... By examination of other children of the same Signs of past disease in child . Causes ..... Transmission of taint from father Transmission of taint from mother Mother seldom escapes if father affected Colles' law .... Twins not always equally affected Other modes of infection Prognosis ..... From observation of parents . From observation of child Importance of considering the intensity of th Importance of certain special symptoms Prevention ..... Treatment ..... Two objects .... Treatment to be begun early . Remarks on the non-mercurial treatment Treatment by mercury Different preparations External applications Ointment .... Mercurial baths To improve general nutrition . Diet ..... Peculiarities of milk in syphilitic mothers Other foods .... Cod-liver oil . Warmth .... Cleanliness .... Treatment of vomiting and diarrhoea Local applications Tonics ..... e gener family al cache: CHAPTER VI. Mucous Disease. Character of the derangement Symptoms Nightmare Somnambulism Incontinence of urine Appearance of tongue Bowels Fetor of breath Complexion Dry rough skin Temperature Bilious attacks Worms a common complication CONTEXTS. XUl PAGE Causes ......... 159 Influence of previous diseases 160 Whoopino-cough 160 Second dentition . 161 Diagnosis . 161 From chronic tuberculosis 161 Value of thermometer . 162 Treatvient . . 162 Diet . . 162 Exclusion of starchy food 162 A dietary 163 Allowable vegetables . 163 Alcohol 163 Restore action of skin 164 Warm clothing 164 Internal remedies . 164 Alkalies 164 Aloes . 165 Iron 165 Purgatives 166 Case illustrating treatment 166 Acids .... 167 Alum . 167 Cod-liver oil . 168 Change of air . 168 CHAPTER VII. Worms. Varieties ...... Description ...... Oxyuris verraicularis .... Ascaris lumbricoides .... Tricocephalus dispar .... Taenia solium ..... Taenia medio-canellata .... Bothriocephalus latus .... Development and mode of obtaining admission into human Symptoms ...... Due principally to accompanying derangement of bowels ..... Emaciation ..... Pain ...... Disturbance of nervous system Convulsions ..... Symptoms when digestive derangement is trifling Migration of worms .... Special symptoms with each variety of worm Diagnosis ...... From tuberculosis .... From tubei'cular meningitis . Treatment ...... Two objects . . To expel worms .... Eemedies required for each variety Threadworms Long worms . . , . 169 169 , , . 169 , 170 . 170 , ^ 171 171 171 human body 172 174 f stomach and 174 ^ ^ 174 . 174 , 175 ^ . 175 175 , 176 ^ 176 177 , 178 ^ ^ 178 , 179 , , 179 , ^ 179 ^ ^ 179 , , 179 180 XIV CONTENTS. Large threadworms .... Tapeworms ..... To restore healthy condition of alimentary canal Treatment of prolapsus ani PAGE 180 181 182 182 CHAPTER VIII. Chronic Tuberculosis. A diathetic disease attacking the organs generally May be acute or chronic Yellow infiltrated tubercle of Laennec not true tube Two forms of tubercle Gray granulations Yellow granulations May coexist in the same organ Differences between them Changes in tubercle . The tuberculous and scrofulous types Distinct but not antagonistic Symptoms . Shape of chest . Fever . Wasting Temperature Diagnosis . In infants Value of the thermomete In older children Causes The result of a constitutional tendency Exciting causes Inoculation of tubercle Prevention . Treatment . Climate Exercise Fresh air Diet Attention to digestive organs Astringents Alkalies Cod-liver oil Tonics . cle CHAPTER IX. Chronic Pulmonary Phthisis. Comprehends several distinct pathological processes Infrequency of extensive pulmonary disintegration in young children Symptoms . Cough . Sputa usually swallowed Haemoptysis rare Rapidity of breathing . Chest pains Diarrhoea CONTENTS. XV Physical signs ..... Percussion ..... Its value . . . . Auscultation ..... Importance of using stethoscope Yalue of stethoscopic signs Bronchial breathing .... Its value as evidence of pulmonary consolidation and tion ..... Disseminated miliary tubercles Physical signs .... Anatomical characters .... Gray and yellow granulations . Pneumonic consolidation May remain unabsorbed and become cheesy Softening and excavation Cavities ..... Cicatrization of cavities Fibroid phthisis .... Diagnosis ...... Of tubercle ..... Of scrofulous pneumonia Its complication with gray tubercle . • Of fibroid phthisis .... Of cavities ..... From dilated bronchi From effusion into pleura Fragments of elastic tissue in sputum as evidence of ulceration Prognosis ...... Causes ...... Of scrofulous pneumonia Treatment ...... General ..... Exercise ..... Fresh air .... . Cleanliness ..... Cold baths bad .... Climate ..... Attention to digestive organs Special ...... Use of expectorants .... Use of opium ..... Method of prescribing expectorants . Alkalies ...... Treatment of unabsorbed pneumonic deposits Counter-irritation. .... of lung CHAPTER X. Tuberculization of Glands. Of glands in general . . . . Of Bronchial Glands, or Bronchial Phthisis . Symptoms ...... Produced by pressure on neighboring organs Pressure on veins . . . . Pressure on nerves , . . . XVI CONTENTS. PAGE Physical signs ........ 229 Alterations in respiratory sounds produced by pressure on trachea and bronchi ....... 229 Mode of termination .... 230 Diagnosis ...... 230 Of Mesenteric Glands, or Mesenteric Phthisis i Tabes Mesen terica ...... 231 Symptoms ...... 231 General ...... 231 Local ...... 231 Pressure on veins .... . 232 Ascites usually the result of peritonitis 232 Perforation of bowel .... . 233 Diagnosis ...... 233 Only to be made by feeling the glands 233 From fecal accumulation . 233 From tubercle of omentum . 233 Anatomical characters .... . 23.5 Of tubercular glands in general . 235 Of bronchial glands .... . 235 Of mesenteric glands . . . 236 Treatment ...... . 236 General . , . . . 236 Special ...... . 236 Of bronchial phthisis . 236 Of mesenteric phthisis . 236 CHAPTEK XI, Diet of Children in Health and Disease Diet in health .... From birth to six months old . From six to twelve months old From twelve to eighteen months old . From eighteen months to two years old After two years Diet in disease In simple atrophy In chronic diarrhoea In chronic vomiting In rickets In mucous disease In tuberculosis and pulmonary phthisis 238 238 240 242 244 245 245 245 246 248 248 249 250 ON THE WASTING DISEASES INFANTS AND CHILDREN. INTRODUCTION. Wasting a sign of defective uutrition — Importance of detecting the cause of mal- nutrition — Wasting not always the first sign, and may even be absent in slight cases — Defective nutrition may be the result of acute disease— Liability of badly-nourished children to secondary acute diseases — Peculiarities of these secondary diseases — Insensibility of the nervous system in cachectic children — Infrequency of reflex convulsions — Importance of diagnosing the secondary diseases — Information to be derived from examining the face of the infant — M. Jadelot's " traits'' — Color of face — Breathing — Cry — Causes of the large belly in infants — Infrequency of mesenteric disease — Mode of examining liver and spleen. General Treatment of Wasting — Uselessness of tonics so long as there remains any derangement of the stomach or bowels — Importance of minuteness in giving directions about diet. External Applications. — Frictions — Counter-irritants — Baths — Hot — Mustard — Cold. Internal Remedies. — Cod-liver oil must not be given in too large doses — Stimulants. Wasting is a sign of defective nutrition : tbe waste of the body continues, but new material is introduced in quantity insufficient to supply the loss of tissue. Wasting may be temporary or persistent. Every deviation from health will affect to a certain extent the nutrition of the body, and according as the interference with nutrition is ' more or less complete, the wasting goes on with more or less rapidity. The interference is great in proportion to the acuteness of the cause which produces it. Any acute disorder, such as an inflammatory attack or an attack of acute diarrhoea, will produce an immediate pause in the nutritive process : the flesh at once begins to feel flabby and soft, and a continuance of the purging, if the drain be 2 18 INTRODUCTION. severe, causes a visible loss of flesh, which is as rapid as it is alarming. On the cessation of the acute attack, the flesh is re- covered almost as rapidly as it was lost: a few days restore the child's ordinary appearance, and with his flesh his color and spirits return. On the other hand, in chronic disorders, emaciation pro- ceeds much more gradually, but nutrition, as it is slowly impaired, is also slow to be re-established. The present volume deals only with cases of slow impairment of nutrition, where the loss of flesh is gradual, and the wasting cannot be attributed, at any rate directly, to any acute febrile attack. In all such cases the cause should be carefully inquired for, as the defect in nutrition can only be effect- ually remedied by removing the cause which has produced it. This cause may be unsuitable food, the child being actually starv- ing from his inability to digest and assimilate the diet with which he is supplied. He may be prevented from assimilating an ordi- narily digestible diet by some unhealthy condition of his alimentary canal ; or some constitutional defect, as the existence of tuberculosis, or the poison of syphilis pervading the system, may interfere with the proper nutrition of the tissues. It is extremely important to detect the earliest symptoms of defective nutrition. Wasting is not always one of the first signs, and may even be altogether absent if the interference with nutrition is not carried to a high degree. Thus, a child may be exceedingly plump, and even excite admiration by his good condition, although he may at the same time be suffering from the insidious com- mencement of rickets, which, if the causes producing the disease continue unchecked^ will shortly assert itself unmistakably. Acute disease is frequently a starting-point for mal-nutrition, either by awakening a dormant diathetic tendency, or by leaving behind it a chronic derangement of the alimentary canal, or by impeding nutrition by some mysterious influence over nervous power. Thus measles not unfrequently excites the manifestations of a previously latent tubercular tendency ; scarlatina and measles are apt to be followed by obstinate diarrhoea ; and diphtheria is some- times succeeded by a loss of nervous power, usually indeed local, but sometimes general and sufficiently serious to interfere with the working of all the functions of the body. In every acute disease there are, therefore, two dangers : the immediate danger and the remote danger. The first presses itself upon our notice, and cannot be overlooked; the second DIMINISHED NERVOUS SENSIBILITY. 19 obscured by distance, is apt to be disregarded. Acute disease always excites attention and receives immediate treatment, but it is not enough to rest satisfied with the cessation of pressing symptoms. There is always the danger that the defective nutri- tion, at first merely temporary, may become confirmed; in other words, that chronic disease may be established. One consequence of the weakly condition to which badly nou- rished children are reduced is their liability to secondary acute diseases. In a child suffering from the results of- chronic inter- ference with nutrition, from whatever cause, the power of resist- ing new injurious influences is very much impaired. In such a state he is constantly found to be affected by causes so slight as to pass almost unnoticed, and which in a healthy child would be completely powerless to do harm. If the emaciation and debility of the child are very great, these secondary diseases may give very little evidence of their presence ; for an infant reduced by mal-nutrition to a cachectic state loses many of the vital character- istics of early childhood, especially the intense excitability of the nervous system which is so striking a peculiarity of healthy in- fancy. In a robust child we constantly find the whole system suffering violently from sympathetic derangement set up by some trifling disturbance. A lump of indigestible food, or a slight im- pression of cold, will not unfrequently produce burning fever, and alarming nervous symptoms, as delirium, convulsions, or even a state approaching to coma. On the other hand, in an infant much reduced by long-continued impairment of nutrition, the most se- rious diseases may give no signs of their presence. Pneumonia may exist with little fever and no cough, and a serious intestinal lesion without pain and with only trifling diarrhoea. A good example of the insensibility of the nervous system to local impressions is seen by attempting the well-known experiment of gently stimulating the genito-crural nerve, described by Sir "William Jenner in his Lectures on Eickets.^ In a healthy child the finger-nail drawn lightly along the upper two-thirds of the inner aspect of the thigh produces an instantaneous rise of the testicle of that side, by the action of the cremaster muscle which draws it up close to the external abdominal ring. In a cachectic child the same experiment is followed by no result whatever ; the • Medical Times and Gazette, March 17, 1860. 20 INTRODUCTION". cremaster does not contract, and the testicle remains motionless. In such cases, therefore, there is absence of the normal excitability of the nervous system so characteristic of healthy infancy. This insensibility of the parts of the nervous system concerned in the production of reflex movements is further indicated by the infre- quency of reflex convulsions in such children. In well-nourished children these are exceedingly common, and the natural nervous sensibility appears to be heightened by anything which causes a sudden weakening of the system, as severe acute diarrhcea, or great loss of blood. When, however, the debility is produced more slowly, the same result does not follow, and the excitability of the nervous system, instead of being exalted, is more or less completely destroyed. For this reason, acute diseases, attacking a child whose nutrition is thus seriously impaired, have a character all their own. They are distinguished by an absence of those peculiarities which we are accustomed to consider inseparable from the disorders of childhood, and resemble more the same diseases as they occur in advanced age. They begin more insidiously ; run their course more slowly ; give rise to fewer symptoms ; and often end suddenly and unex- pectedly in death. Although thus undemonstrative, they are not, however, on that account less dangerous; indeed, the prognosis may be said to be serious in proportion to the fewness of the symptoms by which their existence is announced. By offering an additional obstacle to nutrition they still further weaken the already enfeebled constitution, and the disease, if it does not prove immediately fatal, is apt to hang on, gradually reducing the child more and more, until he sinks under its effects. It is difficult to over-estimate the importance of an early diag- nosis of these secondary disorders. On account of their insidious commencement they are frequently overlooked, and it is often only by the more rapid debility they induce that suspicions of their existence are at last excited. As the infant is unable to commu- nicate his ideas by speech, the eye should be practised to gather from the expression and gestures of the child the information which he can communicate in no other way. A careful perusal of the face is therefore of the utmost importance. By it we can as- certain the existence of pain, and can often distinguish the part of the body which is the seat of serious disease. Thus, pain in the head is indicated by contraction of the brows ; in the chest, by a jadelot's "traits." 21 sharpness of the nostrils ; and in the belly, by a drawing of the upper lip. M. Jadelot, formerly physician to the Hopital des Bnfants Trou- ves at Paris, was the first to draw attention to certain "traits," or lines, which become marked on the face of a child suffering from serious disease, and the situation of which furnishes indications as to the part of the body to which it is necessary to direct our exa- mination. The oculo-zygomatic line, or furrow, begins at the inner angle of the eye, and passing outwards underneath the lower lid, is lost a little below the projection formed by the cheek-bone. This indicates disorder of the cerebro-nervous system, becoming strongly marked in all those diseases whose primary seat is the brain or nerves, or in cases where those organs become affected secondarily to disease commencing in other parts. The 72asal line rises at the upper part of the ala of the nose, and, passing downwards, forms a rough semicircle round the corner of the mouth. Joining this at an angle about its middle is another line, called genal, which reaches from that point almost to the malar bone, and in certain faces forms the dimple of the cheek. These indicate disease of the digestive passages and the abdominal viscera. The labial line begins at the angle of the mouth, and is directed outwards, to be lost in the lower part of the face. It is seldom so deep as the preceding. It indicates disease of the lungs and air-passages. M. Jadelot attributed immense importance to these lines, and even stated that he had been enabled to discover the exact period at which the cough of pertussis assumed its convulsive character by the appearance of the oculo-zygomatic line upon the child's face. Without, however, attaching to them the same significance which they assumed in the opinion of their discoverer, there is no doubt that they often furnish important indications, and are there- fore, points to which attention should always be directed in the examination of a young child. The color of the face should be carefully noted. Lividity of the lips and of the eyelids is a sign of imperfect aeration of the blood, or may indicate digestive disturbance, or merely weak cir- culation. A peculiar waxy-yellow tint is seen in certain parts of the face in inherited syphilis ; and there is an earthy tinge of the face and whole body in many cases of chronic bowel complaint. 22 INTRODUCTIOJSr. Exhaustion is indicated by coolness and pallor of the face, by livi- dity of the eyeballs and mouth, and, in extreme cases, by a half closure of the eyes, so as to leave the lower parts of the whites exposed, while at the same time the fontanelle is deeply depressed. The state of the fontanelle should be always examined, for it forms a very important guide to treatment ; if much depressed, stimu- lants should never be withheld. The breathing must be watched. If rapid and accompanied by movement of the nares, there is usually bronchitis or pneumonia, and a careful examination of the chest should always be made. Unequal movement of the two sides of the chest in respiration generally indicates a serious lesion on the side at which the move- ment is least. If the respiratory action of the abdominal muscles be increased, attention is at once directed to the chest. If the belly be motionless, it is often the seat of an inflammatory complication. The cry of the infant varies very much in character. In cere- bral affections it is sharp, short, and sudden. In lesions of the abdomen, exciting pain, it is prolonged. In inherited syphilis, it is high-pitched and hoarse. In inflammatory diseases of the larynx, it is hoarse, and may be whispering. In inflammatory diseases of the lungs, and in severe rickets, the child is usually quiet, and un- willing to cry on account of the action interfering with the respi- ratory functions. The infant should always be completely stripped for examina- tion. We can at once observe the form and play of the chest, the state of the abdomen, the condition of the skin, whether hot or cool, dry or moist, and the conformation of his limbs. Besides, any eruption upon the skin is at once detected by this means. The large size of the belly in weakly children often attracts the attention of parents, and excites much anxiety. It is most com- monly produced by accumulation of flatus, owing to the weakness of the abdominal walls. It may be also due to displacement of the liver and spleen, such as occurs so often in rickets on account of the depression of the diaphragm forcing those organs dowwards from beneath the cover of the ribs. The liver and spleen may be themselves enlarged ; and great masses of cancer occasionally spring from the kidney and from the other abdominal organs. As- cites may be present from tubercular or simple peritonitis, from Bright's disease, or, rarely, from disease of the liver. Tubercular peritonitis may also produce extreme tympanitis. Accumulations CAUSES OF abdomi:n'al enlargement. 23 of fecal matters may take place in sufficient quantities to cause distension ; and, lastly, the mesenteric glands may be so enlarged as to produce a visible tumor. Flatulence is, however, as has been said, by far the most frequent cause of this condition, and in chil- dren reduced by chronic disease the belly is almost always dis- tended from this cause. The bowels are in such cases, usually de- ranged ; food is ill digested ; and the gas set free by decomposition of the starchy matters is allowed, through the feebleness of the muscular walls, to accumulate and to give rise to much discomfort and swelling. It is of great importance to bear in mind this simple cause of the enlargement, for a big belly in a wasting infant is constantly attributed to mesenteric disease ; and it is not uncommon to hear that a child has been given over for this supposed complaint when he is in reality suffering from nothing else than bad feeding, with derangement of the bowels as its natural consequence. Setting aside the general rarity of mesenteric disease, and its extreme rarity in children under three years of age, there remains the fact that distension of the abdomen is by no means a necessary consequence of this disease. On the contrary, unless the glandular disease be great, the abdominal wall is more often retracted than expanded. It may become occasionally distended from flatus, as in all cases where the bowels are disordered, but the distension is, in such cases, independent of the affection of the glands, and is merely an accidental complication. If the increase in size of the glands is sufficiently great to produce a distinct tumor, the swelling is seated about the umbilicus, and does not occupy the whole abdo- men. In all cases, therefore, where the belly is swollen uniformly, the probabilities are very strongly against mesenteric disease ; and if no tumor can be detected on pressure in the situation of the glands, no foundation exists for attributing the enlargement of the abdomen to this cause. For fuller information upon this subject the reader is referred to the article on Mesenteric Phthisis, where will also be found the method of distinguishing this disease from accumulations of fecal matter in the color. The size of the liver and spleen should always be investigated. The extent of liver-dulness should be estimated by percussion. If the organ descends below the level of the ribs, the hand should be laid fiat upon the belly ; by gentle palpation with the ends of the fingers we can then always feel the thin border, and, unless the 24 INTRODUCTION. abdominal wall be very tense, can generally succeed in inserting the tips of the fingers underneath the sharp edge. The size of the spleen is very easily estimated. The fingers of the right hand are placed at the back, directly below the twelfth rib, and just outside the mass formed by the lumbar muscles; the fingers of the left hand are placed exactly opposite the former, in front of the belly; by pressing the two hands towards one another, the spleen, if it is enlarged, is caught between them. If the hands have been rightly applied, and the spleen is not felt, it may be con- sidered to be of natural size. It must be remembered, however, that both these organs may be felt more readily than is natural without being necessarily enlarged, as they may be displaced bj' pressure of the diaphragm. In the treatment of chronic wasting in a young child our first care should be to remove any derangement of the stomach and bowels. For this object a strict regulation of his diet is indis- pensable. In the great majority of such cases the cause can be distinctly traced to improper feeding, and therefore an alteration in the diet is the first step to a cure. Tonics given to a child whose bowels remain disordered are perfectly useless, for, so long as the derangement of the alimentary canal continues, nutrition cannot be restored on account of the impediment thus presented to the digestion and assimilation of food. Directions on the subject of diet cannot be too precise ; it is necessary to state distinctly, not only the articles of food to be given, but the quantities to be allowed at each meal, and the fre- quency with which the meals are to be repeated. It is advisable to write down all such directions, that misunderstanding may be avoided ; in fact, the same attention should be paid to this subject as is paid to the ordering of drugs. After the diet has been altered to suit the requirements of the case, more special treatment is called for, and the means at our command may be divided into two classes, viz., external applica- tions, and internal remedies. External applications are of great service in all chronic diseases, for it is important to restore as quickly as possible the healthy action of the skin. For this purpose, frictions, counter-irritants, and baths, hot or cold, may be used. Frictions can be employed with the hand alone, with stimulating liniments, or with cod-liver oil. By this means the circulation is EXTERNAL USE OF OIL. 25 rendered more vigorous, and the action of the skin is promoted. The feebleness of the circulation in most cases of chronic disease in the infant is shown by the coldness of the extremities. When these have been warmed by suitable applications, the beneficial influence is often very decided; pain in the belly ceases, and the child usually falls into a quiet sleep. The frictions should be used to the whole body if there is no tenderness. In cases of rickets, however, this cannot at first be borne, as in that disease there is extreme tenderness, which renders the least movement or pressure painful to the child. When, however, the disease is improving, frictions are exceedingly useful, and should never be neglected. Friction with stimulating liniments is merely a mild form of coun- ter-irritation which can be applied generally, and has a more pow- erful influence in stimulating the circulation and promoting a flow of blood to the surface than friction with the hand alone. It is useful in all cases where the debility is great. Friction with cod-liver oil is valuable as a means of intro- ducing nourishment into the sj'^stem, and when the irritability of the stomach is great this is a very useful means of administering the oil. Oily frictions, or the mere application of oil to the surface of the body, has, however, another purpose than that of supplying nou- ris-hment. When the oil, slightly warmed, is smeared over the whole body with a piece of fine sponge, and the child, wrapped in flannel, is afterwards placed in his bed or cot, one of the first effects noticed is a profuse general perspiration. This is accom- panied sometimes by a little erythematous eruption, which resem- bles the rash of measles. At the same time, any irritability of the nervous system is quieted, and the child soon falls into a tranquil sleep. A third effect is an increase in the quantity of all the secretions : the urine is more abundant, and the functions of the liver appear to be rendered more active, for, according to the observations of Bauer, of Tubingen, the stools, from being green and sour-smelling, become yellow and natural. To produce these effects, it is not essential that cod-liver oil be employed : other oils will be found equally efficacious, and are, indeed, generally to be preferred, on account of the disagreeable smell of the fish oil, which is often a source of discomfort. On account of its influence in promoting the action of the skin, anoint- 26 INTRODUCTION. ing with oil is of great service in all the diseases which are here treated of, and in cases where the weakness and emaciation are extreme, the most striking results sometimes follow the applica- tion if it be repeated with sufficient perseverance. A warm bath, or a thorough sponging of the whole body, with very warm water, immediately before the oil is applied, is useful in preparing the skin for the action of the oil, and greatly increases the effects. In the application of counter-irritants to young children, great care must be taken not to carry the counter-irritation too far. An irritant which, in a healthy child, would produce only a moderate degree of redness, will often, where the strength is much reduced, set up very great inflammation, or even produce sloughing of the tissues. Such a result would not only still further reduce the child's little remaining strength, but would act as a direct irritant to the part for which it is intended to be a derivative. For this reason counter-irritation should, as a rule, be general rather than local, being employed in the form of stimulating liniments and hot baths. Sometimes, however, a local counter-irritant is required. In these cases equal parts of flour of mustard and linseed meal should be used. Blisters are inadmissible for infants. For the hot bath, the water should be of the temperature of from 95° to 100° Fahr., and should be sufficient in quantity to cover the child up to the neck. After remaining in the water for three, four, or five minutes, he should be quickly but thoroughly dried, and be then wrapped in flannel and returned to his cot. It is of great importance that he should not be left too long in the hot water. The effect of the hot bath is at first stimulating, but after stimulation comes reaction, and depression is induced. He must be, therefore, removed before the stimulating effect has had time to pass off. Children, especially when unwell, often show great repugnance to the bath, and become much terrified at the sight of the water. In these cases it is convenient to cover the bath with a blanket ; the child, being placed upon this, can be lowered gently down into the water without seeing anything to excite his apprehensions. Sometimes a more powerful stimulant is required. In these cases the child should be wrapped in flannel wrung out of hot water, and upon which some flour of mustard has been sprinkled; the whole being covered with a dry warm blanket. Or the mustard bath BATHS — TONICS. 27 recommended by the late Prof. Trousseau may be adopted.^ For this, some flour of mustard is mixed with cold water, and is put into a linen bag. The bag is then squeezed in the bath, and the water becomes strongly sinapized. The child is held in the warm water until the arms of the person supporting him begin to prick and tingle. The quantity of mustard required for this bath is in the proportion of two ounces to five gallons of water. The immediate effect of the cold bath is directly contrary to that of the hot bath. Its first effect is depressing, on account of the shock. In a few seconds, however, reaction succeeds to the tem- porary depression, the surface of the body glows, and the pulse becomes fuller and stronger. It acts, therefore, as a general stimu- lant and tonic, promoting nutrition, and giving tone to the body. If continued too long, reaction subsides, and there is a sense of chilliness and languor, with loss of appetite, which may last for several hours. The shock is great in proportion to the coldness of the water, and the degree of weakness of the patient. The addi- tion of salt to the water makes it more stimulating, and increases the vigor of the reaction. On account of these effects the cold bath should be used with caution, and is inadmissible until the child is far advanced towards convalescence. It then becomes a valuable means of invigorating the system. The water should not at any time be below the tem- perature of 60° Fahr,, and should be used tepid at the first, the temperature of succeeding baths being gradually reduced as the child gets stronger. Any chilliness or languor after the bath are signs that too cold water has been used, or that the bath has been continued too long. To be beneficial, the whole process should be rapid. The child should be quickly sponged, and should then be dried briskly with a thick soft towel. The whole body should be afterwards well and firmly rubbed with the open hand to assist the reaction. Of internal remedies little need be said in this place, as full di- rections will be given afterwards in considering the treatment of the different diseases. The important point to remember is the uselessness of tonics so long as any derangement of the digestive or- gans remains uncorrected. In order that tonics may be beneficial, the stomach and bowels must be in a healthy state. It is only ' Clinique M6dioale. 28 INTRODUCTION. when digestion is restored that these remedies are admissible ; they will then prove of extreme service, increasing the vigor of the stomach, and improving the tone of the whole body. To the general list of tonics, cod-liver oil is an important addi- tion. It is, indeed, more a food than a medicine; but for this very reason it should not be given in too large quantities. If more of the oil is being taken than can be digested, the surplus passes down through the bowels, and is seen unchanged in the stools, where it is at once recognized by its appearance and smell. In ad- ministering the oil our object should be to give as much as can be readily digested, but no more. For a child under two years of age, ten drops will be a sufficient dose at the first. The quantity, after the first few days, can be gradually increased, but a careful watch must be kept upon the stools, and the appearance of any oil unchanged in the evacuations is a sign that the quantity must be reduced. For a child of this age we can seldom go beyond thirty drops for the dose, three times in the day. It must always be re- membered that the oil is an addition to, not a substitute for other food, and is therefore only useful so long as it is well borne by the stomach. If it be found to impair the appetite, or to interfere in the slightest degree with digestion, its use should be immediately discontinued. "With regard to stimulants; they are always required when the fontanelle becomes much depressed. The best form is pale brandy, of which a few drops (five to ten) may be given in cold water or a little milk, as often as circumstances seem to demand the repetition. CHAPTER I. SIMPLE ATEOPHY FKOM INSUFFICIEXT NOURISHMENT. Simple Ateophy from Insufficient Nourishment. — An exceedingly common con- dition. — Causes — Insufficient supply of food — Varieties of breast milk — Ef- fect of preponderance of butter in the milk — Test of a good nurse — Unsuitable food — Dependence of nutrition upon power of digestion — Over-feeding — Varieties of food required for perfect nutrition — DiflFerences between woman's and cow's milk — Cow's milk cannot always be digested. Syinptoms. — Two classes, according to cause — Food suitable but insufficient — Food unsuitable — Wasting — Constipation — Cause of inactivity of bowels — Flatulence — Colic — Ravenous appetite — Eruptions on skin, strophulus and urticaria — Thrush, its importance in prognosis — Inward fits — Attacks of vomit- ing and diarrhoea — Convulsions — Aphthae — Danger of secondary diseases — Mode of death. Treatment. — Suckling — By mother — By nurse — Rules for choosing nurse — Direc- tions for efficient suckling — Advantages of putting child early to breast after birth — Times of suckling — Artificial feeding — Directions — Feeding bottle — Importance of cleanliness — Different infants' foods — Liebig's food — Cow's milk may disagree — Weaning — Usual time — Must sometimes be anticipated — Method of weaning — Reason why a child may refuse the breast — Diet after weaning — General management of infants — Treatment of— Constipation — Flatulence and colic — Convulsions — Thrush — Aphthae — Diarrhoea and vomit- ing. This is the commonest form of disease, and the most frequent cause of death in infants. Many thousand children die yearly in Loudon alone for the simple reason that tbey are fed systematically and persistently upon food which they cannot digest. And so long as the children of the poor are allowed to leave their schools utterly uninformed as to duties which in after life they will be called upon to fulfil, so long this dreadful mortality may be ex- pected to continue. Causes. — The supply of food may be actually insuflficient. This is found in cases where the child is nourished entirely by the breast, and the milk of the mother is poor and watery ; or in those cases where the breast has remained the sole support of the child after the time when some other food ought to have been given in 30 SIMPLE ATROPHY. addition. "When the mother is weak, anemic, and evidently ill- nourished, her milk no doubt always suffers from the impoverished state of her blood ; but the converse of this is not always the case, for the milk of a woman may still be of very inferior quality, although in her health and general appearance she may present no sign of weakness. From the researches of MM. Yernois and Bec- querel ^ we find that the richest milk is far from being secreted by women of the greatest muscular development. On the contrary, their investigations tend to show that a robust figure is inferior in milk-producing power to one slighter and less apparently vigor- ous. The following table, formed after an analysis of sixty-three cases of the former, and twenty-three of the latter, will make this apparent. Under the first head (strong constitution) they place brunettes, with well-developed muscles, fresh complexions, moder- ate plumpness, and all the other external signs of constitutional strength. Under the second head they range fair-complexioned women, with light or red hair, flabby muscles, and sluggish mus- cular contraction. strong Weak Constitution. Constitution. Normal. Specific grav 1032.97 1031.90 1032.(57 Water 911.19 887.59 889.08 Solid parts 88.81 112.41 110.92 Sugar 32.55 42.88 43.64 Casein 28.98 39.21 39.24 Butter 25.96 28.78 26.66 Salts 1.32 1.54 1.38 It will thus be seen that in women ranked under the head of strong constitution the deficiency in the amount of the sugar and the casein is very remarkable, while in those of apparently weaker constitution these elements very nearly attain the normal standard. There is another condition of the milk which appears to exercise a great influence upon the health of the nursling. Out of 89 infants suckled by women in apparently good condition fifteen were found by MM. Vernois and Becquerel to be inefficiently nourished. On a careful analysis of the milk it was found that in all these cases the relative proportion of the butter was raised considerably above the normal standard, being on an average 33.22 against 26.66, the healthy amount, while the proportions of the casein and the sugar remained unaltered. > "Du Lait Chez la Femme." 8vo. Paris, 1853. UNSUITABLE FOOD. 31 For practical purposes, we may make a guess at tlie quantity and quality of the milk by inspection of the breasts of the mother or nurse. They should be pear-shaped, hardish, and mottled with blue veins. On pressure of the gland the milk should squirt out. The milk itself should be opaque and of a dull white color : under the microscope it should present fat globules of medium size, not too small. As a rule, the number of the fat globules is a rough indication of the quantity of casein and sugar, although this, as has been said, is not always a trustworthy guide. The best test, however, of the goodness of the milk is derived from observation of the child. He should be watched while at the breast, and if he sucks vigorously, finishes the meal with the milk running over his lips, and requires suck but a few times in the day, we may infer that the milk is sufficiently abundant. If, on the other hand, he constantly requires the breast, sucks laboriously and with effort, occasionally desisting and crying peevishly, the milk is probably scanty. As an additional test the infant may be weighed immedi- ately before and after taking the breast : the increase in weight should be from three to six ounces, according to his age. Besides the above cases, where the quantity of the food is at fault, there is another class of cases where nutrition is equally unsatisfactory, although the supply of food, as food, is liberal enough. These cases occur where weaning is premature, or where the child has been brought up by hand, and the kind of food chosen to replace the natural nourishment is injudiciously selected, so that the limited digestive power of the child is unable to con- vert it into material necessary for the growth and development of the tissues. Here the diet substituted for the mother's milk, although nutritious enough in itself, yet supplies little nutriment to the infant. A child is not nourished in proportion to the bulk of the food he receives into his stomach. He is only nourished by the food he can digest. Weakness in a child otherwise healthy, while it shows a deficient degree of nutrition, and therefore calls for an increased supply of nourishment, yet at the same time calls for increased care in the selection of the kind of food. There is a difference between food and nourishment. A child may take large quantities of food into his stomach, and yet from weakness of his digestive organs, or from the indigestible nature of the food swallowed, may derive no nourishment from it whatever. On the contrary, it may cause great irritation and pain in the alimentary 32 SIMPLE ATROPHY. canal, and, setting up a febrile state, still further reduce the child whom it was intended to support. The tendency of mothers is to overfeed their children — to mistake every cry for the cry of hunger. Consequently, as the peevishness and irritability of the child in- crease in proportion to the pain excited in the bowels, the food is made more and more " nourishing ;" the louder the cry the thicker the " sop," until at last a violent attack of vomiting or of diarrhoea takes place, or a convulsive fit warns the parent that it is time to desist. Cases of steady emaciation will be constantly found due to this cause, especially in children who are brought up by hand. Amongst the poorer classes they are commonly fed upon fari- naceous food as soon as they are born. This, of course, they are totally unable to digest. As a consequence, they dwindle and rapidly die, or, if of particularly robust constitution, linger on, weak, ailing, and rickety, until an attack of bowel complaint, or other intercurrent disease, carries them off". The very fact that the secretion of saliva in the young child does not become esta- blished until the third month after birth, seems to indicate that before that age farinaceous articles of diet are unsuited to the infant, as saliva is one of the most important agents in the digestion of starchy foods. Besides, for perfect nutrition four classes of foods are required — viz., albuminates, fatty substances, carbo-hydrates, and salts. These are found in the most digestible form and the most perfect proportions for the young child in the casein, butter, sugar, and salts of the human milk. The casein supplies the waste of the nitrogenous tissues, as the muscles, and probably the brain and nerves, and by its oxidation, when it has formed part of these tissues, contributes also to animal heat. The butter is essential to the formation of muscular and nervous tissues, and also aids by its oxidation in the production of heat. The sugar is probably en- tirely heat-giving. The salts form the necessary constituents of all tissues. In nutrition, it is important that tissue change should be rapid, and in young children, where development, as well as growth, is so brisk, this is of especial importance. It is effected by the oxi- dation of old material, which is then removed, to be replaced by new matter. For rapid change, therefore, it is indispensable that no needless impediment should exist to the free oxidation of the tissues. Now, starches, and sugars into which the starches are converted by digestion, have a greater affinity for oxygen than woman's milk and cow's milk compared. 33 albuminates; thej, therefore, tend to appropriate the oxygen which is reoj' uired for the removal of waste matters, and so to prevent the proper changes from taking place. For this reason alone, and without any refereace to their indigestible properties, they form a very unsuitable diet for a young child. Even those children who are fed entirely upon cow's milk are not free from danger. By referring to the table' we see that the Specific gravity. Water. Solids. Sugar. Casein. Butter. Salts. Woman's milk 1032.67 889.08 110.92 43.64 39.24 26.66 1.38 Cow's milk . . . 1033.38 864.06 135.94 38.03 55.15 36.12 6.64 specific gravity of cow's milk is higher than that of woman's milk, and that it contains a larger quantity of solid matters, owing prin- cipally to an increase in the amount of casein. On the other hand, the proportion of sugar is less than that found in human milk. In adapting it, therefore, as a substitute for the natural food of the child, it will be necessary to remedy these differences by dilution with water, and by the addition of a small quantity of sugar of milk. But this is not enough. There is another distinction between the two fluids which it is extremely important to take into consideration. On the addition of rennet, the casein of human milk coagulates into light, loose clots, formed by the aggregation of little flocculi, while that of cow's milk congeals inio heavy com- pact lumps. The same thing takes place in the stomach of the child, as is shown by producing vomiting in an infant directly after a meal by friction over the belly ; the light loose clots formed from human milk are then readily distinguishable from the dense masses of casein produced by coagulation of the milk of the cow. The difference in the digestibility of these two products is very evident. While the one is readily assimilated without any undue demand upon the digestive powers, the other tasks these powers to the utmost, and, unless a very moderate quantity have been taken, will undergo fermentation, and give rise to much flatulence, colic, and perhaps diarrhoea in its progress along the alimentary canal. Children are, no doubt, frequently found to thrive upon this diet, their digestive power being equal to the demands made upon it. Others, however, and by far the larger proportion, are not equal ' Vernois and Becquerel, loc. cit. 34 SIMPLE ATROPHY. to this daily call upon their powers. They oannot assimilate this mass of curd. Consequently, unless rejected by vomiting, it passes through them undigested ; their wants are not supplied ; and they starve for lack of nourishment, although swallowing every day a quantity of milk which would be ample support to a much stronger and healthier infant. Such children are exceed- ingly restless and irritable. They cry day and night ; at one time from abdominal pains excited by the presence in the bowels of this undigested mass ; at others, from the hunger which the pas- sage of this meal has failed to appease. The nurses say, very truly, that the "child is ravenous," and that "the milk does not satisfy him;" but the baked flour, the infant's biscuits, and the tops and bottoms by which they propose to themselves to attain that end, are by no means calculated to do so. Instead of miti- gating his distress, they aggravate it ; and every additional meal, although it may quiet him for the time, yet, by the discomfort which it is certain to produce, forms a subject for future com- plaints. It is, however, often very difficult to persuade mothers and nurses of the importance of what has been stated. They see that the child is wasting under the diet they have first adopted, and therefore will not but infer that something more solid must be required. It is necessary to impress upon them very strongly that a child may actually starve on the fullest diet, and that the presence of large quantities of farinaceous or caseous matters in the alimentary canal is not necessarily followed by any additional supply of nourishment to the tissues. In all cases where the food of an infant is said by nurses to be insufficient, the stools should be carefully examined, and if, as is so frequently the case, they are found to consist of pale, round, hardish lumps, exhibiting in their interior the cheesy appearance so characteristic of a mass of curd, we may safely conclude that it is not that too little is being given, but too much ; and by taking the necessary precautions, we may succeed in providing the child with a diet he is capable of digesting. Besides the weakness produced by the withholding of nourish- ment, there is an additional cause of debility in the constant attacks of vomiting and diarrhoea to which this indigestible diet invariably leads. Each of these attacks reduces him more and more, and by weakening his digestive power renders him less than ever able to obtain any nourishment from the food with which he is supplied. Synqytoms. — The symptoms of simple wasting from insufficient SYMPTOMS. 35 nourishment may be divided into two classes, according to the nature and quantity of the food taken : — Food suitable, but insufficient. Food unsuitable. In the first of these classes there are no very striking symptoms. The infant gradually loses his plumpness; his fat slowly disap- pears; and the muscles get very flaccid and soft. He does not seem to grow. His face becomes pale, and his lips pale and thin. He is peevish as a consequence of his hunger ; takes the breast ravenously at the first, and then, if the secretion of milk is scanty, desists at intervals to cry passionately as if in vexation at his in- ability to obtain the means of satisfying his wants. His skin is moist, and he perspires readily and copiously. The fontanelle is level or slightly depressed. At night he is exceedingly irritable, and sleepless. In the day-time he will often lie quietly enough, holding both thumbs in his mouth, and sucking at them until the skin at the sides of the nail becomes raw and abraded. If the milk is poor but abundant, the child is usually very quiet and drowsy, passing almost all his time asleep. He may even sleep while at the breast — a sure sign that the milk is thin and serous. The bowels are usually confined, and the motions rather solid, although otherwise natural. No symptoms are found to indicate disease of any particular part of the body. In this class of cases nutrition is defective on account of the inferior quality and insufficient quantity of the mother's milk, and nothing is added to compensate lor these defects. The remedy is, of course, to supply the deficiency. When the required nourish- ment is given, the wasting stops at once, the peevishness ceases, and the child, rapidly regaining flesh, becomes strong and healthy. In the second class of cases, where the food is bad in quality, we find the symptoms of defective nutrition combined with other symptoms produced by the irritation of the digestive organs to which the presence of indigestible food necessarily gives rise. The child is dull and languid, his flesh becomes flabby, and he begins to waste. The skin is moist, at the first, although afterwards it is apt to become dry, except about the head ; and the fontanelle is, or soon becomes, depressed. The face and body generally are pale, and the complexion sometimes turns yellowish, assuming a half-jaundiced tint, which remains several hours, or even days, and then disappears. The tongue is clean, pink, and moist, and remains 36 SIMPLE ATROPHY. SO as long as there are no symptoms of acute digestive disturbance. The bowels are irregular and capricious ; constipation alternating with occasional attacks of diarrhoea. The common condition is constipation ; a stool occurring every second day, consisting of hard, whitish lumps, co'vered with a stringy mucus, and formed almost entirely of undigested food. Its evacuation is often attended with much straining, and may be preceded by some pain in the belly. The cause of this sluggishness of the bowels is the presence of mucus secreted in unusual quantities on account of the irritation to which the membrane lining the alimentary canal is exposed. This mucus, being coagulated by the acid resulting from the de- composition of the starchy food, covers the contents of the bowels, and also forms a tenacious lining round the inner surface of the intestine. Consequently, the bowels in their peristaltic action, glide over the slippery surface of the masses of food, and lose their power of propelling these forwards towards the outlet. Sometimes, however, instead of being confined, the bowels are open three or four times a day, the stools being green, half-liquid, slimy, and extremely offensive. In either case the food which the child has taken passes through him without being digested. Flatulence is a source of great annoyance to the infant. It may cause paroxysms of violent pain, in which the face becomes white, the upper lip livid and everted, and the belly tense. The child utters piercing cries, at the same time drawing up the lower limbs suddenly and violently upon the abdomen. Even during sleep frequent startings and moanings, elevation of the corners of the mouth, and, if the pain be severe, a contraction of the brows, show that the child is suffering from abdominal pains. The smile which is sometimes seen upon the child's face during sleep is a result of the same cause, although, of course, to a much less degree. The wind is often evacuated in large quantities, or comes up aS sour-smelling eructations, affording great relief. The temper is exceedingly irritable. The pain and uneasiness from which these children suffer, and which is constantly being renewed by every additional meal, makes them noisy in their lamentations to a degree which is almost unbearable. As the mothers say, " they wear one's life out." At night this is especially the case. At that time they are apt to be feverish, and are often seized with fits of screaming which nothing will appease, and which sometimes continue until actual exhaustion compels them to desist. Even then, however, NETTLERASH — STROPHULUS — THRUSH. 37 the cries are renewed at intervals, as a fresh attack of abdominal pain rouses them from uneasy sleep. At these times the feet are usually cold, although the belly, hands, and cheeks may be dry and hot. But in spite of all this, or rather as a consequence of it, the appetite is usually enormous. The uneasiness produced by acidity and flatulence will often excite in children a great desire for food, and unless the uneasiness amount to actual pain, they will swallow ravenously whatever is offered to them. The amount of farina- ceous matter an infant will consume in this way is sometimes very large, and the fact that, in spite of such voracity, the child should still continue to waste, excites much wonder amongst his attend- ants. Attacks of nettlerash and strophulus, either separatel}'' or com- bined, are very common. With the appearance of nettlerash every one is familiar. Strophulus may be either of the red or the white variety. Red strophulus (red gum) begins in a red blotch, the centre of which is slightly elevated. The redness soon fades, and the cen- tral elevation enlarges and forms a flattened papule, often of con- siderable size. These are seated on the face, neck, arms, and sometimes cover the whole body. White strophulus appears in the form of pearly white opaque.., papules, smaller than the preceding, and about the size of a small pin's-head. They are seen usually on the face and arms. The presence of either of these eruptions (nettlerash or strophu- lus) on the body of a young child is a certain sign of digestive derangement. Thrush (parasitic stomatitis) is another consequence of the un- suitable diet to which the child is exposed, and is especially com- mon in warm weather. The mucous membrane of the mouth becomes red; then little concretions, transparent at first, afterwards pearly white, appear on the reddened surface, unite, and form patches varying in size, and looking like little bits of curd ad- hering to the tongue, and to the inside of the cheeks and lips. In very bad cases, they line the whole interior of the mouth, and may extend into the fauces, and even down to the gullet. According to Trousseau, they are not developed on the interior of the sto- mach or bowels, being limited to parts of the mucous membrane which are covered with scaly epithelium. At the same time 88 SIMPLE ATROPHY. there is a little febrile disturbance, with some thirst ; usually vomit- ing ; and often a thin watery diarrhoea, from the irritation of deranged intestinal secretions. If, as frequently happens, the nates become red and excoriated by the discharges from the bowels, the thrush is said by nurses to have "gone through " the child. There is some tenderness of the mouth, and if the child be put to the breast in the course of this complaint, he often refuses to suck on account of the pain excited by the movements of the tongue and cheeks. The concretions are due to a cryptogamic vegetation (oidium albicans), the sporules of which increase with great rapidity, and form tubular fibrils. These, with an increased formation of epithe- lial scales, constitute the white patches seen on the mucous mem- brane. The plant finds a nidus in the altered secretions of the mouth. This is either a mild or a severe complication, according to the general condition of the child in whom it is found. If it occur in a child who has been reduced to a state of great weakness by a long course of improper food, it is of very unfavorable augury, for in such a case our hopes of improving his health depend upon the rapidity and completeness with which new materials for nutri- tion can be introduced into his system. Anything, therefore, which tends to prevent the introduction of nourishment tends to deprive the child of this his only means of recovery, and the presence of thrush betrays a condition of the digestive passages extremely un- favorable to the ready assimilation of food. Besides, the diarrhoea which is so apt to accompany the disorder, especially in weakly children, is another reason for regarding the occurrence of this complication, in such cases, with considerable anxiety. In stronger children, want of cleanliness, or temporary derange- ment set up by improper food, may give rise to thrush, but here, if the strength is satisfactory, recovery is usually rapid ; the con- cretions become grayer, then yellow ; fall off, and are not renewed. Another symptom of the irritation excited by unsuitable food is that known in nurseries under the name of "inward fits." The phenomena which constitute the condition denoted by this rather vague expression, are ablueness, or lividity of the upper lip, which is rather everted, and may twitch; a slight squint, or a peculiar rotation of the eye ; with contraction of the fingers, and twisting inwards of the thumbs. These symptoms should never be disre- APHTHA. 39 garded, as they are often the precursors of an attack of convul- sions. If a great accumulation of food has taken place in the alimen- tary canal, or the child has swallowed some substance which is more than usually indigestible, or has been exposed to cold, the symptoms may become more alarming. The skin gets very hot, the face flushed, and there is violent vomiting of sour-smelling food, with mucus, preceded by great retching. The efforts to vomit may continue after the stomach has been emptied, and then green or yellow bile is thrown up. At the same time the bowels become very loose, and large dark green, or putty-like, offensive motions are passed, with great straining. The motions often con- tain little lumps, and each action of the bowels is preceded by much griping, during which the child screams, draws up his legs, and throws himself uneasily from side to side. The tongue is rather dry, and is thickly coated, white or yellow, with large, round, red or pink papillge scattered over its surface, peering through the fur. The belly is full, rather hard, and irregular to the feel. The child refuses all food, but is very thirsty ; he usually, however, vomits the fluid he has taken very shortly after swallow- ing it. Sometimes a convulsive fit ushers in this attack, and may be repeated several times. Occasionally these fits recur in such numbers, and with such violence, as to cause death by the exhaus- tion they induce. The vomiting usually ceases after the first day, or is repeated at longer intervals, but the diarrhcea continues two or three days, unless treatment be quickly had recourse to, and the motions change their character, becoming watery, and usually of a brown color, still remaining extremely offensive. If the straining be great there may be slight prolapse of the bowels, with a little blood in the form of red streaks in the motions. In children over twelve months old, these attacks are often ac- companied by aphthge of the mouth. They are found on the tip of the tongue, round the anterior part of its margin, and on the inside of the lower lip. They consist of small circular superficial ulcers, seated at the follicles of the mucous membrane. According to MM. Rilliet and Barthez,^ aphthiB begin as vesicles, the epithe- lium of the follicle being raised up by altered secretion in its inte- rior. This bursts, and a small ulcer is the result. At the same ' Maladies des Enfants, tome i. 8vo., Paris, 1861. 40 SIMPLE ATEOPHY. time the lower gums are usually red, swollen, and shining; they easily bleed, and may be ulcerated along the roots of the incisor teeth. There is also increased secretion from the mucous mem- brane of the mouth, with some salivation. The number of the aphthae varies from two or three to fifteen or even twenty. They are very rarely solitary ; usually about five or six. When the attack subsides, the infant, unless a better system of management be adopted, goes on as before, the wasting continues, and he becomes gradually weaker and more languid. The attacks of acute indigestion recur at short intervals, each, as it passes off, leaving him more prostrate, and less able to withstand the injurious influences which are gradually wearing away his life. His face becomes wrinkled and old-looking; his eyes dull and heavy; his expression languid, or peevish ; and, as his debility increases, the griping pains to which he is still subject excite no longer a fretful cry, but only a plaintive moan, or merely a contraction of the features without any sound. His emaciation becomes extreme ; his belly large ; his skin harsh and dry ; his fontanelle deeply de- pressed ; and, finally, some secondary disease arises, and puts an end to his existence. Any acute disease attacking a child in such a condition is almost certainly fatal, for all resisting power has been starved out of him, and he falls a ready victim to a disorder which, in a healthy child, would be easily manageable, and quickly cured. The least catarrh runs on to bronchitis or lobular pneu- monia ; the slightest chill may set up an uncontrollable diarrhoea ; and it is to chronic diarrhoea that the final cause of death may be most usually attributed — a diarrhoea which may last weeks or months, and there is matter for much astonishment in the length of time a child will linger on, although reduced apparently to nothing but skin and bone. If the child has been brought up en- tirely by hand, and has been fed improperly from his very birth, he seldom lives longer than two or three months. If he has been suckled for some months before the commencement of the im- proper food, he has greater power of resistance; and although un- der the new diet he will soon become dull, and pale, and flabby, yet the eftects upon his flesh and strength are less noticeable, and he usually drifts into rickets before any appearances have been thought sufficiently serious to require medical interference. Treatment. — The treatment of simple wasting from insufficient nourishment consists principally in so selecting the diet of the in- MATERNAL SUCKLING. . 41 fant, with due regard to his age and capabilities, that he may be able to digest, and therefore to be nourished bj all the food he takes. To do this, we must be thoroughly acquainted with the scale of diet suited to a healthy child from his birth onwards ; we are then able to vary this diet according to the digestive power we find in our patient. The weaker the child, the more nearly does his condition resemble that of a new-born infant in his power of assimilating different articles of food, and therefore, the earlier in the scale must we look for the nutriment suited to his wants. A short sketch of this subject will, then, not be out of place. The child ought, if possible, to be suckled by his mother. Most mothers are able to perform this duty : all mothers ought to try ; partly for their own sakes, as it insures uterine contraction, and prevents mammary abscesses ; partly for the child's sake, as the milk of his own mother is, as a rule, better suited to him than that of a stranger. In cases where the choice lies between mater- nal suckling, and artificial feeding, the mother ought to do every- thing in her power to avoid the latter alternative. " Every woman," says StolV " who can bear a child, can suckle it, at least during the time she keeps her bed ;" and even to be kept to the breast for this short time is an advantage to the infant by no means to be despised. If the mother be delicate and the secretion scanty, good diet, especially stout, will often cause a marked increase in the secretion of milk. On the other hand, if she have been over- stimulated by a too rich diet, diminishing the quantity of her food, and the administration of a gentle saline purgative, generally pro- duces a plentiful supply of milk. Feverishness, from whatever cause, will necessarily tend to diminish the lacteal as well as the other secretions of the body ; in such cases, therefore, increasing the quantity of food would have an effect the very opposite of that which it is desired to produce. If these measures fail, the breasts may be galvanized, as recommended by M. Bouchut.^ Should the mother, after repeated trials, prove unable to suckle, a wet-nurse must be provided. In choosing a nurse, attention should be paid to two points — viz., the state of her health, and the age of her milk. With regard to her health, she should be ex- amined for signs of phthisis, scrofula, or syphilis; her breasts ' Prselectiones in diversos Morbos Chronicos. Max StoU. Volumen ii. p. 115. 2 Hygiene de la premiere Enfance. Paris, 1862. 42 , SIMPLE ATROPHY. should be inspected, and we should endeavor to estimate the con- dition of her milk from its appearance, by the naked eye and by the microscope. The best test, however, is the condition of her child, who should always be examined. If he is healthy and thriving, the milk is in all probability in a satisfactory state. The age of the milk is a point of considerable importance, for the farther lactation is advanced, the more casein will the milk con- tain, and the richer will be its quality. It is, therefore, advisable that her confinement should have taken place at about the same time with that of the mother whose place she is to supply, other- wise the milk may be unsuited to her nursling. It is often neces- sary to change the nurse, for, as appears from the investigation of MM. Vernois and Becquerel, already quoted, in the milk of some women the quantity of the oily constituent greatly predominates. In such cases the milk may not agree with the child. We must not rest until a nurse has been provided w4io is in every way fitted to make the infant strong and healthy. The diet of the nurse should be liberal ; a certain amount of fresh vegetables and fruit should be included in her meals, and she may take reasonable quantities of wine or beer. Young mothers with a first child are sometimes awkward in the handling of their. charge, and this is not unimportant. Infants held awkwardly to the breast often find a difficulty in retaining the nipple, and may refuse the breast and be very fretful on this account. The mother should not hold herself too erect, but should bend over the child so as to allow the nipple to fall easily into his mouth. The child should be placed partly on his side, and the mother should support the breast with the two first fingers of her unoccupied hand, so as to keep it steady while the child draws the milk. If the milk flows too quickly and abundantly, as sometimes happens, it may cause vomiting from the rapidity with which it has to be swallowed. In these cases she should be taught to press gently with the two fingers which hold the breast, so as to regulate the flow. The new-born infant should be put to the breast a few hours after birth ; or as soon as the mother has recovered from the first fatigues of labor. This course has several advantages : it insures the proper contraction of the uterus, for when the child has once taken the breast, no danger from after hemorrhage is to be appre- hended : the child has the benefit of the thin, watery colostrum ADVANTAGES OF EARLY SUCKLING. 43 which precedes the appearance of milk in the breast, and which acts as a gentle laxative upon the bowels, clearing out the meconium with which thej are loaded ; and the nipple is drawn out while the breast is still soft. If suckling is delayed until the secretion of milk has become regularly established, the breast is apt to be dis- tended by its secretion, so as almost to hide the nipple. The child has then great difficulty in obtaining a hold of the nipple, and may besides suffer much pain from the pressure of his face against the hardened gland. No food of any kind should be given to the child at this time. The practice of giving butter and sugar, gruel, &c., to a new-born babe, is a mere cruelty, and must be strictly forbid- den. The child should be put to the breast, as Dr. White^ has ob- served, " whether there be signs of milk or not," and there is more or less colostrum, which forms a sufficient nourishment until the supply of milk becomes confirmed. Whether the mother is after- wards to suckle her child or not, she should endeavor at any rate to do so for the first month, during which time a fitting nurse can be secured, if a wet nurse is really required. The child should take the breast at regular intervals, every two hours during the day for the first six weeks, and he should suck from each breast alternately. At night it is important that the mother should be undisturbed ; and besides, it is well to accustom the child to quiet during the hours of sleep. He should, therefore, be fed for the last time at 11 P. M., and be then put to rest in a cot in the nurse's room, until five o'clock on the following morning, when he may again take the breast. By this means the mother is insured six hours' uninterrupted sleep. If, during the interval, he awakes and cries, he may be pacified by a little cow's milk and water; but it is wiser, at any rate after the first few weeks, to ac- custom him to take nothing between the hours mentioned, for chil- dren, like their elders, are creatures of habit. The infant soon becomes used to the plan, and will wake and sleep again with per- fect content if he knows that his cries will be disregarded. After six weeks the interval between the meals should be increased to three hours or even longer if the child shows no desire for the breast. It is as great a mistake to urge an infant to take nourishment as it is to quiet him with the breast whenever he cries. The mother should be able to perceive when her child cries from hunger, and when ' Treatise on the Management of Pregnant and Lyiug-iu Women. By diaries White, M.D. 8vo. 2d edit., 1777. 44 SIMPLE ATROPHY. from uneasines or ill-temper. If the babe rouses himself and seems pleased at the sight of the mother, clenching his hands, and flexing his limbs, he is hungry. If he remains passive, he does not require the breast. If he cries peevishly, has a hot skin, and jerks his lower limbs uneasily about, he is troubled with indigestion, and the milk would only increase his discomfort. Up to the age of six months the breast must remain the child's sole nourishment, provided that the secretion of milk, and its quality, are found to be satisfactory. If not, and the child wastes, or does not grow, other food must be given in addition, as will be afterwards described. If the mother cannot suckle her infant, and a wet-nurse cannot be provided, the child must be " brought up by hand," feeding from a bottle. Here the greatest care is requisite. The substitute for human milk should resemble that fluid as closely as possible, or by proper preparation should be made to do so. The milk of the ass approximates most nearly to woman's milk in the proportion of its several constituents, and forms a very good diet for infants, although, sometimes, it is found to have a slight purgative action upon the bowels. If this, however, cannot be procured, cow's milk is the one to which recourse is usually had, and this has at any rate the advantage of being always obtainable. Cow's milk, as has already been stated (see page 33), has a higher specific gravity, and contains more casein, but less sugar, than human milk. Dilution with water, and the addition of sugar, will readily remove these differences. The other, and greater, objection to this milk, viz., the firm clot formed by its casein when coagulated, can also be removed by the addition of an alkali. For this purpose carbonate of potash, in the proportion of one grain to each ounce, or lime-water, may be used, and of these the latter is usually preferred. Lime-water contains half a grain of lime to each fluidounce. For the first six weeks the milk must be diluted with an equal quantity of lime- water, and must be sweetened by adding a teaspoonful of sugar of milk^ to each six ounces. To this Sir William Jenuer^ recommends ' Sugar of milk, or lump sugar pounded, should always be used for children. The ordinary brown sugars contain albuminous matters, which decompose, and set up a kind of fermentation. They are very apt, therefore, to disagree. Sugar of milk also usually contaius the salts of the milk, which are not without their value in nutrition. " Lectures on Rickets. Medical Times and Gazette, May 12, 1860. The creaui is also useful in preventing the lime-water from causing constipation. MODE OF PREPARING COW's MILK. 45 the addition of a little cream, in the proportion of two teaspoon- fuls to the half pint. The milk must not be boiled, but the cold mixture must be warmed to a temperature of about 95° Fahr. by dipping the bottle containing it, for a few minutes, into hot water. After six weeks the quantity of lime-water may be diminished, one-third part being added to two-thirds of the milk ; and after three months, the quantity may be still further reduced to one- fourth. After four or five months the cow's milk may be given pure. During all this time the quantity of sugar of milk, and of cream added, is to remain the same. The child must be fed at regular intervals, from three to four ounces being given every two hours for the first six weeks. The alkalinized and diluted milk should be put into a feeding-bottle, and the child allowed to suck until its contents are exhausted. If before that time he seems satisfied, he should never be pressed to continue ; the first show of indifference is a sure sign that he has had enough; and when the meal is concluded, the bottle should be at once removed. It is injurious for infants to suck at an empty vessel, as they thereby swallow air, which is afterwards a cause of great uneasiness. If any milk remains in the bottle at the end of a meal, it should by no means be laid aside and warmed for a subsequent meal, and only the quantity required for each particular repast should be prepared at one time, to avoid fermen- tation. The kind of feeding-bottle to be used is of little importance. Maw's feeding-bottle, and the " Mamma" bottle, which have each a mouth-piece of caoutchouc, or a bottle sold by Mr, Elam, of Oxford Street, in which the mouth-piece is made of fine cork, can all be recommended. It is, however, of extreme importance, that the apparatus should be kept perfectly clean. Each time after being used, it should be washed out with water, in which a little soda has been dissolved, and it should then be placed in a basin of cold water until again wanted. It is best to have two bottles which can be used alternately. The quantity given to the infant must be carefully regulated. For the first two or three weeks, six or eight tablespoonfuls at each meal will be sufficient; this can be gradually increased as the child grows older. When the child is six months old, a little farinaceous food can be given without danger, and will be indeed a useful addition to 46 SIMPLE ATROPHY. his diet. The kind of farinaceous food to be chosen is of consider- able importance, and in the selection we have to consider not only what food is best in itself, but also what food is best digested by the child. The same food will not agree equally well with dif- ferent infants, and in cases where our first trial is unsatisfactory it will often be necessary to change the food several times before we have found the one which is suited to the particular case. The farinte contain nitrogenous matter, starch, and salts in vary- ing proportions, and those of them best suited as food for infants which approximate most nearly to milk, the natural diet of the child, in the relative proportion of their several constituents. Thus, the relation of the nitrogenous or nutritive element to the calori- fiant is, in human milk, as one to four ; in' wheaten flour, one to five; in potatoes, one to nine; in rice, one to ten; and in arrow- root, tapioca, and sago, one to twenty. The calorifiant matter exists in farinaceous substances in the form of starch, which during the digestive process becomes converted into sugar before being taken up by the absorbent vessels. But that this change should take place, it is important that by proper preparation the starch granules should be brought into a suitable condition, so as to be readily acted on by the digestive organs. The food which is best in itself, and which is most commonly found to agree, is wheaten flour prepared in the following way : a pound of pure wheaten flour, tied up very tightly in a pudding- cloth, is placed in a saucepan of boiling water, and is allowed to boil constantly for ten hours. On removing the cloth at the end of this period, a yellowish-white ball is seen, feeling softish and rather elastic to the touch, like India-rubber. When cold, the softer outer coating is cut away, and the hard nucleus which is left, is reduced to powder with a fine grater. This powder, exceed- ingly light and delicate, is of a pale straw color. The quantity of this farinaceous food to be given is of extreme importance. An excess of this diet is one of the most frequent causes of the acid indiges- tion so common amongst infants, and which so often leads to the most disastrous consequences. A child of six months old will seldom be found to digest more than two teaspoonfuls of this food in the four-and-twenty hours, and in many cases half that quantity will be sound sufiicient. It is best to give the farinaceous food twice in the day. For each of these meals one teaspoouful of the prepared flour is rubbed up with a tablespoonful of cold milk into FARINACEOUS FOOD. 47 a smooth paste, continuing the rubbing until all lumps have disap- peared. A second tablespoonful of cold milk is then added, and the rubbing is repeated until the mixture has the appearance of a perfectly smooth cream, A quarter of a pint of boiling milk, or milk and water, is then poured slowly upon the mixture, stirring briskly all the time, and the food is ready for use. If the boiled flour prepared as described be not found to agree, a smaller quantity should be given, or if necessary some other farinaceous food should be tried. Any of the so-called " infant's food" may be made use of, and sometimes one, sometimes another, will be found to succeed ; but in no case should farinaceous matter be given oftener than twice in the day. For the other meals sim- ple milk, or milk and lime-water, should be used as before directed. After the eighth month, a little thin mutton or chicken broth may be added, all grease having been carefully removed. This must be given as an independent meal, and not as an addition to his ordinary meals. With some children, in spite of all possible precautions, cow's milk alone, however diluted and alkalinized, causes indigestion and flatulence. In these cases it is necessary to make some addi- tion to the milk. We occasionally find that young infants who vomit the cow's milk and lime-water sour and curdled almost immediately after swallowing it, will yet bear well and even thrive upon the same milk prepared with a small quantity of farinaceous food. The action of the farinaceous matter is here principally a mechanical one. By itself it probably contributes little to the nutrition of the body, but when thus mixed intimately with the , milk, it separates the casein into minute portions. The curd, there- t fore, coagulates, not into one large clot, but into a multitude of small clots, which are more readily attacked by the digestive fluids. It is, however, always a risk to give farinaceous food to very young infants, for, before the secretion of saliva has become esta- blished, there is alway danger lest the farinaceous matter, lying undigested in the bowels, should ferment and give rise to acid dyspepsia. The desired object may be as readily effected, and without danger to the child, by adding a little isinglass or common gelatine to the diluted milk. One teaspoonful of isinglass dis- solved in four ounces of milk and water will prevent the running together of the curd while it is itself a harmless addition to the 48 SIMPLE ATROPHY. meal. It is in cases such as these that " Liebig's food for infants,"^ is so valuable a resource. This, when properly prepared with milk, is, so far as the author's experience goes, always well digested even by the youngest infants, who thrive upon it when they have been unable to take any other food. In cases, however, where milk- alone is found to disagree, we should be careful to satisfy ourselves that it is really the milk which is at fault, and not its method of preparation, or the way in which it is given. Too large a quantity may have been given at once, or the meals may have been too frequently repeated, or, as so constantly happens, the whole secret may lie in a want of clean- liness of the feeding apparatus. Amongst the poorer classes, so common is this fault, that it is really the exception to find a per- fectly clean feeding-bottle, and a large proportion of the deaths amongst their children may be traced to this carelessness alone. Even amongst the wealthier classes, in cases where the direction of the child's meals is left entirely to servants, the necessary cleanli- ness is not so common as could be wished. The first care of a medical man, when called to a child brought up by hand, should be to send for the feeding-bottle, and to satisfy himself by sense of smell that it is fit for use. The above description of the method of bringing up a child by hand is also applicable to cases where the child is being suckled on impoverished milk. In such cases the breast should be given only twice a day, his feeding at other times being conducted accord- ing to the rules laid down. A useful addition to the breast-milk, where an addition is required, during the first few weeks of life, is a mixture of cream with diluted whey, one tablespoonful of fresh cream is added to two of whey, and the mixture is diluted with two tablespoonfuls of hot water. This may be given from a feeding-bottle every three or four hours. The whey should be made fresh in the house, as required, by adding prepared rennet to new cow's milk in the proportion of a teaspoonfal to the pint of milk, after which the curd is removed by straining through muslin. This diet must not, however, be continued too long. After a few weeks a tablespoonful of milk may be added, and this quantity can be afterwards gradually increased. ' The best form of this food is the one known as "Liebig's patent extract," prepared by Mr. Mellin, of " Liebig's Concentrated Patent Milk Company," 16, Tichborne-ritreet, Quadrant. Full directions are given upon the bottles. WEANING. 49 The time of weaning is very important. Premature weaning is not without its dangers, but when deferred too long it is a fruitful source of evil. In ordinar}'' cases, where the child is healthy, and the strength of the mother is sufficient for the task, twelve months should be allowed to elapse before the child is weaned. A longer continuance of suckling would make too great a demand upon the strength of the mother, and would be of no advantage to the child, who has by this time become well accustomed to other food. It is sometimes stated, particularly by French authors, that the time of weaning should be regulated by the progress of dentition ; that the child should not be deprived of the breast until the period has passed during which the accidents attendant upon dentition may be expected — which time they fix at the evolution of the canine teeth. This, however, is not a very safe guide, as rickets, a com- mon result of mal-nutrition, may postpone indefinitely the evolution of the teeth. In these cases, to continue the suckling would be to encourage the very evil which it is our principal object to prevent. The existence of chronic disease in an infant reared entirely by the breast, so far from being an impediment to weaning, is, on the contrary, the very strongest argument in favor of a change of diet ; and the common objection of mothers that, on account of the chikVs weakness, they "dare not wean him," is the very worst objection that could be possibly urged, and is a sufficient proof that the suckling has already been continued far too long. Human milk is the best food for infants, not on account of any specific property it possesses, but merely because it is the most digestible. When, however, it is so poor as to be no longer nutritious, it ceases to rank as food ; and by pursuing this course, we fill the child's sto- mach with a fluid which is incapable of nourishing him, but which, by satisfying his appetite for the nioment, prevents his taking a meal which would be really beneficial. In every case we must attend, not to popular prejudice, but to the actual condition of the child. Wasting, in a non-syphilitic infant, shows the necessity for some change in the diet. But this change does not, unless the child be twelve months old, consist necessarily in weaning, His condition may be owing to a too liberal, or to a too scanty supply of food, and we must make him depend more upon the breast-milk, or less upon that source of nourishment, according as to which of these two causes a history of his previous diet leads us to attribute his disease. 4 50 SIMPLE .ATROPHY. In giving additional food to children at tbe breast, a difficulty often arise from the repugnance of the child himself to this mode of feeding. Many children, particularly those who have been suckled too frequently, and to whom the breast has been offered as a means of quieting their cries, greatly prefer this way of taking- nourishment to any other, and indeed continually refuse it in any other form. In these cases, should the mother's milk be poor in quality (which it often is, although very abundant) it is better, if all other means fail, to wean the child suddenly, as this offers the only plan by which he can be efficiently nourished. This course, however, should only be resorted to when, in spite of great perse- verance, Ave have not succeeded in attaining our object. A little judicious starvation will often do much. Although, if circumstances will allow it, the child should be suckled for twelve months, yet it may be necessary to wean him at an earlier period, thus : — If the mother's health suffers from nursing. If from some 'cause, as pregnancy, or the occurrence of acute disease, her milk is rendered unwholesome to the child. If the child is insufficiently nourished upon the breast-milk, and yet refuses to take additional food. In all these cases the ordinary time of weaning must be antici- pated. A moment should be chosen for weaning when the child is not feverish, nor suffering pain from the actual cutting of a tooth. It is best to wean him gradually, lessening by degrees the number of the times he is allowed to take the breast, and continuing for about a week, still to give it to him once a day; after which this too must be stopped. If the child has been fed as directed, there is very little difficulty about weaning; he may be fretful for a few days, and even refuse his food, but by perseverance he becomes reconciled to his loss. Children sometimes wean themselves, seeming suddenly to take a dislike to the breast, although they are quite healthy and are apparently thriving upon the milk. This, however,may be some- times occasioned by scantiness of the milk. Usually, when chil- dren refuse the breast, some cause can be discovered by which the process of sucking is rendered difficult or painful. Thus — Retraction of the nipple may make it impossible for the child CAUSES OF EEFUSAL OF BREAST. 51 to obtain any milk until the nipple has been drawn out by a stronger child, by a cupping glass, or by the mouth of the nurse. Colic, or flatulence, when severe, prevents the child from suck- ing until the pain has subsided. In milder cases of abdominal discomfort, infants are, however, often particularly ravenous, as be- fore explained. Thrush, or aphthae of the mouth, may have the same effect- Here the pain caused by the movements of the mouth during the act of sucking is the reason of the refusal. Closure of the nares from syphilitic swelling and incrustation, or from measles, obliges the child to breathe entirely through the mouth. Here, whenever he attempts to take the breast, a sense of suffocation compels him to abandon the nipple. In bronchitis, pneumonia, and broncho-pneumonia, the child sometimes refuses the breast ; for there is laborious respiration, and both nose and mouth are wanted for air-passages. In tongue-tie^ and cleft palate, there is a mechanical obstacle to sucking, in the impossibility of producing the necessary vacuum in the mouth. The former is readily cured by snipping the freenum. The latter necessitates artificial feeding; but by an ingenious and simple contrivance, designed by Mr. Oakley Coles, the impediment to sucking from a feeding-bottle can be overcome, although the child is still prevented from taking the breast. The plan consists in attaching to the nipple of Maw's feeder a flap of elastic India- rubber, cut to fit the roof of the mouth. This flap, shaped like the bowl of a teaspoon, is cut out of the sheet elastic, and is sewn to the upper part of the stalk of the nipple where this projects from the shield. In the mouth of the infant the flap forms an ar- tificial palate, against which the nipple is pressed during suction, and the fluid is thus prevented from passing into the nose in the act of swallowing. "When the child has become accustomed to do without the breast- milk, he may begin to take the food which is hereafter to form his ordinary diet. Potatoes carefully mashed with a spoon, with gravy ; light puddings; eggs very lightly boiled ; or a bone to suck, may be allowed. No meat, however, should be given till the sixteenth 1 By " tongue-tie" is here meant those cases where the frsenum is attached to the whole under surface of the tongue as far as the tip. Such cases are exceed- ingly rare. The ordinary cases of so-called tongue-tie present no real obstacle to sucking, and need not be interfered witli. 52 SIMPLE ATROPHY. or eighteenth month, when he may begin with a very small quan- tity once in the day. The best kind is a small piece of roast mut- ton, without any fat or grease. This should be very finely minced, or even pounded in a mortar to insure fine division, for a young child will not chew his food. With this he may drink plain water, toast-water, or milk-and-water. For further and more complete information on the subject of feeding children, see Chap. XL, Diets 1 to 11. In making the different changes in the diet, it is important to watch the child carefully, so that too great precipitancy may be avoided. Any signs of labored digestion should be carefully noted, and a simpler diet at once returned to. The child when awake should be active and cheerful, and his sleep should be tran- quil and undisturbed. While attention is thus paid to diet, all the other precautions, indispensable to perfect health should be observed. The greatest cleanliness must be maintained. Every morning the whole body should be well washed with soap and warm water, and should be bathed every evening with tepid water before he is put to bed. After each bath the body and limbs should be gently rubbed with the hand. The younger the child the warmer should be the water employed. At first the temperature should be about 90° Fahr., but after a few months it may be gradually used cooler, although it should never be lower than 60° Fahr. Soap is re- quired thoroughly to remove the tenacious cutaneous secretions and the dirt. The use of soap is said by some writers to make the skin too dry, and subject to cracks, but if frictions are used after each bath, this objection is removed, as the skin is thus excited gently to act, and remains sufficiently lubricated. His napkin should be changed sufiiciently often, and the nates after each action of the bowels should be well sponged with warm water, and carefully dried. He should sleep by himself in a little cot, without curtains ; not in the same bed with his nurse. The nurseries should be large and well ventilated, but not too hot, especially at night. They should face the south, if possible, as sunlight is of great import- ance. He should be taken out frequently into the air, whenever the weather permits. His out-door dress should be warm, and as a further protection against the cold, he should wear a flannel ban- dage round the belly. CONSTIPATION. 63 From the sketch given in the preceding pages of the scale of diet suited to a healthy child, it is easy so to arrange the number and quality of his meals that a sufficient amount of nourishment may be given without overtasking his digestive powers. When the diet has been properly regulated, the child is found rapidly to regain flesh, his peevishness and irritability disappear, and his health returns. Any digestive derangement which may occur should be at once attended to, and as this is usually due to some deviation from the prescribed rules, a return to the proper diet will generally cause it quickly to disappear, especially if a gentle laxative be given at the same time. The constipation, Avhich is so common a result of the improper food, often continues after the change of diet. In these cases, if the child be at the breast, the mother should take an occasional saline aperient, and should increase the quantity of fresh vegetables to her meals. Should this plan be insufficient, a teaspoonful of castor oil may be given to the child ; or a few grains of magnesia with syrup of ginger, in some aromatic water, may be administered; or a little manna in a teaspoonful of infu- sion of senna. If, after repeated attempts, we find that a daily ac- tion of the bowels cannot be obtained, without a daily repetition of the aperient, the constipated condition of the bowels may be natural to the child. We should, therefore, wait to see if his health or temper suffers from his costive habit. Should we find that acidity, with flatulence or colic, results from constipation, we must continue our efforts to remove this tendency. When it is thus necessary to continue the laxative from day to day. Dr. Underwood^ recommends a cold infusion of senna to be combined with some bitter tonic, as the infus. gentianse co. This may be given in in- creasing doses until the torpor of the bowels is overcome; or a small piece of castile soap, introduced as a suppository, will have the same effect. Daily frictions over the belly with the hand, or with some stim- ulating liniment, are also very useful in promoting a daily evacua- tion. Dr. Merriman^ sug-srests the addition of aloes to the liniment : — "03^ I^. Tinct. aloes co., ,^ss ; Liuim. saponis co., §j. M. ft. linimentum. ' Treatise on the Diseases of Cliildren. Edited, with additions, by Henry Davies, M.D. London, 1846, tenth edition. 2 Underwood, p 192. 54 SIMPLE ATROPHY. This should be rubbed into the belly every morning. If the child is twelve months old, aloes given by the mouth is warmly advocated by Dr. Dunglison.^ A drachm of the powdered soco- trine aloes should be dissolved in an ounce of simple syrup; of this one teaspoonful may be given, and may be repeated, if neces- sary, until a satisfactory stool is obtained. In cases where the constipation is very obstinate, where hard clay-colored motions, often mottled with streaks of green, are passed at rare intervals, with violent expulsive efforts giving rise to much suffering, Dr. Ringer recommends one or more drops of a solution containing one grain of podophylline in a drachm of alcohol, to be given to the infant on a lump of sugar two or three times in the day. This treatment restores the natural color to the motions, removes the abnormal distension, and eases the colic. Enemata are often very serviceable, administered either alone, or as an aid to the action of purgatives taken by the mouth. Two or three drachms of castor oil, with four ounces of thin, warm gruel, may be used for a child of twelve months old ; or ten to twenty grains of socotrine aloes dissolved in four ounces of boiled milk, may be administered to a child of the same age. In using these injections, the tube must be well oiled, and must be very carefully introduced, remembering that the bowel inclines gradu- ally to the left side. The fluid should be thrown up with moderate force. In children who suffer from habitual constipation, care should be taken to keep the feet perfectly warm. A warm bath will often produce an action of the bowels when aperients have been given without any effect. Rhubarb should not be used as a purgative in children where the constipation is obstinate, unless combined with jalap or scam- mony, or some other purgative, on account of its after astringent effects ; but for the same reason it is extremely valuable in the looseness of the bowels which is the result of acidity. Acidity is produced by fermentation of the food in the alimentary canal, and gives rise to much flatulence, shown by sour-smelling eructations and griping pains in the belly. In these cases the feeding appa- ratus should always be examined, A want of cleanliness in the '■ Commentaries on Diseases of the Stomach and Bowels of Children. By Robley Duuglison, M.D. Loudon, 182'4. CASE ILLUSTRATING SIMPLE ATROPHY. 55 bottle is a common cause of this teasing derangement. If the griping is accompanied by constipation, the bowels should be opened by a gentle purge, as magnesia and senna, or castor oil, after which the following mixture may be ordered : — I^. Sodse bicarb. 5j » Sp. chloroformi, Tiuct. myrrlige, aa Jss ; Aq. menth. pip. ad |ij. M. 3J sextS, quaque hora. Aromatics are very useful in these cases, and indeed should always be included in mixtures for children wherever there are any signs of intestinal irritation. The following case well illustrates the value of alkalies and aromatics conjoined with a regulated diet, in the treatment of simple atrophy accompanied by constipation and flatulence. George M., aged two months, has been pining away ever since birth. "Is not half the size he was." Does not cry loudly but " frets and pines." Is suckled, but the mother has very little milk ; is therefore fed besides on sago and corn flour made with water. Child is bright-looking, but very small and thin. Fontanelle depressed. Lips rather pale. Nasal furrow not marked. Tongue clean, color of rust of iron. Skin cool, not rough or harsh : a little eczema about folds of groin. Anus a little red, but no cracks or fissures there. Does not snuffle. Is not sick. Bowels act once or twice a day. Motions in little light-colored lumps with mucus, not offensive, passed with some straining. Moves legs uneasily, as if griped. Was ordered to be fed on milk and lime-water, in equal propor- tions, given every three hours. No other food except breast-milk. A flannel bandage to be applied round the belly. A teaspoonful of the following mixture to be given three times a day : — 5. Sod?e bicarb, gij ; Syrupi zingib., Aq. menthae piper., aa ^ss. Aquam ad §iij. M. At the next visit a week afterwards : — Continues to waste. Sometimes refuses the bottle and the breast, apparently from the pains in belly. Belly very hard; child wrinkles forehead, draws up the corners of his lips, and flexes thighs on to abdomen. Bowels open twice a day with straining. Motions light-colored, 56 SIMPLE ATROTHY. solid, aud smell sour ; no mucus. Feet examined and found to be very cold. Tongue clean. Feet to be kept warm by friction with the band. The milk and lime-water to be continued. I^. Pulv. rlifei, Sodse Lic/irb. aa gr. iij. Ft. pulv. statim. sumend. I^. Bismutlii subuitratis, 9j ; , Pulv. cretse aromat., gss ; Syrupi, Mucilaginis, aa .^iss. Ft. mist, jij ter die. On the following week : — Child very much better ; is beginning to gain flesh. Motions still light colored and rather firm ; two in the day. Still rather flatulent; turns "deadly white" at times (when violentl}'' griped). To continue the same diet. Half a drop of tinct. capsici added to each dose of the mixture. After this the flatulence ceased ; the motions became natural ; and the child rapidly became fat and well. If the bowels, instead of being confined, are rather loose, with dark, slimy, offensive stools, a dose of powdered rhubarb and mag- nesia, five grains of each, should be given, and may be followed by the above mixture, with the addition of half a drop of laudanum to each dose ; or the following^ may be given : — ^. Tinct. opii, iH^xij ; 01. ricini, 3j ; Syrupi zingib., ^ss ; Mucilag. acacise, ad §ij. M. 3j ter die. If there is a sour smell from the breath, a few grains of prepared chalk may be substituted in each dose for the castor oil. At the same time all farinaceous foods should be suspended for a day or two, and the diet be limited to milk and lime-water, or plain milk. In all these cases of abdominal pain, the feet should be examined, for cold feet alone may be the cause of the griping ; should such be the case, on warming them the manifestations of pain will cease. If a return to the ordinary diet is followed by the same flatulent condition, and this happens several times in succession, the food ' In the screaming fits, accompanied by constipation, this combination of cas- tor oil with laudanum is exceedingly valuable. FLATULENCE AND COLIC. 57 evidently does not agree with the child, and some alteration is required. Trials should be made of different kinds of foods, for, as already explained, the same food is not suited to every case. Liebig's food is a great resource under such circumstances. Some- times it is the milk which disagrees, and we are forced to discon- tinue it altogether, giving instead beef, veal, or mutton broth, thickened with some farinaceous food.^ When the flatulence is thus obstinate, frictions with a stimulating liniment should be em- ployed daily to the belly, the flannel bandage being removed for the purpose, and afterwards replaced. A.t the same time a mix- ture containing infusion of rhubarb, with a little tincture of myrrh, may be given twice or three times in the day, to give tone to the bowels, and increase their peristaltic action : — ^. Infusi rhsei, §j ; Syrupi zingib., ^ss ; Tiuct. myrrlije, 5s3 ; Aq. meiith. pip. ad §iij. M. gij bis vel ter die. If sickness accompanies the flatulence, a teaspoonful of ipecacu- anha wine should be given to relieve the stomach ; after which a mixture containing bismuth and magnesia may be ordered : — I^. Bismutlii subnitratis, 5==^ ; Magnesise carb., ^ij ; Syrupi zingib., ^ss ; Mncilag. tragacanth. §ss ; Aquamad3ij. M. 3J ^^^ ^^'^' Or the mixture containing bicarbonate of soda with spirits of chlo- roform and tincture of myrrh (see p. 55) may be used. When the colic is very severe, great alarm may be excited by the state of apparent collapse into which the infant is thrown. The child should be placed in a warm bath ; the bowels should be re- lieved by an injection of warm water; and a few drops of brandy or sal volatile should be given in milk or water. On being re- moved from the bath, the child must be carefully dried ; a hot lin- seed meal poultice, on which ten or fifteen drops of laudanum have been sprinkled, should be applied to the belly ; and he should be then wrapped up in warm flannel. If the fontanelle remain depressed, the brandy may be repeated, and a mixture containing sal volatile with spirits of chloroform and a little bicarbonate of soda may be prescribed : — ' See also Diets 12 aud 13, Chap. XL 58 SIMPLE ATROPHY. ^ . Sodse bicarb., ^ij ; Sp. chloroformi, gss ; Sp. amnion, aromat., ^ss ; Aq. anethi ad 5ij. M. ^ij tertia quS,qiie bora. Convulsions may arise from this condition of the bowels, and must be treated in the same way. If, however, they continue, and are not relieved by the measures adopted, Dr. Graves^ recom- mends turpentine to be given : — I^. 01. terebintbinse, 3j ; 01. ricini, giv ; Mist, acacise, Aq. cinnamomi, aa §iij. M. 5j tertiS. quaque horS,. This acts on the bowels and produces a copious discharge of urine. On recovery, great attention should be paid to the diet and bowels, that the symptons may not return. Thrush is readily cured by attention to cleanliness. It should be made a rule always to wash out the child's mouth immediately after a meal, to prevent any accumulation of food or milk round the gums. This is readily done with a good-sized camel's hair brush, or a piece of linen rag dipped into warm water. Attention to this point will prevent the appearance of thrush, especially if care be taken that the nipple of the mother is perfectly clean. When thrush has appeared, the bowels should be cleared out with a gentle aperient, and the mouth, after being cleansed with warm water, should be brushed over with a solution of borax in glyce- rine (half a drachm to the ounce), or with a solution of hyposul- phite of soda. By these means the parasite is readily destroyed. If aphtha form, the same attention should be paid to cleanliness ; a powder of rhubarb and jalap, with a grain of hydrargyrum cum creta should be given to evacuate the bowels ; after which the fol- lowing mixture should be prescribed: — R. Potas. chloratis, 9ij ; Syrupi simpl. 5ss ; Aquam ad 5iij. M. ^ij quarta quaque bora. This must not be diluted, as it is important that the solution of chlorate of potash should be tolerably strong. When attacks of acute indigestion come on, with hot skin, furred tongue, thirst, vomiting, and diarrhoea, accompanied by griping pain, all food must be stopped, and nothing be allowed but cold barley-water. ' Graves' Clinical Medicine. Edited by Dr. Neligan. ACUTE INDIGESTION. 59 The stomach should be relieved by an emetic of ipecacuanha, after the action of which a purgative of rhubarb and magnesia should be given to clear out irritating matters from the bowels. A mix- ture of chalk and catechu with aromatic confection can then be given; or the following: — IJl. Bismuthi subnitratis, 9j ; Fnlv. cretse aromat., 3j ; Syvnpi, 3SS ; Mueilag. tragacanth., §ss ; Aquam ad §iij. M. gij ter die. If the diarrhoea continues after the toiigue has become clean, half a drop of laudanum can be added to each dose of either of these mixtures, or small doses of sulphuric acid may be given with opium: — ^. Acidi sulphurici aromat., jSS ; Tinct. opii, iTj^vj ; Syrupi, gss ; Aqiaam carui, ad §iij. M. 5'j ter die. When the irritability of the stomach has subsided, milk and lime- water may be given, but with caution, lest the vomiting return ; and, after subsidence of the fever, great prudence should be exer- cised in recommencing the ordinary diet. CHAPTEE II. CHRONIC DIARRHCEA, Chronic Biarrhcea. — May be secondary to acute disease — Or primary — When primary — Mode of commencement — Increased peristaltic action of bowels — When disease established — Character of the stools — Other symptoms — Complications — Serous elFusions — Pneumonia — Exanthemata — Convulsions, uncommon, except towards beginning — Thrombosis of cerebral sinuses — Death without complication — Diarrhoea may cease before death — Influence of the disease upon dentition. Causes. — In infants — Bad hygiene — Cold — Previous acute disease — In older chil- dren — Worms — Tubercular disease of bowels. Anatomical Characters. — Non-tubercular — Tubercular. Diagnosis. — Between simple and tuberculous form. Pro(/nosis. — Signs — Favorable — Unfavorable. Prevention. — Attention to diet — Avoidance of cold — Influence of dentition. Treatment. — Diet and general management — External applications — Internal remedies — Antacids — Astringents — Enemata — Opium— Nitrate of silvei* — Raw-meat plan — Tonics. Chronic Diarrhoea may either occur as the sequel of an acute attack, or may begin insidiously. In the former case it is often secondary to some acute disease, as measles or scarlatina. Here there is, in addition to the diarrhoea, fever, though perhaps of slight intensity, abdominal pains, languor, loss of appetite, and, very frequently, vomiting. This attack may subside for a time, but recurs again and again, until the chronic disease becomes established. When chronic from the first, fever is absent. The stools are not very frequent, usually three or four in the day. They are pale, often of the color and consistence of putty, and are evacuated with much straining and pain. At this stage the disease seems to consist merely in increased peristaltic action of the intestines forcing along their contents too rapidly to allow of efficient diges- tion being performed. The motions consist of curds and farina- ceous matter, from the milk and food which has been swallowed, mixed with some half-liquid feces, and, if there be much straining, CHARACTER OF THE STOOLS. 61 with mucous and blood. The blood at this time is iu the form of red streaks, and results from the rupture of small vessels about the anus in the act of straining. In such a form it is a common accompaniment of diarrhoea in children where there is much te- nesmus. The stools have often an offensive sour smell. The child looks rather dull and pale, but is still tolerably lively, and takes his food with appetite. This state of things may continue for a considerable time, often for several weeks, or even months. The child gradually loses flesh, and becomes paler, and more languid ; but there is no actual diarrhoea. The nurses, on being questioned, will say that the bowels are " nicely open," and it often requires careful cross-exa- mination of the attendants to discover the cause of the loss of flesh. In these cases, therefore it is important to inspect the evacuations. After a time the stools become more frequent and more liquid ; but vary considerably in appearance from day to day. At one time, they are thin, watery, and brownish, like dirty water ; at others, thicker, and clay-colored, like thin mud ; they frequently contain mucus, free, or mixed with a grumous matter, when they are called "slimy" by nurses, and almost always present little masses of undigested food. Occasionally they contain particles of grass-green matter, from altered blood, an indication of some addi- tional irritation of the bowel. The smell becomes more putrid, and is often exceedingly offensive. When the diarrhoea is regularly established, the tendency of the stools is to become more and more liquid, and less and less homo- geneous ; but there is no regular progression from bad to worse. There are alternations of improvement and relapse; sometimes the disease is better for a day or two, and may even seem almost cured ; a relapse then takes place, and the condition of the child is as bad as before. These variations in the intensity of the diarrhoea will often be found, in the earlier periods of the disease, to coincide with variations in the temperature and humidity of the air. A damp, chilly day is usually accompanied by increased severity of the symptoms, while on a bright, clear, warm day the disease is better. The child begins early to waste ; but unless the evacuations are very copious, the emaciation does not progress very rapidly. He gets pale, and, after a time, of a peculiar earthy tint which is very characteristic. The skin is dry and harsh, the eyes are hollow, the 62 CHROXIC DIARRHCEA. lips pale and thin, and the fontanelle is depressed. His strength diminishes, and as the disease advances he seems to lose all power of supporting himself, and lies like a log in his cot, or on his nurse's lap. Still, the appetite is usually preserved, and he will often take food eagerly whenever it is offered ; but each meal is followed by a notable increase in the diarrhoea. His food, as the nurses say, seems "to pass through him directly it is swallowed." The tongue is moist, often quite natural, although sometimes the papillae at the edges and tip appear unusually red and prominent. The belly may be quite flaccid and soft, but often becomes swollen and tense from gas generated by the fermenting food. At these times there is some pain, shown by plaintive cries, by uneasy movements of the legs, and by elevation of the corners of the mouth. Tenderness may also be present, but, until the disease is far advanced, is usually inconsiderable. If the diarrhoea continues, the wasting becomes more and more marked; the bones project; the cheeks get hollow ; the forehead becomes wrinkled ; and the aspect generally is that of a little, infirm old man. The wrinkling of the forehead is due to loss of elasticity of the skin, which retains the folds into which it is drawn. The buttocks and inner parts of the thighs become red from eczema occasioned by the irritation of the urine and fecal discharges. The appetite at this stage may be preserved, or even increased ; but more often it becomes capricious, and the child, refusing milk and sop, craves for beer, or for the more tasty articles of diet which he sees eaten around him. Sometimes, however, he refuses to take any nourishment whatever. All this time there is no fever. In- deed, the temperature is lower than is natural, being often no more than 97.5 in the rectum. The stools are now excessively frequent, ten, fifteen, twenty, or even more, in the four-and twenty hours ; there is often very great straining with each evacuation, and the bowel may even prolapse. The motions often look like chopped spinach in a dirty-brown, stinking water, and may contain blood — not in bright red streaks as at the first, but of a dirty, brownish-yellow color, and mixed with mucus and pus. When this occurs, and there is at the same time great tenderness of the belly on pressure, with gurgling, the bowel is probably ulcerated. There are certain complications liable to occur in this disease which often hasten the end. COMPLICATIONS. 63 Serous effusions mny take place on account of the poverty of the blood, and the relaxed, attenuated state of the coats of the vessels. They begin usually at the feet, which hang down as the child lies in his nurse's lap. The instep gets quite round, and feels doughy ; the skin over it is thin, and looks almost transparent : the contrast thus presented between the thin wasted leg and the bulbous foot is very striking and peculiar. The backs of the hands and the fingers then become swollen, and occasionally the face and eyelids are also oedematous. Effusions may also take place into the serous cavities, the pleura, peritoneum, and pericardium. Hypostatic congestion of the lungs is very liable to occur, for, as the child lies constantly upon his back, stasis of the blood takes place in the most depending parts of his lungs. Death is not at all uncommon from this cause. For the same reason, pneumonia is not an unfrequent complication, and, if the child is very much reduced, may exist without producing cough, or any of the other symptoms by which its presence is usually manifested. TIlc exayithemata are very apt to attack children the subjects of this disorder, either from the diminished resisting power of the system induced by the debility, or from such a condition as ob- tains in chronic diarrhoea being especially favorable to the absorp- tion of miasmatic poisons. Convulsions may carry off the child early in the disease. They are not, however, commonly seen in the later stages. Convulsions are very common in children in whom there is a sudden depres- sion of the vital powers, and are therefore frequently seen in acute diarrhoea, where there is a great and rapid drain upon the system. In these cases, however, where the debility is produced more gradually, although a greater degree of prostration may be reached, convulsions are rare, for the child then assumes some of the physio- logical characters of old age, and is much less liable to be affected by reflex stimuli. Tliromhosis of the cerehral sinuses may be a cause of death. In these cases, the child dies with symptoms of suffocation, or falls into a state of stupor, with dilated pupils, occasional strabismus, contraction of the muscles of the nape of the neck, fulness of one or both jugular veins, and sometimes paralysis of the facial nerve on one side of the face. Some interesting cases of this complication are given by Dr. 6-i CHRONIC DIARRHCEA. You Dusch, in his paper on this subject.^ On post-mortem exami- nation clots are found in one of the sinuses — usually the longitu- dinal — plugging its channel. These clots are more or less dis- colored, may be laminated in structure, completely fill the sinus, and adhere more or less firmly to its walls. The veins opening into the obstructed sinus are distended with blood. The cause of the plugging is thus explained. The profuse watery discharge from the bowel produces inspissation of the blood at the same time that it diminishes its quantity. Absorption of water then takes place from the substance of the brain, decreasing its volume. As a consequence, the fontauelle sinks in, and the bones at the sutures overlap from the pressure of the atmosphere endeavoring to fill up the resulting space. If this is not enough to compensate for the lessened volume in the interior of the skull, the vessels of the brain and the sinuses become distended with blood. Now the rapidity of the current of blood in the sinuses is, even in a healthy state of the body, comparatively slight ; partly on account of the dilatations in their calibre, and the projecting par- titions in their walls ; partly on account of the increased friction between the blood and the sides of the channel, caused by the an- gular form of the sinuses. If, then, this natural sluggishness of the current is increased by the diminution in the general mass of blood, and its inspissation — which result from the diarrhoea, and also by the weakened force of the heart's action — which is a con- sequence of the debility, we have a condition set up which is particularly favorable to the occurrence of thrombosis in these sinuses. That the clotting of the blood is not a post-mortem change is shown by the color, or rather want of color, of the plug, by its laminated structure, and by the fact of its completely filling, and being adherent to, the sides of the sinus. That it is not due to inflammation is shown by the absence of all traces of inflammation in the walls around it. "When the disease terminates fatally, the child often dies from one of the above causes. Sometimes, however, he sinks and dies without our being able to say that any of these complications are present. In these cases the emaciation becomes extreme. The ' New Sydenham Society. ISGl. DEATH WITHOUT COMPLICATIONS. 65 eyes, deeply sunken in their sockets, have a dull, ghastly look ; the cheek-bones project ; the cheeks sink in ; the nose looks sharpened ; a furrow passes on each side from the upper part of the ala of the nose, and forms a rough semicircle round the corners of the mouth , the lips are red, cracked, and covered with sordes ; and the inside of the cheek and lips, and the surface of the tongue, become aphthous, or are covered with thrush. The tongue becomes dry, and, when free fyom thrush, is apt to have a granular appearance from projecting papillae. The complexion is dull and earthy looking, and the skin seems tightened over the projecting bones of the face. The fontanelle is deeply depressed. The body gener ally appears to consist of little more than the bones covered by the dry, rough, flaccid skin ; each rib stands out sharp and distinct on the wasted chest. The belly may be flaccid, but more usually is full and prominent, as the emaciated and relaxed walls yield before the pressure of the flatus in the bowels. The skin of the abdomen becomes of a dirty-brown color, or is speckled with brownish spots. The feet and hands are cold, and often look purple even when not actually cold to the touch. The child lies quiet, with eyes half closed and dim. Occasionally he draws up the corners of his lips, and wrinkles his brow as if to cry, but makes no sound ; but for this plaintive sign, and for his slow, quiet breathing, he might be thought to be dead. In these cases, death takes place almost without a struggle, and it is often difficult to say at what precise moment the child ceases to exist. Sometimes for a few days before death the evacuations entirely cease, but no false hopes should be raised by this change, if a corresponding amendment does not take place in the general symp tomgf In cases of recovery, the stools gradually become more homo geneous, more solid, and more fecal, and one great sign of improve- ment is the reappearance of bile in the stools. The child at the same time becomes less torpid ; his eyes grow brighter ; he grows intensely fretful, and manifests his uneasiness by crying. The reappearance of tears is a very favorable symptom, and one which allows us to entertain strong expectations of his ultimate recovery. He ceases to emaciate, and soon begins to regain flesh — very slowly at the first, and the earliest advance in this respect is seen about the buttocks, which will be noticed to have become a little fuller and more rounded. The stools gradually lose their fetid 5 66 CHRONIC DIARRHCEA. character, get more healthy-looking, and constipation usually re- places the previous purging. Although the nutrition of the body is so much interfered with in this disease, and the child daily emaciates more and more, yet it is exceedingly curious to find how in certain cases — usually the less severe ones — the growth and development of the teeth may continue in spite of the general condition. In the cases in which this occurs the teeth are for the most part cut easily, and without any apparent aggravation of the other symptoms. Nor does the eruption of each tooth appear to be accompanied by any special improvement which can be attributed to that as its cause. Denti- tion goes on rapidly and easily, while the diarrhoea remains sta- tionary, or slowly improves. These cases generally recover. In an infant of eight months old whom the author attended for this complaint, five incisor teeth made their appearance in the course of a month. The child got well. From this consideration we may conclude that the common idea which associates this disease with dentition, as a result of the cutting of the teeth, is one en- tirely without foundation. Dr. Cheyne,^ who first described this disorder, under the name of atrophia lactantium, or the weaning brash, also takes this view. He states that this disease is often in cases where there is no swelling or inflammation of the gums, no salivation nor any appearance of pain or tenderness about the mouth, in cases where the child is cutting his teeth easil}'", and even in children of three months old, who have no teeth at all. We shall see that it may begin almost at birth. Causes. — Chronic diarrhoea may usually be traced to three dif- ferent sets of causes, viz., bad hygienic conditions, impressions of cold, and the occurrence of some previous acute disease. • The disorder is very apt to attack children who are exposed to bad hygienic conditions, and the younger the infant at the time when these injurious influences are at work, the more liable is he to suffer from their effects in this particular way. Improper food has already been strongly insisted on as a cause of defective nutrition in the child, and by the weakness which it invariably induces would alone render him less able to resist any other pernicious agencies to which he might be exposed. But in addition, the continued passage along the bowels of masses of in- • Second Essay on Diseases of Children. By John Clieyne, M. D. 1802. CAUSES. 67 digestible food must cause constantly renewed irritation to bis delicate mucous membrane, and, if the same diet be persisted in, must lead in time to diarrhoea. When due to this cause, there are three periods at which the disease is most usually found to mani- fest itself. If the cliild be brought up by hand he may be subject to it from his very birth. In these cases the infant not only does not grow, but, as his fat gradually disappears, he seems even to become smaller and more puny. It is not uncommon for a mother to say, speaking of a child of two or three months old, who all his short life has been suffering from this complaint, " No food seems to do him any good ; he is smaller than when he was born." If the mother is able to nurse her child, he often goes on well for four or five months, but then being supplied with other and less digestible food, as an addition to the breast- milk — food which is often ill-selected, and consists, not unfrequently, of portions of the meals of his parents — he begins to waste, and the diarrhoea is set up. The third period at which this disorder is apt to show itself is the time of weaning ; and so frequently is this the case, that the dis- ease has obtained the name of atrophia lactantium. It is at this time Avhen, the simple food on which he has hitherto principally subsisted being withdrawn, he is so exposed to danger from the mistaken kindness of his attendants, who, confusing substantial with nutritious food, supply him with articles of diet which they consider suitable to his requirements, because they know them to be sufficient for their own. The length of time during which children, amongst the poorer classes, are suckled in this country, also favors the result described. The infant is often kept at the breast long after there is any nourishment to be obtained from his mother's milk. The degree of weakness to which he is reduced by such a system enfeebles his digestive power, and prevents him from assimilating even such a diet as, were he in health, would afford him the nourishment he requires. Even while at the breast the infant is not exempt from danger. Hired nurses, in whom the breast milk is not sufficient in quantity or quality for the child's support, will often feed him secretly with farinaceous or other food, in order that this deficiency may pass undetected. This is not an uncommon source of disease in very young infants. In these cases it is difficult to extort a con- 68 CHRONIC DIARRHCEA. fession from the nurse, but our suspicions are often verified by a microscopic examination of the stools, when starch granules will be found in large numbers. Bad air, want of sunlight, and want of cleanliness, are also fruitful sources of this disease, especially when, as is usually the case, they are combined with the preceding. The crowding to- gether of children in rooms, where they live and sleep in a close atmosphere, is a frequent cause of derangements of the stomach and bowel ; and amongst French authors residence in a hospital is systematically included amongst the causes which increase the gravity of these disorders. In an institution with which the author has been for several years connected, founded for the tem- porary reception of single women with their offspring, it was noticed that when the occupants of the infants' sleeping nursery reached a certain number, one or two deaths were certain to occur from bowel complaints, and this in spite of all possible precautions in the way of ventilation, etc. It was only by making arrange- ments for distributing the number amongst several rooms that this mortality could be avoided. Chilling of the surface is another common cause of diarrhoea. This will be afterwards discussed under the head of " Prevention." The diseases which lead especially to this disorder are measles, scarlatina, variola, pneumonia, typhoid fever, croup, bronchitis, angina, and pleurisy. MM. Rilliet and Barthez^ found that out of 140 cases of secondary chronic diarrhoea in children, 37 had been preceded by measles, 27 by pneumonia, 17 by typhoid fever, variola, and scarlatina, respectively, and 29 by the other diseases which have been mentioned. Of this number, only 21 cases were cured ; the others proved fatal. In older children the presence of the ascaris lumbricoides in the alimentary canal will give rise to a diarrhoea which may continue for months, now better, now worse, and only be finally arrested by the expulsion of the worm. In these cases the diarrhoea is most troublesome at night, the bowel during the day being much less disturbed, and is accompanied by great straining, and often by prolapsus ani. Besides the causes which have been mentioned, chronic diar- rhoea may have also a tubercular origin, arising, however, not ' Traite des Maladies des Enfauts. Paris, 1861. ANATOMICAL CHARACTERS. 69 directly as a consequence of the tubercle, but as a consequence of the inflammation and ulceration which the presence of the tubercle excites. It usually occurs in children who are suffering at the same time from mesenteric phthisis or tubercular peritonitis, of which diseases the presence of this complication very greatly in- creases the danger. Tuberculous diarrhoea is very rare in infants, and is most common in children between the ages of six and ten years. Anatomical Characters. — Not unfrequently on opening the bowel after death we find absolutely nothing at all to account for the serious nature of the disease: the alimentary canal may have a perfectly sound appearance from one end to the other. In other cases we find the mucous membrane of the large intes- tine studded with fine, dark-colored points, giving the so-called "cut-beard appearance" — an appearance which is due to a ring of congestion round the openings of the little follicles. In other cases, again, the mucous membrane of the large intes- tine may be inflamed. The inflammation, however, is seldom gen- eral; it is usually limited to the summits of the longitudinal folds into which the lining membrane of the bowel is thrown. Lastly, the mucous membrane may be not only inflamed, but ulcerated. The ulcers are shallow, and are often difficult to detect except by looking sideways at the surface, for their bases are of the same color as the parts around them. They may occupy either the summits of the longitudinal folds — when they are elongated and sinuous, or may be situated between the folds — when they are very small and circular. The ulcers no doubt result from the breaking down of follicles which had been previously enlarged by cell proliferation and had undergone cheesy transformation. Mixed up with the ulcers we see the solitary glands and follicles enlarged and elevated above the surface, looking like little transparent pearls. The same pearly appearance of enlarged follicles is often seen during life on the inside of the mouth dotting the mucous membrane of the cheek. The mucous membrane, when^ much inflamed, is often exceed- ingly soft, and may be much thickened. M. Bouchut, however, states that where the disease is very chronic, and there is great emacia- tion, the lining membrane becomes thin, and in some cases hardly seems to exist all. 70 CHRONIC DIARRHCEA. These changes are sometimes found to extend into the small in- testine, which may be inflamed or ulcerated for a short distance above the ilio-csecal valve, but in the large majority of cases the lesions are limited to the colon. The mesenteric glands are occasionally swollen, but otherwise appear unchanged in structure. It is probable that these appearances depend upon the passage over the mucous membrane of the larger bowel of the acrid secre- tions poured out by, and descending from, the small intestine. The contact of these matters irritates the gut in the same way that the skin over the buttocks and inner part of the thighs is irritated by the same fluids when they have been ejected from the body. Tubercle of the bowels is seen as small gray or yellow granula- tions beneath the mucous membrane. They may occupy the whole extent of both small and large intestines, but are usually in the greatest quantity in the smaller gut, especially that part of it which is just above the ilio caecal valve. The presence of the tubercle excites inflammation, which ex- tends through the thickness of the wall of the bowel, and may glue the serous coat to contiguous parts, so that coils of intestine are matted together, and are oftent adherent to the peritoneal lining of the abdominal wall. The mucous membrane ulcerates, and the ulcers are circular or oval, with uneven, jagged edges, red, soft, thick, and rather de- tached ; underneath the borders are seen tubercles, either crude or softened. The ulcers vary much in size : when oval or elongated, their greater diameter lies transversely. The floor of the ulcer is red or grayish, and is formed by different coats of the intestine, ac- cording to the depth to which the ulceration has extended. Some- times they penetrate as deeply as the peritoneal covering of the bowel ; but extravasation into the peritoneal cavity is rare, on account of the thickening of the tissue at the base of the ulcer, and the adhesions which are formed with the parts around. Diagnosis. — It is very important to distinguish the variety of diarrhoea with which we have to deal: whether it is due to a sim- ple catarrh of the intestines, or i^ dependent upon a tuberculous ulceration of the bowels. To determine this question we must consider the age of the child, the circumstances under which the purging commenced, and the existence of tubercle in other organs. Tuberculous diarrhoea is exceedingly uncommon during the first DIAGNOSIS — PROGNOSIS. 71 year, or even the first two years of life, and therefore the occur- rence of purging at this time argues against its being due to tu- bercle. If the disease began a few days after birth, or its commencement can be distinctly connected with weaning, or with the administra- tion of unsuitable food, the case is probably one of simple intesti- nal catarrh. If it occur in older children, the other organs should be care- fully examined for signs of tubercle. The existence, especially, of mesenteric phthisis, or of tubercular peritonitis, renders the same condition of the bowel exceedingly probable. Even in these cases, however, we cannot be sure of the correctness of our diag- nosis, for tubercle of other organs may be complicated by a simple catarrh of the bowels. When thus in doubt as to the presence or absence of tubercle, the thermometer becomes of great service. In simple chronic diarrhoea the temperature is lower than in health, and does not become elevated in the evening. If then there should be found persistent elevation of temperature at night, without any cause such as teething or any external irritation to which the ele- vation can be attributed, the presence of tubercle becomes a matter of the very strongest suspicion. While, on the other hand, a low temperature in the evening affords just grounds for believing that we have to deal only with an ordinary case of chronic functional derangement. Another important test is the result of treatment. Tuberculous diarrhoea is so fatal, that if the child recovers, and especially if the purging is found to be arrested by an alteration of diet, or by a return to the breast, its non-tuberculous origin is at once established. The converse of this, however, is not equally true. If the disease resists all treatment, it is not therefore necessarily tuberculous. Simple chronic diarrhoea, as has already been stated, is very frequently fatal. When the child, after cessation of the diarrhoea and the com- mencement of convalescence, suddenly ceases to improve, the presence of some complication should be suspected. In such cases the lungs should be always carefully examined for pneumo- nia. Prognosis. — Chronic diarrhoea, when it becomes confirmed, is exceedingly fatal, but so long as it remains uncomplicated we may entertain some hopes of a favorable termination. 72 CHRONIC D1ARRH(EA. When secondary to some acute disease, the case is graver than when it is primary and non-febrile from the first. When it is due unmistakably to error in feeding, we may hope by a change in the diet to arrest the purging before any organic lesion has been set up in the alimentary canal. The form of stool which is of worst augury is that composed of greenish matter, like chopped spinach, in dirty-brown, stinking- fluid, and mixed with purulent mucus and blood. The putridity here results from decomposition of the albumen in the serum, while the purulent and bloody matters, especially if there is at the same time great tenderness on pressure of the abdomen, indicate ulceration of the mucous membrane of the large intestine. The thicker and more homogeneous the motions become, although they may at the same time remain intensely ofi'ensive, the more favor- able is the prognosis. The occurrence of any complication should give rise to very great anxiety. Measles especially is apt to cause a sudden and violent increase in the intensity of the diarrhoea, and, besides, its own course is often rendered irregular by the presence of the in- testinal disorder, so that retrocession of the eruption and other alarming symptoms may ensue. The prognosis is also rendered very unfavorable if the tongue become dry and rough, if thrush appear upon the inside of the mouth, or if dropsy occur. If tubercle can be detected in other organs, the diarrhoea is in all probability due to tuberculous ulcera- tion of the bowels: death is in all cases almost certain. Amongst the favorable signs may be included — continuance of the natural progress of dentition, the appearance of tears, and the occurrence of any eruption ^ (unconnected, of course, with any of the exanthemata) upon the child's body, even although the diarrhoea may not at the time have undergone any visible improvement. Prevention. — Diarrhoea may be prevented by attention to the diet and general management of the child. All indigestible food is calculated, in its passage through the bowels, to give rise to irritation, and therefore to cause an increased flow of watery fluid from the vessels of the intestines. It is unnecessary to repeat here the directions which have been already given for the feeding of young children, and the reader is referred to the section on the • Underwood, he. cit. '. PREVEXTIOX. 73 treatment of simple atrophy for full information upon this subject. It may, however, be remarked that the practice of giving to very young children sweet cakes, and articles of confectionery, between their regular meals, and as rewards for good behavior, is one to be very strongly deprecated. Sweet cakes are especially to be avoided, as they are so apt to undergo fermentation in the ali- mentary canal. As cold is so common a cause of diarrhcea in children, great care should be taken to shield them from this source of danger. But they should not, therefore, be confined too strictly to the house. Fresh air is as important to them as simple nourishing food. Healthy infants should be taken out at certain periods of the day whenever the weather permits. It is not so much cold as damp air which is dangerous to infants, and even in damp air, unless it be actually raining, a short expedition is not hurtful to a robust child, provided sufficient precautions be taken. The child should be warmly dressed, should be walked briskly about, and should not be allowed to remain out too long at a time. If there is any wind his face should be protected with a woollen veil. As an additional defence, a flannel bandage should be worn round the body next to the skin. This is an article of clothing no infant or young child should be without. It should be looked upon as a necessary part of his dress. The band should be sufficiently wide to cover the whole belly from the pubes to the ensiform cartilage, and long enough to go twice round the body. It should be secured by buttons or by tapes, not by pins ; and in fitting it care, should be taken to wrap the bandage tightly round the crests of the ilia so that it may not slip up and leave the lower part of the bell}^ exposed. The band is more elastic if cut diagonally from the piece of flannel. Sudden changes of temperature are especially to be avoided, and a rapid change from cold to heat appears to be as prejudicial as a similar passage from heat to cold. It is, therefore, necessary to prevent an infant being taken too quickly to a hot fire after exposure to the cold of the outside air. The child should not be allowed to wait, clothed in his out-door dress, in a warm room before taking his airing. He should be taken out directly he is dressed for the walk. While out, he should be kept in movement, and should not be allowed to remain motionless in a current of cold air. If able to walk, he should be placed from time to time 74 CHROXIC DIARRHCEA. upon bis feet, and be allowed to trot along holding the hand of his nurse. If the weather is cold, damp, and gloomy, he should be brought back to the house after only a short stay in the open air. A pinched look about the face, with coldness and blueness of the extremities, are certain signs that he is no longer receiving benefit from his airing. Bathing the chest and belly in the morning, on first rising from bed, with equal parts of vinegar and water, or with a mixture of one part of vinegar, one of eau-de-cologne, and two of water, is said to diminish the susceptibility of the body to the impression of cold. This is worth trying in weakly children. During dentition the rules here laid down must be especially observed, for it is at such times, when the teeth are pressing through the gum. that diarrhoea is so common. Many children are said always to cut their teeth with diarrhcea. Perhaps, how- ever, dentition in these cases is not so entirely to blame as is commonly supposed. ISTo doubt, during the cutting of the teeth the bowels generally are in a state of irritability, for we know that at these periods the follicular apparatus of the intestines is undergoing considerable development. The bowels then are ripe for diarrhoea ; there is increased sensitiveness to the ordinary ex- citing causes of purging ; but without the presence of these ex- citing causes diarrhoea is by no means a necessary result of such a condition of the alimentary canal. "We find that looseness of the bowels is a more common accompaniment of dentition in summer and autumn than in winter ; that is, at a season when the changes of temperature are so rapid and unexpected, and when therefore the child is particularly exposed to sudden chills, rather than at a time of the year when the temperature, though lower, is more uniformly low, and when precautions are more naturally taken against the cold. Dentition, too, commences at a period when the child is beginning to require additional food besides that furnished by his mother's milk, and consequently at a time when he is so liable to be supplied with articles of diet unsuited to his age. Even if the diet be a suitable one for the infant when in health, it by no means follows that the same regimen should be found equally appropriate at a time when the febrile irritation set up by the ad- vancing tooth has temporarily reduced his digestive power. His ordinary diet may then become indigestible, and therefore irri- tating: to his bowels. TREATMENT — CLEANLINESS. 7o Treatment. — The marked influence exercised upon chronic diar- rho3a in children by variations in the temperature and degree of moisture of the air indicates an important means of checking the disease. The infant must be kept as nearly as possible in an equable temperature of from 60° to 65° Fahrenheit. Free ventilation must be sustained by an open fire, or in warm weather by a lamp placed in the chimney ; but all draughts of air should be carefully guarded against. Where practicable, two adjoining rooms, having a door of communication between them, should be chosen. The child may then inhabit them alternately, and during his absence the un- occupied apartment can be freely ventilated. Even where this convenience is unattainable, two rooms, although separated from one another by a passage, should be always made use of: the child can be taken from one to the other without danger if wrapped from head to foot in a blanket. At night, air should be admitted into the room as freely as is consistent with the avoidance of draughts ; with this object, the door of the room may be left open, or in dry warm weather the window may be opened for a short distance at the top. In damp weather, however, or in seasons when the temperature falls notably at sunset, this must be pro- hibited. If possible, the infant with his nurse should be the only occupants of the bed-room, and no cooking of any kind should be allowed in either nursery. The most scrupulous cleanliness must be observed. The nates should be carefully sponged and dried after each motion, and should then be dusted over with powdered h^copodium, or, if the skin is abraded, with equal parts of this and of powdered oxide of zinc ; while the whole bod}'- should be bathed twice a day with warm water. All soiled napkins must be at once removed from the room, and the night-cot and bedding should be taken away every morning and be freely exposed to the air. If a flannel bandage have "not been previously in use, it must be at once applied as directed above. This precaution should on no account be neglected. Flannel, which is a non-conductor, forms by far the most efl&cient protection to the belly against sudden changes of temperature. Chronic diarrhoea is, no doubt, frequently kept up by a succession of chills, just as a coryza or pulmonary catarrh may be prolonged almost indefinitely by the same means. By the use of this safeguard, we at any rate insure ourselves from 76 CHRONIC DIARRHCEA. having to deal with a series of catarrhs. For the same reason tlie feet and legs should be covered with woollen stockings. It is well known that cold feet have a very bad effect on irritable stomach and bowels; and in children, otherwise healthy, often produce severe pain in the belly. In a child suffering apparently from ab- dominal pains the feet should always be examined, and if cold, it is usually found that on warming them the manifestation of pain ceases. The next thing is carefully to regulate the diet. In chronic diarrhoea children are often excessively ravenous, and the mothers and nurses, true to their principle of giving the most solid food to the weakest children, are in all probability filling him with everything that is most calculated by its indigestible properties to aggravate his abdominal derangement. "The child," they say, "will eat anything," and they give him " anything" accordingly. All this must be at once put a stop to, and the diet of the child must . be so arranged that he will still be nourished, while the demands upon his digestive power are reduced to a minimum. In all cases, if the infant be at the breast, he should be limited strictly to it. If he have been lately weaned, the breast should be returned to. Even if he have been weaned some months, the plan is still often of service ; but, under such conditions, the child frequently refuses the breast, and no persuasions can induce him to return to this mode of feeding. In these cases, therefore, or in cases where from any reason a return to the breast is impossible, our great trust should be placed in cow's milk more or less copiously diluted with lime- water. The diet, however, will vary considerably according to the age and strength of the child, and also according to the character of the stools. Thus for a child under six months old nothing should be allowed but milk or some preparation of milk, as milk and lime-water (equal parts), whey with cream, or milk and water thickened with isinglass, in the proportion of a teaspoonful to four ounces. Cases, however, are sometimes met with in which no milk can be borne : these will be considered afterwards. Farina- ceous food should, as a rule, be rigidly excluded from the diet of infants under six months old ; but Liebig's food for infants (Mel- lin's) may be allowed, and is often well digested in quantities of one teaspoonful to four ounces of milk and water. By the above means the successive meals can be made to vary in character, and they should be so regulated that the quantity taken on each occasion, and DIET. 77 the length of the intervals by which the meals are separated, may be properly proportioned to one another and to the state of the patient. The more copious the diarrhoea, the smaller should be the meals, and the more frequently should they be repeated ; for any large quantity of liquid food taken at once would be directly absorbed from the stomach into the circulation, and, where the purging is severe, would, by lowering the density of the blood, be immediately followed by an increase in the flow from the bowels. When the stools are frequent and watery, liquids should never be given in larger quantities than one tablespoonful at a time. Beyond the age of six months, a little beef or veal tea and the ^'■elk of one egg unboiled may be added to the diet. The egg is best digested when beaten up with a few drops of brandy and a tablespoonful of cinnamon-water, as in the ordinary egg-flip of the Pharmacopoeia. As with younger infants, the quantities to be given at one time must depend upon the strength of the child and the state of his bowels. If the child be over twelve months old, very small quantities of farinaceous food may sometimes be ventured upon, and will often agree. The best form in which this can be given is the boiled flour prepared as described on page 46, or the baked flour so strongly recommended by Dr. Underwood.^ Farinaceous food can, however, only be allowed in very small quantities. Its value is no doubt principally owing to its mechanical action in separat- ing the casein of the milk into minute portions, so that the masses of curd formed are small and easily acted upon. One teaspoonful to the four ounces of milk is all that should be allowed. More than that quantity would probably be undigested, and by ferment- ing in the bowels would increase the irritation, and render useless all our efforts to check the diarrhoea. The ordinary farinaceous foods should not be given to children under twelve months old. Liebig's food for infants (Mellin's) can, however, be used at any age. It is, perhaps, next to breast-milk itself the most useful food in all cases of deranged digestion in children, and seldom disagrees even with the youngest infants. In its preparation the starch of the ' Dise§,ses of Children, p. 244. The flour is slowly baked for a long time in a small covered jar, until it breaks into a soft grayish-colored powder. During the progress of baking, the jar must be occasionally removed from the oven, and the contents stirred up from the bottom and sides : this insures its being equally baked throughout, and prevents the formation of hard lumps. 78 CHRONIC DIARRHCEA. wheaten flour which forms one of its constituents is ah^eadj con- verted in great measure into dextrine and grape-sugar, so that the most important part of the work of digestion is performed before the food reaches the stomach. Whatever be the diet adopted, our object is to keep up the nutrition of the body with the smallest amount of irritation to the alimentary canal, and the food, whatever it may be, which will produce this result is the food best suited to the case. Without attention to this point all treatment by drugs is useless, for a lump of indigestible food will neutralize the effect of the most powerful astringents. The successful adjustment of the diet, an adjustment in which the quality and quantity of food to be allowed for each meal is accurately adapted to the powers and requirements of the patient, is a matter which can be properly learned only by experi- ence, and which often makes large demands upon the tact, the ingenuity, and the patience of the medical attendant. This experi- ence every one should labor to acquire, for without it success can seldom be attained in the treatment of the chronic functional derangements of young children. Although milk in some form is our great resource in the cases here treated of, as affording the most digestible and at the same time the most nutritious diet we have at our disposal, yet it is not always suitable. It is not so very uncommon to find cases where milk, whether diluted with lime-water, or thickened with isinglass or with Liebig's food, cannot be digested. Here the passage of four or five large pale putty-like stools in the twenty-four hours is evidently dependent upon the milk diet, and resists all treatment so long as that is continued. In such cases the milk must be replaced either wholly or partially by other food. A good scale of diet for a child of nine months old, in whom this peculiarity is noticed, is the following,^ consisting of five small meals in twenty-four hours. First meal. — One teaspoonful of Liebig's food for iuftxnts (Mel- lin's) dissolved in four ounces of milk and water : equal parts. Second meal. — Four ounces of beef-tea, of the strength of a pound of fillet of beef to the pint of water. Third meal. — Four ounces of fresh whey containing a teaspoon- ful of cream. 1 See also Diets 14, 15, 16, aud 17, Chap. XI. DIET. 79 Fourth meal. — The unboiled yelk of one egg, plain, or beaten up with a tablespoonful of cinnamon-water, a little white sugar, and ten drops of pale brandy. Fifth meal. — Same as the first. In this dietary the first and the fifth meals contain a small quan- tity of milk. If that be found to be undigested, the food may be dissolved in barley-water, alone or diluted with an equal quantity of weak veal broth, or weak veal broth alone may be given. In any case the quantity of four ounces should not be exceeded, for it is wise, especially at the first, to be sparing rather than liberal in regulating the allowance of food. It is better that the child should be hungry than overloaded; and so long as the stools retain their pasty character it is evident that the food taken remains in great part undigested. In these cases, and, indeed, in all cases where a special diet is recommended for children, a dietary, as given above, should be written out by the medical attendant for the benefit of those to whose care the child is intrusted. Not only the kind of food, but the quantity to be given at each meal, and even the hour at which the meal is to be taken should be duly set down, so that no excuse may be available for neglect or misapprehension. It cannot be too often repeated that in cases such as these it is upon the judicious arrangement of his food that the recovery of the child depends, and that where the diet is properly selected, the exact medicine to be ordered becomes a matter of very secondary importance. External applications are excedingly useful in this disease, for the secretion of the skin is usually suppressed at an early period. The hot bath may be used at first every night, with all the precau- tions already enjoined (see page 26), after which the whole body should be freely anointed with warm olive oil, and the child be well wrapped up in flannel. When the prostration becomes marked the mustard bath may be ordered. In cases where ulcera- tion of the bowel is suspected, and it is thought advisable to ap- ply local counter-irritation, a poultice consisting of equal parts of flour of mustard and linseed meal should be used. This should be applied at some distance from, and not directly over, the seat of disease — to the chest, and not immediately to the belly ; and its effect should be carefully watched that the irritation thus excited may be kept in due bounds. If the child is very weak, the mus- tard, after remaining on a few minutes, should be removed, and a 80 CHRONIC DIARRHCEA. hot poultice of linseed-meal should be applied in its place. When the tenderness of the abdomen is very great, it is advisable to keep the whole belly constantly covered with a large hot linseed-meal poultice. This must be changed frequently, but with great care that the child be not chilled in the process. Gentle frictions with the hand over the abdomen and body gen- erally are useful in the earlier periods of the disease, and, so long as there is no tenderness of the belly, may be continued with ad- vantage. When tenderness is present they should only be used to the legs and feet. Internal remedies.^ — If the patient is seen at the first, before the diarrhoea has become established, and when there is nothing but pallor, languor, gradual loss of flesh, griping and tenesmus, with large, pale, sour-smelling stools, a small dose of powdered rhubarb, with carbonate of soda, should be ordered, and then, when the bowels are relieved, a mixture containing tinct. opii with bicarbonate of soda in some aromatic water: — IJ,. Tinct. opii, it^x ; Sodge bicarbonatis, 9ij ; Syrupi simplicis, • Aquae carui, aa §j. M. Ft. mist, ^j ter die. The opium at once renders the peristaltic action of the bowels more regular, and the stools become darker and less offensive in the course of a few days. This, with regulation of the diet, a flannel bandage, and due precautions for the avoidance of cold, is all that is required. A mixture containing tinct. opii and castor oil is also very useful if the tongue is furred : — R.. Tinct. opii, Tr|^xvj ; 01. ricini, 5jss ; Syrupi zingib., §ss ; Mucilag. acacise, §jss. M. 3j ter die. But it should not be used if the tongue is clean, and must not be continued longer than forty-eight hours if no benefit be found to result from its employment. Alteratives are in these cases of little value, for it is no use attempting to stimulate the functions of the liver, by cholagogues. The large white putty-like stools consist, in great part, of undi- ' All the prescriptions given in this section are adapted to a child of twelve months old. ASTRINGENTS. 81 gested food, and we sball best succeed in restoring the digestive power by antacids and aromatics, as directed above, and, more than all, by the careful adaptation of the food, both in quantity and quality, to the enfeebled powers of the child. It is in these cases that milk is seldom well borne, except in very small doses well diluted with lime-water, and is often necessary to replace this by otl\er articles of diet, as already described. AVhen the purging sets in, if the stools are green, and slimy or watery, with a sour smell, it is best to begin with a dose of bis- muth and chalk : — I^. Bismutlii albi, gr. xvj ; Pulv. cret?e aroinat., ^ij ; Syrupi simplicis, Mucilag. tragacanth, aa §ss ; Aqiiffi, 3j. M. Ft. mistiira. 3j sextis lioris. If there is much tenesmus, half a drop of tinct. opii may be added to each dose of the mixture; or an injection containing four or five drops of laudanum, with five grains of bicarbonate of potash, to half an ounce of thin warm starch, may be thrown up the bowel. Dr. Evanson^ strongly recommends the addition of the alkali, which, he says, greatly increases the efficacy of the injection. So long as the stools remain sour-smelling, antacids should be persisted with. An aromatic should always be combined with the antacid. " This," says Dr. Underwood,'^ " is of more importance than is usually apprehended. I have known a careful attention to this circumstance alone happily suppress complaints in the bowels, which had long continued obstinate, though, in other respects, properly treated." In these cases, too, an emetic is often of great service. If, when the tongue cleans, the diarrhoea continues, and the stools are found to consist of dirty-brown stinking water, astringents must be used. Of these, the best, perhaps, is a combination of lead and of opium : — I^. Plumbi acetatis, gr. xij ; Acidi acetici, dil., Tr\xx ; Tiuct. opii, ^^.xii ; Syrupi simpl., 3SS ; Aquae, 5Jss. M. 5j sexta quaque liora. ' Diseases of Children, by Maunsel & Evanson, 8vo., 1847. 2 Uuderwood, p. 236. 6 82 CHEOXIC DIARRHCEA. With this an astringent enema, ^. Ext. Kramerise, gr. xv ; Mucilaginis arnyli, §iv. M. Ft. enema, may be used twice a day, if the emaciation is great and the diar- rhoea very violent. It should be given a quarter of an hour after a copious injection of warm water. It is well to vary the astringent draught every two or three days, and the following mixtures may be used to alternate with the lead : — I^. Acidi Gallici, Qj ; Acidi sulphurici aromat, 5s3 ; Tiuct. opii, lU^iij ! Spirit, jetheris, gss; Syrupi, §ss ; Aquse, ad gij. M. 5j quarta quaque hor^. ;^. Tinct. capsici, ni.vj ; Syrupi simp., ^ss ; Decoct, hsematoxyli, |jss. M. 3j quarta quaque horS,. This combination of capsicum with the astringent is often ex- ceedingly useful in cases where there is no tenderness of the abdo- men or straining. If these symptoms are present it should not be used, but tinct. catechu may be substituted for the capsicum in the proportion of five drops for the dose. Where the diarrhoea is very obstinate, nitrate of silver is strongly recommended by many authors, and in many cases is very suc- cessful in checking the disease after everything else has failed. R. Argenti nitratis cryst., gr. j ; Acidi nitrici diluti, 'n\.v ; Mucilaginis acaciae, Syrupi, aa 3 vj. M. 5J qi^arta- l^^iue liora. This mixture is especially useful in cases where the emaciation is extreme, and the stools very frequent, non-fecal, and containing variously -colored mucus and blood. Mr. Aiken states that in a case in which he tried it, " the first dose of the nitrate seemed to increase the discharge. However, in about six hours the dejections improved ; they became more feculent, and every symptom under- went a corresponding improvement."^ When the prostration is great, with aphthous ulcerations of the mouth, the nitrate is often of much service. ' Rankiug's Abstract, vol. vi. 1S47. TREATMENT BY RAW MEAT. 83 It is in cases like the above where very slimy motions are passed with much straining and pain ; and where the lumps of coagulated bloody mucus found in the stools are compared by the attendants to " lumps of flesh," that the bichloride of mercury treatment is so valuable. One teaspoonful of a solution, containing a grain of the salt to half a pint of water, is given every hour or two hours. Very speedy success often follows this remedy. Injections of nitrate of silver are valuable in the latter stages, particularly if there are any signs of ulceration of the large intes- tine. The bowel should be first cleared out with warm water, and then an enema, containing one grain of the nitrate to five ounces of water should be administered. Trousseau recommends that in bad cases, it should be repeated twice in the twenty-four hours. These astringent enemata must not, however, be continued too long they should be suspended every two or three days in order to watch the effect, and in the interval enemata of simple starch may be used as recommended by MM. Eillet and Barthez. All this time the diet must be attended to, and all the other pre- cautions already recommended must be continued. The external applications, as before described, must also be made use of, em- ploying more and more decided counter-irritation as the weakness of the child increases, and his prostration becomes more marked. Stimulants will also be required as the child grows weaker, and must be given pretty freely when the sinking of the fontanelle and the other symptoms show that he is becoming exhausted. Five or ten drops of pale brandy, or double the quantity of dry pale sherry, may be given in milk three, four, six times a day, or even every hour, as required. Good beef gravy, free from fat, is also useful at these times. Not seldom, in spite of all our efforts, the child goes on from bad to worse. The diarrhoea resists all treatment, and continjies obstinate whatever be the measures adopted. In these cases the treatment by raw meat becomes a valuable resource. All food must be stopped, and the child must be nourished in the following way: A piece of raw mutton or rump-steak, free from gristle or fat, is finely minced, and is pounded in a mortar till it is converted into a pulp. The pulp is then strained through a fine sieve or a piece of muslin, to remove the bloodvessels and cellular tissue. Of the meat so prepared, a teaspoonful is given at regular intervals four times in the day, and every day the quantity administered is 81 CHRONIC DIARRHOEA. gradually increased, until half a pound is taken each day in divided doses. During this treatment no other food of any hind must he allowed, and no fluid but thin barley-water, or a drink made by mixing the unboiled whites of three eggs in a pint of water, sweetening it, and flavoring with a little orange-flower water. This diet usually causes the motions to have an intensely offensive smell ; but this is of no consequence, and the parents should be warned of its liability to occur. The patients them- selves often like this food, and take it eagerly. If, however, as may happen, they show any repugnance to it, the pulp may be sweetened with white sugar, or a little confection of roses may be added to make it more palatable, or it may be given in a small quantity of veal broth. As medicine, we must give at the same time the bismuth and chalk mixture, with the addition of one drop of tinct. opii to each dose. This mode of treatment is strongly recommended by Professor Trousseau, from whom the above method of preparation is derived. There can be no doubt about the value of this remedy. Under its influence the stools become less frequent and less liquid, and although they remain for a time horribly fetid, yet they gradually assume more and more the character of healthy evacuations, while the other symptoms un- dergo a like amendment. For the first day or two the meat will be found in the motions almost unchanged, except for decomposi- tion, the dejections consisting of colorless fibriue, with a little cellular tissue and mucus ; but by perseverance we find that it begins gradually to be digested, and less of it appears every day in the stools. When from this or other treatment the diarrhoea has been ar- rested, and the stools have become more healthy-looking, a tonic should be given, and the one best adapted to continue the im- provement is the solution of the pernitrate of iron, which has besides a beneficial influence upon the alimentary canal. It is best given with dilute nitric acid : — ■ K.. Liq. ferri pernitratis, ^ss ; Acidi nitrici diluti, 5ss ; Syrupi ziiigib., §j ; Aquaui Anethi, ad |iij. M. ^ij sextS, quaque hora. Other tonics may afterwards be given, as the decoction of bark with syrup, the citrate of iron and quinine, cod-liver oil, &c. If the oil be given, its effects must be carefully watched. It is best DANGER OF RICKETS. 85 to begin with a small dose, as ten drops, in a teaspoonful of milk three times in the day ; but if there be any smells of the oil in the stools, even this small quantity must be diminished. The consti- pation, which usually succeeds to the diarrhoea, should not be lightly interfered with. If two or three days have passed without any action of the bowels, a very small dose — about twenty drops — ■ of castor oil may be administered, and may be repeated, if neces- sary, after four or five hours. As so much harm is often done in these cases of chronic diar- rhoea by little indiscretions, it is of extreme importance that we should not allow improvement to make us relax in our attention or diminish our precautions. It is a good rule in all cases where the child is getting better to act as if he were getting worse, to redouble our vigilance rather than to relax in it, for at any time a chill or a fragment of indigestible food may undo all that has been done, and throw the child back into a state from which it has required perhaps weeks of unremitting care to deliver him. After the cessation of the diarrhoea the child must not, however, be kept too low. As his digestive power increases, his diet should be improved in proportion. This is very important, as rickets is not an uncommon result of the impairment of nutrition produced by the disease, and is therefore favored by anything which tends to prolong the weakly condition of the infant. CHAPTER III. CHRONIC VOMITING. Chronic Vomiting, its Symptoms and Tkeatment. — Frequency of slight attacks of gastric disturbance — Such attacks easily remedied — Chronic vomiting non- febrile — Symptoms, those of gradual interference with nutrition, ending in exhaustion — Spurious hydrocephalus. Causes. Diagnosis. — From tubercular meningitis — Diagnosis of spurious hydro- cephalus. Treatment. — Attention to diet — Return to breast — Substitute for wet-nurse — Warmth — External applications — Baths — Medicines — Bismuth and magnesia — Calomel — Dilute hydrocyanic acid — Enemata — Emetics — Rules for giving these — Stimulants. Slight attacks of vomiting, lasting for twenty-four bonrs, or even for several days, are not at all uncommon in infants even while at tbe breast. The matters ejected consist of the food, of stringy mucus, and of bile ; at the same time there is some beat of skin, thirst, loaded tongue, and constipation or diarrhoea. These attacks, unless aggravated by much meddling, always end favor- ably. The only treatment required is an emetic of ipecacuanha wine to relieve the stomach, followed by a gentle purge, and by careful regulation of the diet. Sometimes it is necessary to forbid even the breast-milk for a time, and to restrict the infant to cold thin barley-water given with a teaspoon. These attacks are of little consequence. The child may get a little flabby and pale, but when convalescent a week of ordinary feeding restores bim to his former state of health. Vomiting may, however, become chronic and persistent. It is then much more serious, and produces very great wasting and prostration. Symptoms. — There is no fever. Tbe child vomits at irregular intervals, tbrowing up the milk curdled and sour-smelling, and, at the first, tinged green or yellow from bile. The bile, however, soon disappears from the vomited matters, and clear fluid, like water, is ejected, alone or mixed with the food. On pressure of the epigastrium the child writhes as if in pain. The belly is full, SYMPTOMS. 87 often tympanitic, and gurgles wlien pressed upon. Eructations occur of fetid, sour gas, and the bowels are obstinately confined. An eruption of stropliulus often covers the body and arms. The child gets thinner and paler, and is very fretful. The fontanelle becomes depressed. Some diarrhoea may at first alternate with the constipation, but after a few days the bowels become again confined, and the motions, when they occur, consist of rough, hard lumps, very light-colored, evacuated with great straining. The lumps may be covered with tough mucus. The tongue is coated with a thick layer of dirty -yellow fur : it is not very moist, and dull-red papillae of medium size are seen peering through the fur, here and there, on the dorsum of the tongue. The breath smells sour. The lips are dry and red. A furrow passes down from each side of the nose to encircle the corner of the mouth, so that the lips seem to project. The mouth seems clammy and parched, and the child takes the breast eagerly to relieve this parched feeling by the flow of milk, but rejects what he has swallowed very shortly afterwards. After the child has remained in this state for a considerable time, often with occasional intervals of improvement for several months, the vomiting becomes more frequent. It occurs not only after taking food, but also in the intervals of feeding, and seems to be excited by the slightest movement, or by a touch, so that the mere act of wiping the mouth may bring on a fresh attack of retching. The milk is thrown up uncurdled. Emaciation then goes on rapidly. The skin is dry and harsh, and hangs loose and flaccid : the eyes get hollow ; the nose sharpened ; the cheeks sunken ; and the belly retracted. He lies with the knees drawn up on to the abdomen, and, when they are straightened out, returns them as soon as possible to their former position. Occasionally he moves his legs uneasily, as if in pain. He is intensely fretful, breaking out into sudden cries, or, as he becomes weaker, into a low, pitiful wail, which is even more distressing to hear, and never seems to sleep, night or day. The tongue is dry, and is still furred, so that it has a rough, granular appearance. At length the child is reduced to a state of extreme emaciation. The surface of the body is pale and cold ; the hands and feet become more or less purple ; and the temperature, as shown by a thermometer placed in the rectum, may sink as low as 97° Fahr. ; vomiting occurs at the slightest movement ; the child lies dozing or in a state of semi- 88 CHRONIC VOMITING. stupor, with eyes half closed, and the only sign of vitality is respi- ration. When thrush appears upon the inside of the cheeks and lips, it is a sign that the end is approaching, and he gradually sinks and dies, the constipation persisting to the last. Towards the end of the disease, symptoms which have been described as "spurious hydrocephalus" are often noticed. Dr. Gooch,^ in his valuable paper on this disorder, says, "It is chiefly indicated by heaviness of head and drowsiness; the age of the little patients whom I have seen in this state has been from a few months to two or three years ; they have been rather small of their age, and of delicate health, or they have been exposed to debili- tating causes. The physician finds the child lying on its nurse's lap, unable or unwilling to raise its head, half asleep, one moment opening its eyes, and the next closing them again with a remark- able expression of languor. The tongue is sliglitly white, the skin is not hot, at times the nurse remarks that it is colder than natural ; in some cases there is at times a slight and transient flush : the bowels I have always seen already disturbed by purgatives, so that I can scarcely say what they are when left to themselves : thus the state I am describing is marked by heaviness of the head and drowsiness, without any signs of pain, great languor, and a total absence of all active febrile symptoms." The symptoms thus described are not peculiar to chronic vomit- ing, although they are especially apt to occur with that disease. They may be found in all cases where great exhaustion is induced from whatever cause, and are therefore not uncommon in chronic diarrhoea. In all these cases the fontanelle is deeply depressed, showing deficiency in the amount of bood circulating through the brain; the pupils are often dilated and immovable, and there may be coma, with stertorous breathing. In cases of recovery the vomiting becomes less frequent, and gra- dually ceases, although for some time it is liable to recur if much food be taken at once. The constipation, however, remains obsti- nate for some time after the cessation of the vomiting. The child then begins to regain flesh, and often becomes exceedingly fat. Causes. — Most of the cases of this disorder which have come under the author's notice have b'cen in infants of a few months, old, > On Symptoms in Children erroneously attributed to Congestion of the Brain. New Sydenham Society, 1859. CAUSES — DIAGNOSIS. 89 and have usuall}' resulted from premature weaning, the child being taken from the breast and fed upon farinaceous or other articles of diet which he is unable to digest. It is not an uncommon com- plaint in infants whose mothers have obtained the situation of wet- uurse, and who are in consequence left to the care of ignorant and often careless attendants. The crowding of children together in close nurseries, or, amongst the poor, the stifling atmosphere of the one room in which a whole family is so often lodged, is another common cause of the disorder. These causes have already been fully discussed under the head of chronic diarrhoea. Severe operations upon the child, such as that for stone in the bladder, are often followed by an acid dyspepsia, which may lapse into obstinate vomiting ; a chronic catarrh of the stomach and bowels being set up, which may lead to death after the more im- mediate effects of the operation have been recovered from. Any cause, in fact, which lowers the easily depressed general strength will reduce also the digestive power, and thus predispose to this complaint. Diagnosis. — The combination of obstinate vomiting, with consti- pation, might give rise to the suspicion of tubercular meningitis, but the two diseases are readily distinguished. The age of the child, tubercular meningitis being exceedingly rare under twelve months; the temperature of the body, which is depressed instead of being elevated ; the sunken fontanelle ; the rapid, feeble, but regular pulse ; the state of the belly, swollen rather than retracted ; all tend to exclude the latter disease. Towards the end of the complaint, when the symptoms of spu- rious hydrocephalus are noticed, the history of the case, the cold- ness of the skin, the depressed fontanelle, and the state of the pulse, are all adverse to the idea of cerebral lesion, and point to the true nature of the complication, viz., a deficiency of blood circu- latino- throutrh the brain. Ireaiment. — ^Our first care must be to attend to the proper feed- ing of the child. If he has been prematurely weaned a wet nurse should be provided, and great care must be taken that the person selected should produce milk of a quality suited to the infant, for the milk of different nurses differs very much in quality. If, therefore, a return to the breast is not followed by the expected improvement, the nurse should be changed, or measures should be 90 CHRONIC VOMITING. taken to render the secretion better adapted to the infant. If, on examination, the milk appears to be deficient in fat globules, a more nourishing diet should be recommended ; if, on the other hand, it be too rich, the amount of meat must be restricted, and she should take fresh vegetables, with an occasional saline ape- rient. If these measures do not succeed, there should be no hesi- tation in changing the nurse if another can be procured. When the disease has continued a long time, and the child is much reduced, the mere act of sucking appears often to excite retching. In such cases the nurse's milk may be given with a tea- spoon. In all cases the child should take the breast at regular intervals, and should not be allowed to suck too long at one time; the amount of nourishment he is permitted to swallow being regu- lated, on each occasion, by the degree of irritability of the stom- ach, and by the result which has followed the previous meal. If that has been rejected, the quantity of milk allowed to be drawn at the next suckling must be diminished. In many cases a tea- spoonful of the breat-milk given at intervals of ten minutes, or even longer, is all that can be retained. Often, however, on the other hand, the stomach, which has rejected all other food, at once recognizes the change of diet, and the vomiting is speedily arrested by a return to the breast. If a wet-nurse cannot be obtained, ass's milk, or equal parts of cow's milk and lime-water must be given instead, beginning with very small quantities at the first. These can be gradually increased according to the readiness with which they are retained. In some cases, where milk alone, or with lime-water, is persistently vom- ited, Liebig's food prepared with milk and water (a teaspoonful of the food to four ounces of fluid), is kept down : in others, fresh whey with cream prepared as recommended on p. 48, is successful.' In these cases of obstinate vomiting it is an important point to remember that the food, whatever it may be, should be given either hot or cold; but not tepid, as liquid food given in a lukewarm state would be apt to favor a return of the vomiting. The infant should be warmly clothed, with a flannel bandage round the belly, and, while the vomiting is urgent, should be kept in a room comfortably warm, but not too hot. Fresh air should be freely admitted, and at night, if there is no fire, a lamp should ' See also Chap. XI. IMPORTANCE OF WARMTH. 91 be placed in the chimney. Great cleanliness should be maintained ; clothes and linen moistened with the vomited matters should not be allowed to remain in contact with the child's body, but should be at once removed from the room. The whole body should be well sponged with warm water twice a day. It is extremely important to keep the feet warm. Thick woollen socks should be supplied, and the feet should be occasionally well rubbed with the hand alone, or with a liniment composed of equal parts of linimentum camphorge co. and linimentum saponis. If they still continue cold, they may be placed in a mustard foot-bath, with water sufficient to cover the lower extremities as high as the knees. Warm applications to the epigastrium and belly are of great service; hot linseed-meal poultices, made more stimulating by the addition of a little mustard, should be applied to the pit of the stomach, and at times frictions may be used over the belly with the same embrocation as has been directed for the feet. If there is great prostration, the child may be placed for a few min- utes in a bath of the temperature of 90° Fahr., or the mustard bath may be used. All these applications are useful, not only as counter-irritants, but also as tending to promote the free action of the skin. With the same object, inunctions of olive oil may be made use of, the oil, well warmed, being smeared over the whole body once, twice, or oftener in the day, as already recommended (see Introduction). By this means, also, a considerable quantity of nourishment can be introduced into the system; it is a measure which should never be neglected when the vomiting is obstinate. "With regard to the medicines^ to be employed : — if the child is seen early, before the strength is much reduced, and there is a sour smell from the breath, with a thickly furred tongue, an emetic should be at once administered. A teaspoonful of ipecacuanha wine is the form in which this can be given. Afterwards, when the stomach has been emptied of the acrid secretions and mucus, a mixture containing bismuth with magnesia should be ordered : — ^. Bismuthi alb., gr. xvj ; Magnes. carb., ^ij ; Tinct. myrrhae, gss ; Syrupi, Mucilag. tragacanth., aa 533 ; Aquam, ad §ij. M. 5J ^^^ ^'^^' ' All the prescriptions given in this chapter are adapted to an infant of six months old. 92 CHRONIC VOMITING. The bowels, which are usually confined, should be excited to act by an enema. For a child of six months old, a small teacupful of ■warm barley-water, containing a tablespoonful of olive oil, may be injected into the bowel, or ten grains of powdered socotrine aloes dissolved in the same quantity of barley-water, or of boiled milk, may be used. The action of the bowels must be maintained either by enemata, by suppositories of castile soap, or by purga- tives given by the mouth. The latter method is inapplicable as long as tbe vomiting continues incessant ; but when this becomes less frequent, a grain of calomel may be placed on the tongue, or a mixture containing ten to twenty drops of tinct. aloes may be given two or three times in the day. The tincture of aloes is strongly recommended by Dr. Davies^ in these cases, combined with a few drops of sal volatile. If the vomiting continues unabated, small quantities of calomel may be given ; a sixth of a grain being laid on the tongue ever}' four hours. The effect of this medicine is sometimes very striking; as the nurses say, " it acts like a charm." Should this, however, not succeed, small doses of dilute hydrocyanic acid may be given with nitre, as in the following mixture. Nitre is a powerful seda- tive to the stomach : — I^. Acidi hydrocyanici diluti, 11^ vj ; Potas. nitratis, 5j ! Syrupi, 5SS ; Aquffi, §js3. M. 5J ter die. And if, in spite of this, the irritability of the stomach remains undiminished, half a drop of tinct. opii may be added to each dose of the mixture. One-drop doses of vinum ipecacuanhse, or of liq. arsenicalis, will often succeed in arresting the vomiting even in very obstinate cases, and after all other treatment has proved ineflfectual. Thus, one dro]5 of ipecacuanha wine may be given in a teaspoonful of water every two or three hours, or even every hour, according to the urgency of the case. The following case illustrates the influence of this remedy, com- bined with altered diet, in checking vomiting of long standing: — "Jessie W — , aged six months, has been brought up by hand from her birth. Has been gradually wasting for four months. ' See Underwood's Treatise on Diseases of Children, p. 227. INTERNAL REMEDIES. 93 She vomits all food, although different diets have been adopted, and is now excessively emaciated. Feet always cold. Belly rather full and tense. Fontanelle large and rather elevated, but not tense. Veins of side of head rather full. Complexion earthy. Breath smells sour. Tongue rather dry and granular looking from projecting papillte. Motions yellowish and hard. " Ordered. Diet : Equal parts of new milk and lime-water, to be given in small quantities at regular intervals. I^. Vin. ipecaciiauhse, TTj^xvj ; Aq. meuth. pip., AqucB, aa §j M. gj tertia liorS,. " A teaspoonful of cod-liver oil to be rubbed into belly every night. "A flannel bandage to be applied to the belly, and the feet to be kept perfectly warm. " By these means the vomiting was stopped at once. After a few days, the complexion cleared, the earthy tint disappearing, and the child began to regain flesh. The mixture was then changed to— ^. Ferri et ammoii. citratis, gss ; Potass, bicarb., 5Jss ; Tr. opii, H\,viij ; Aquani, ad 3ij. M. 3J ter die." If the vinum ipecacuanhas do not succeed, one-drop doses of liq. arsenicalis may be tried, given in a teaspoonful of water three times a day. The same remedy should not be continued too long at a time, if no improvement be seen to follow its employment. Our greatest trust should be placed in warmth, in stimulation of the suri'ace, and in promoting free action of the bowels. When the fontanelle becomes much depressed, stimulants are always indicated ; and of these pale brandy, given in five-drop doses, in a teaspoonful of breast-milk, or of the milk and lime-water, seems to answer the best. When the prostration is great the stimulant may be re- peated every hour, or even oftener. With regard to a repetition of the emetic, a few words may be said. An emetic is only required when there is reason to suspect the presence of acrid secretions in the stomach. If, however, the tongue is tolerably clean, and there is no sour smell from the breath, an emetic is no longer indicated, and its employment would 94 CHRONIC VOMITIXG, only increase the prostration. Yoraiting is sometimes kept up by debility of the stomach, and this would be only increased by the exhibition of nauseating remedies. When the prostration, as shown by the condition of the fontanelle, is very great, much caution should be exercised in giving emetics, as fatal syncope is some- times seen in such cases to follow their employment, and if the fontanelle is deeply depressed they should on no account be made use of. If the vomiting continue after the tongue has become clean, stimulants should at once be given, and the following are very useful : — ;^. Sp. ammon. aromat., Sp. chloroformi, aa gss ; Ext. glycyrrhizae, 9ij ; Decocti cinchonse, 5ij. M. 3j ter die. IJl. Acidi nitrici diluti, Sp. aether, nitrosi, aa 3ss ; Tinet. myrrhse, 3j ; Syrapi ziugib., §3S ; Aquam carui, ad ^ij. M. gj quartl. quaque borS,. Either of these may be used, and should be continued for some time after the vomiting has ceased. As the child improves he may be taken out of doors, if the weather is not too cold,' for a free supply of fresh air is a most im- portant agent in the treatment of this as of all the other chronic diseases of children. The symptoms which have been described as "spurious hydro- cephalus" show a very dangerous degree of prostration, and must be treated with stimulants. CHAPTER IV. RICKETS. Rickets. — Preliminary symptoms those of general malnutrition — Symptoms of commencement — Deformities of bones — Enlargement of ends of bones — Soften- ing — Thickening of flat bones — Mechanical deformities — Bones of head and face — Distinction between the rickety and hydrocephalic skull — Cranio-tabes — Dentition — Spine — Thorax — Deformities of long bones and of pelvis — Ar- rest of growth of bones — Articulations — Relaxation of ligaments — Other symptoms — Enlargement of liver and spleen — Intellect — Complications — Catarrh and bronchitis — Diarrhoea — Laryngismus stridulus — Convulsions — Chronic hydrocephalus — Death from intensity of general disease. Patliology. — Rickets a general disease — Anatomical characters of bony changes — KoUiker's views — Virchow's views — Analysis of rickety bone — Emphysema and collapse — Alterations in lymphatic glands — In spleen — Liver — In other organs — Urine. Diagnosis. Prognosis. — Importance of complications. Causes. — Rickets not a diathetic disease — Bad feeding and hygiene — Connection between rickets and syphilis. Prevention. Treatment. — Diet — Dry bracing air — Attention to digestive organs — Tonics — Value of mechanical supports — Treatment of complications — Catarrh Diarrhoea — Bronchitis — Laryngismus stridulus. Rickets, although one of the most preventable of children's diseases, is yet one of the most common. It begins insidiously, presenting at first merely the ordinary symptoms of defective assimilations, and attention is often not attracted to it until the characteristic changes occur in the bones which place the existence of the disease beyond a doubt. Many of the symptoms described under the head of simple atrophy, constitute a preliminary stage of rickets. They are not, as has been said, characteristic of this special disease, but merely mark the process of gradual reduction of strength, and of inter- ference with the assimilative functions, which must take place to a certain degree before the disease can be established. This pre- liminary stage is not, however, always present. Rickets is the result of malnutrition : any disease, therefore, which seriously 96 RICKETS. interferes with the assimilative power, and causes sufficient im- pairment of the general strength, may be followed directly by the disorder under consideration, without any intervening stage. Re- duce the strength to a given point, and rickets begins. Prolong this state of debility sufficiently, and the characteristic changes resulting from the disease manifest themselves. Any cause, there- fore, which will reduce the strength to this point lays the founda- tion of rickets. Symptoms. — The commencement of the disease is indicated by the following symptoms : — Profuse sweating of the head, or of the head, neck, and upper part of the chest. The perspiration is extreme : it will be seen standing in large drops upon the forehead, and often runs down the face. There is increased moisture of the parts usually in the day as well as at night; but if the child falls asleep, it is instantly augmented, and at night is sufficient to make the pillow wet. AVhen awake, the slightest exertion or elevation of the temperature excites it at once. At the same time, the superficial veins of the forehead are large and full, the jugular veins are distended, and the carotid arteries may sometimes be felt strongly pulsating. The irritation excited by this constant perspiration will often give rise to a crop of miliaria about the temples, the upper part of the forehead close to the roots of the hair, and at the back of the neck. While the head and neck are thus batned in perspiration the abdomen and lower limbs are usually dry and hot. Another characteristic symptom is the desire of the child to lie cool at night. In the coldest weather he will kick off the bed- clothes, or throw his naked legs outside the counterpane. The mother often notices this as one of the earliest symptoms, and will say that she has been obliged to wrap her child up in flannel to prevent his catching cold, as he will not remain covered by the bed-clothes. These two symptoms precede the deformities of the osseous structure ; but there is another symptom which appears later, and marks the commencement of morbid changes in tiie bones. It is, however, frequently absent in mild cases. This symptom is gene- ral tenderness. The child at first shows signs of uneasiness when danced up and down in the arms of his mother. As the tender- ness increases, he becomes peevish at being touched, and prefers sitting quietly in his little chair, or lying down in his cot, for all GENERAL TENDERNESS. 97 voluntary movements increase the pain. Eventually, as the dis- ease progresses, he lies motionless in his bed, and cries violently even at the approach of persons who have been accustomed to play with him. This conduct, so different from that of a healthy child, who delights in all movement, is highly characteristic. These special symptoms are accompanied by all the other phe- nomena which preceded the commencement of the disease. The bowels remain confined, or are more or less capricious, a day or two of relaxation being followed by an equal period of constipa- tion. More often, however, there are three or four evacuations in the course of the twenty-four hours, accompanied by considerable straining. The stools consist of whitish, curdy-looking matter, mixed with mucus, and are extremely offensive. The food taken seems to pass almost unchanged through the alimentary canal, being, no doubt, forced too rapidly along from abnormal exalta- tion of the peristaltic action of the bowels, so that sufficient time is not allowed for digestion. The urine becomes more abundant, and deposits a calcareous sediment, or abounds in phosphates. There is usually some thirst; but the appetite is often voracious, so that the child very shortly after a meal will show a disposition to eat again. This is what we constantly meet with in cases of dyspepsia in the adult, where the peristaltic action of the intestines is unnaturally brisk. The child soon loses his power of walking, and sits, or lies about. He becomes dull and languid, and neglects his playthings. There is usually some emaciation; but if the symptoms are not severe at the first, he may be plump in appear- ance, although his flesh feels soft and flabby. In the daytime he is drowsy, but at night is restless, turning his head uneasily from side to side on the pillow. The symptoms proper to rickets very seldom appear before the fourth month, and not commonly before the seventh or eighth. From his own experience the author would say that the disease manifests itself most frequently between the seventh and eighteenth months, less frequently between the eighteenth month and the end of the second year, and rarely after the end of the second year. Still, we may find it commencing at a later period ; and Sir Wil- liam Jenner mentions the case of a girl, aged nine years, who- was then only just beginning to suffer. The deformities of the bones usually begin at the time when general tenderness is first complained of The osseous system is 7 98 RICKETS. attacked as a whole, and therefore all the bones in the body seem to suffer at the same time. Sir William Jenner,^ in his Lectures on Eickets, thus enumerates the most constant changes which are found to occur in them. "Enlargement of the ends of the long bones, of the parts where the bone and cartilage are in contact, i. e., where the cartilage is preparing for ossification, and where ossification is advancing in the cartilage. " Softening of all the bones. " Thickening of the flat bones, e. g., the bones of the skull ; the scapula ; the pelvis. " Deformities which follow from mechanical causes acting on the softened bones, e. g., the deformities of the thorax, pelvis, spine, long bones." In a well-marked case of the disease we find all these changes ; but very commonly many of them are absent. Even when present thev do not always occur to an equal degree : sometimes the soften- ing of the bones is more marked than their enlargement; at others the enlargement is out of proportion to the softening, M. Gueriu- has stated — he has even laid it down as an absolute rule — that the deformities of the bones begin from below upwards, that the tibiae become affected before the thigh bones, the thigh bones before the pelvis, and so on to the arms and head. This, however, is not correct. In some cases we certainly find the legs and thighs bowed earlier than the other parts, but it is in children who have walked, or can still walk ; and in them the weight of the body determines the deformities of the lower limbs before the pressure upon the other bones has been sufficient to make them crooked. Besides, if a very heavy child be put on his legs at too early an age, the tibia3 may bend a little, although there is no reason to suspect the child of being the subject of rickets. The changes in the different bones will now be described. Bones of the head and face. — The skull is larger than it ought to be, and is of a peculiar shape. Its antero-posterior diameter is increased ; the fontanelle remains open — often widely open — long after the end of the second year, the ordinary period of its closing ; the thickening of the bones is most marked at the centres of the ' Medical Times and Gazette, March 17, 1860. 2 Memoiie sur le Rachitis. Paris, 1857. MORBID CHANGES IX BONE. 99 parietal bones, the bosses of the temporal bones, and at tlie edges of the bones outside the sutures, so that the situation of the sutures is indicated by deep furrows ; the vertex is flattened, and the sutures are expanded or remain open. The forehead is high, square, and projecting, and is out of proportion to the face. This disproportion is exaggerated by the arrest of growth of the bones of the face, particularly of the bones of the upper jaw and the malar bones; therefore, while the forehead is larger, the face is smaller than natural. The projection of the forehead is due partly to thickening of the frontal bone, partly to expansion of the frontal and ethmoidal sinuses, but principally, according to Sir W. Jenner, to disease of the cerebrum. The under jaw appears rather elon- gated. It is important to distinguish between the rickety enlargement of the skull, and the expansion which takes place in hydrocephalus. In hydrocephalus there is greater disproportion between the skull and the face ; the enlargement is more globular and regular, the antero-posterior diameter not being greater than the lateral ; the bones of the skull do not give to the finger the sensation of being thickened ; the fontanelle is more open, and if the accumulation of fluid be great, the bones at the sutures are more widely separated; the sutures themselves are not bounded by a ridge of thickened bone. The fontanelle in hydrocephalus is elevated ; in rickets it is depressed, partly on account of the debility, partly on account of thickening of the bones which form its boundaries. In rickets we find other well-marked symptoms showing the nature of the disease. The two diseases are, however, occasionally combined, and the diagnosis may be thus rendered difficult ; but so long as the fontanelle remains depressed, we may positively exclude hydrocephalus. A curious condition of the skull, known as cranio-tabes, is some- times found. This was first detected by Elsasser,^ and has been carefully described by Dr. Alfred VogeV of Munich. On using gentle pressure with the tips of the fingers on all the posterior sur- face of the head, spots can be sometimes detected where the bone is thinned. The bone at these spots is elastic, feels '" like cartridge paper," and presents a concavity, or depression, which varies in 1 Der weiclie Hinterkopf. Stuttgart, 1843. 2 Lelirbucli der Kinderkranklieiteu, von Dr. Alfred Vogel. Erlaugeu, 1863. 100 RICKETS. size according to the extent of the thinning. The usual size of these depressions varies from a linseed to a bean ; but, according to Dr. Vogel, one whose size does not exceed a line in diameter can be detected by the practised finger. These local losses of substance are confined to the occipital bone, of which any par.t may be affected except the protuberances. The frontal and parietal bones are, however, greatly thickened, often to double their natural depth. This cranio-tabes is said by Dr. Yogel to be one of the earliest signs of rickets, preceding the beading of the ribs. It is seldom found before the third month, or after the second year. The progress of dentition is arrested. If the disease makes its appearance before any of the teeth are cut, their evolution may be . almost indefinitely postponed. If some teeth have already ap- peared, the further progress of dentition is interrupted. This influ- ence over the teeth is peculiar to rickets. In no other disease, in which general nutrition is affected, do we find any interference with the natural course of dentition. In a child greatly wasted by chronic diarrhoea, or improper food, the development of the teeth does not seem to be hindered by causes which exercise so powerful an influence upon his general health ; and in tubercu- losis and congenital syphilis the teeth are usually cut early. Teeth which have already appeared speedily become black, decay, and drop early from their sockets. This is due, according to Dr. Vogel, to insufiicient development of the dental enamel. It is not at all uncommon to see a rickety child of eighteen months or two years old with very few teeth as yet in his head, and those few black and carious. In some rare cases, however, we find dentition unaffected, and even particularly forward, although the other symptoms of rickets are well marked. Thus, " Herbert K. cut his first tooth when five months old, and at the age of one year and nine months dentition was completed. He could not stand until his seventeenth month, and, when a year and a half old, could not walk without assistance. It was only just before cutting his last tooth that he was able to walk alone. When seen, he was aged two years and nine months, a pale and rather weakly-looking boy ; wrists large ; tibia3 bowed; the teeth, however, were perfect and particularly sound." Tlie spine is bent, but the curvature is only strongly marked when the muscular debility is very decided. The direction of the DEFORMITIES OF THE THORAX. 101 curve varies according to whether the child can or cannot walk. If the child cannot walk, the cervical anterior curve is increased, and there is a posterior curve reaching from the first dorsal to the last lumbar vertebra. This is an exaggeration of the ordinary curve which exists when a child sits unsupported on the arm of his nurse. If the muscular debility is very great, the curvature may be so pronounced as to be mistaken for angular curvature. It is, however, readily distinguished by holding a child up, sup- porting him with the hands under the arms : the weight of the body will then usually straighten the spine at once, particularly if gentle pressure is at the same time made on the projecting part. If the child is able to walk, the dorsal spine is curved back- wards, the lumbar forward. As a consequence of the cervical curve, and the accompanying weakness of the muscles, the head is no longer efficiently sup- ported; it therefore falls back, and the child usually favors this falling back, in order that he may see what is going on around him. Lateral curvatures are occasionally seen, but they are far less common than the antero-posterior. Their direction is determined by the position assumed by the child. If it is carried constantly on the left arm, there is lateral curvature, with convexity to the left; if on the right arm, the convexity is to the right. The thorax is curiously deformed. Flattened behind, projecting sharply in front, it presents an appearance which Glisson^ compares to the prow of a ship, and which forms the condition commonly known as "pigeon-breasted." The ribs, as they leave the spine, are directed at first almost horizontally outwards, then bend sharply at an acute angle at the junction of the dorsal and lateral regions, and from that point pass forwards and inwards to unite with their cartilages. The cartilages curve outwards before turning in to their articulations with the sternum, so that the breast-bone is forced forwards, and the antero-posterior diameter of the chest is unnaturally increased. The lateral diameter is greatest opposite the acute angle formed by the ribs; least, at the points of junction of the ribs with their cartilages. This curving inwards of the ribs, and outwards of their cartilages, forms a groove on the antero-lateral ' De Rachitide, sive Morbo Puerili. F. Glissoii, edit, tertia. Lugdanum Bata- vorum, 1671. 102 EICKETS. face of the chest, which reaches from the ninth or tenth rib below, to the third, second, or even first rib above, and the groove is deepest just outside the nodules formed by the enlarged ends of the ribs. The groove varies on the two sides in length and in depth, for the liver and the heart support to a certain extent the ribs under which they lie. Thus the groove reaches downwards to a less distance on the right side than on the left, on account of the liver ; and at the level of the fourth and fifth ribs it is shallower on the left side than on the right, on account of the heart. The enlargement of the ends of the ribs gives a peculiar appearance to the surface of the chest ; a line of nodules is seen, looking like a row of large beads under the skin, lying along the inner side of the groove. Below the sixth rib the chest widens, as the walls are forced outwards by the underlying liver, stomach, and spleen. If we strip a rickety child and watch his breathing, we see that in inspiration there is sinking in of the chest walls. The lateral depressions deepen; the sternum moves forwards; the abdomen expands ; and a deep horizontal groove furrows the surface, divid- ing the chest from the belly, and marking the upper borders of the abdominal viscera. This recession of the chest walls shows the mechanism by which the deformity is produced. In the healthy subject, when the diaphragm contracts, and the ribs are elevated in the act of inspiration, air rushes in through the glottis to expand the lungs, and to enable them to follow and remain in contact with the expanding chest walls. The atmospheric pressure is, therefore, overcome by the power of the osseous and muscular walls, aided by the pressure of the inspired air. In the rickety child, however, one of these agents is comparatively powerless. The softened ribs can afford little assistance to the air within the chest in counter- balancing the pressure outside : they therefore sink in at their least supported parts, and produce the lateral furrows which have been described, while at the same time the sternum is carried forwards in proportion to the recession of the ribs. Sir William Jenner denies the truth of Eokitansky's statement that want of power in the inspiratory muscles is the cause of the deformity. Repeated dissections have conclusively proved to him that the points of insertion of the muscles of respiration, and the points of recession of the chest walls, have no correspondence whatever. He also denies the influence of the diaphragm in pro- ducing the circular or horizontal depression described above. That CAUSE OF THE DISTORTION OF LONG BONES. 103 depression corresponds, not to the points of attachn^.ent of the diaphragm, but to the upper borders of the liver, stomach, and spleen, which thus support the parietes, and prevent their sinking in under the pressure of the air. A similar cause produces an apparent bulging of the pra3Cordial region during inspiration, for the heart supports the ribs behind which it lies, and prevents their receding to the same extent as the walls around. The thoracic deformity is sometimes seen to lessen at the time the legs are bending. This seems to be due to the disease having diminished, and the muscular power having increased sufficiently to allow of the child walking before the bones of the legs are strong enough to bear the weight of the body. The c?«u/c7e is also distorted. There are two great curves: the principal one, forwards and rather upwards, is situated just outside the points of attachment of the sterno-mastoid and pectoral muscles. The second, backwards, is about half an inch from the scapular articulation. The hnnierus is sometimes curved just where the deltoid muscle is inserted. The radius and ulna are curved outwards, and also twisted. These deformities are ascribed by most authors to muscular action, aided by the weight of the limb. Sir "W, Jenner, how- ever, excludes altogether the first-mentioned cause from any share in the production of these distortions. They are due, he says, to the habit practised by all rickety children, owing to their deficiency in muscular power, of supporting the body, while sitting, upon the'open hands placed upon the bed or floor. The weight of the trunk is therefore, in a great measure, thrown upon the arms, and we see in consequence the deformities of the clavicle, the humerus, and the bones of the forearm, which have been described. The curvature of the humerus is also aided by the weight of the forearm and hand when the limb is raised by the action of the deltoid. The weight of the arm on the humeral end of the clavi- cle — the sternal end being supported by its muscles and ligaments — will also assist in producing the disfigurement of the collar-bone. The scapula is very much thickened, and is said occasionally to be so deformed as to interfere with free motion of the shoulder- joint. ^he pelvis varies greatly in shape, but is more often triangular than oval. Pressure may be brought to bear upon it in many dif- 10-i RICKETS. ferent directions : thus it is pressed upon from above by the weight of the spine and the contents of the abdomen ; from below by the heads of the thigh bones. The exact direction in which these compressing forces will act varies, firstly, according to the position of the child — lying, sitting, standing, or walking; and secondly, according to the age at which the disease comes on, and therefore according to the degree of ossification of the bones, for the carti- lages are less yielding than the bones themselves. The distortion of the pelvis thus produced is often very remarkable. In a child of four and a-half years old.Mn whom lithotomy was performed by Sir Henry Thompson, at University College Hospital, the outlet of the pelvis was so contracted as barely to allow a stone, measuring IJ in. in length, I in. in breadth, and f in. in thickness, to pass through in its long axis. The child died shortly after the operation from peritonitis, and on examination of the pelvis, the brim was found to be exceedingly contracted. Its shape was obliquely caudate : the sacral promontory was distant | in. from the left pubic ramus, | in. from the pubic ramus of the right side, and I in. from the symphysis of the pubes. Beside the softening of the bones there is, however, another cause which assists to produce a diminished capacity of the pelvis, as will be afterwards explained. The f emu 7' is curved forwards if the child cannot walk. If he can walk it is curved forwards and outwards, being an exaggera- tion of the natural curve. Sometimes the head of the femur is seen bent at an acute or an obtuse angle to the shaft. The tibia, before the child walks, is curved outwards, and the knees are then seen, as the child is held upright, to be widely separated from one another. After the child walks, the weight of the body determines the bending. In these cases the distortion is seen principally at the lower third, and the curve is very abrupt, seeming to project over the foot; or the bend may be outwards, projecting over the outer ankle. In these cases, also, the deformity can be explained otherwise than by the influence of muscular action. While the child sits in his mother's lap the weight of the legs and feet, pulling upon the lower end of the femur, produces the forward curvature of that ' An account of this case will be found in the Medical Times and Gazette for December 5, 18tj3. INTENSITY OF THE DISEASE. 105 l3one. As the child sits cross-legged on the floor or bed the pressure on the external malleolus causes the normal curve of the tibia to be exaggerated. The changes in the bones thus described may take place to any degree. Some may be more marked, others less, according to the severity of the disease, the age of the child, and the time at which treatment is commenced. If the premonitory symptoms have been very mild, tenderness may be altogether absent, and the afifection of the bones be limited — at any rate, at first — to beading of the ribs, enlargement of the wrists and ankles, retardation of dentition, and abnormal openness of the fontanelle. The child, if able to walk, is still pretty strong on his legs ; he is lively, often plump, and does not appear to suffer much from the disease under which he is laboring. If treatment is at once had recourse to, nutrition is restored, growth and development recommence, and health quickly returns. On the other hand, if the general symptoms which precede the attack have been very severe, ^. e., if the de- bility resulting from the deficient nutrition is very great, the ten- derness of the bones is a well-marked symptom, the softening will usually precede, and be out of proportion to, the enlargement of the ends of the bones, and all the distortions which have been described will be the result. Again, the older the child when rickets first appears the less likely is he to be affected early by softening of the bones, while if the child is very young, the bones usually soften very quickly. This, however, is perhaps merely a consequence of what has just been stated, for the younger the child the more likely is his sys- tem to be profoundly affected by malnutrition, and therefore the more severe will be the consequences of that malnutrition. Besides the softening of the bones, and the deformities which result from it, there is another effect of the disease which is not less remarkable. This effect is the arrest of growth of the bones.^ The arrest is seen not only while the disease is still in progress, but it even continues after apparent restoration to health. In a rickety skeleton all the bones are found to be stunted in growth, and this combined with the bending of the lower limbs, which must necessarily detract from the height of the individual, is the ' See two papers, by Mr. Shaw, published iu the Transactions of the Mecl.-Chir. Society, vols. xvii. and xxvi. 106 ^ RICKETS. cause of the short stature of persons who, when young, have been subject to this disease. The arrest of growth affects some bones more than others, being principally noticeable in the bones of the face, of the lower limbs, and of the pelvis. As it affects the pel- vis the want of growth is very important from its influence upon child-bearing in after life. In the child the size of the pelvis and lower limbs is small in proportion to the rest of the body ; in the adult female it has so increased as to be relatively larger than the other parts of the bony framework. If then the growth and deve- lopment of the pelvis are arrested, its brim and outlet do not undergo the usual expansion, but remain small and contracted, retaining the characters of the infantile pelvis. The obstacle to the passage of the foetal head, under such circumstances, becomes extreme, especially if conjoined with deformities produced by softened bone, and usually requires craniotomy or embryotomy before the child can be extracted. This condition of the pelvis may also interfere with operations upon the child, as in the case of litho- tomy already referred to. According to Mr. Shaw, there is a cor- respondence between the degree to which the pelvis suffers from this arrest of growth and development, and the degree to which the lower limbs suffer from the same causes"; we can therefore by observing the amount of stunting of the lower limbs make some estimate of the extent to which the pelvis is likely to be modified in size and capacity. The articulations. — As the ends of the long bones are enlarged the joints into which these bones enter must necessarily be en- larged also. They have therefore a knotted, bulbous look, an appearance which is aggravated by the atrophy of the muscles of the limb. In addition to this the ligaments which hold the bones together are relaxed : the joints are therefore loose and unsteady, and can be moved freely in directions which, in a healthy state, would be impossible. This looseness and mobility of the joints forms alone a great impediment to walking, even should the bones themselves be healthy, and in fact the relaxation of the liga- ments does not always bear a due proportion to the osseous changes. It is often an early symptom, and we frequently see it carried to a high degree in cases where the disease in the bones is as yet comparatively trifling. In these cases, if we hold the child upright, so that the weight of the body rests upon the feet, we see that each lower limb forms an obtuse am^le at the knee ; the knees MOBILITY OF THE JOINTS. 107 touch; the legs are directed outwards; and the foot is more or less everted from relaxation of the ligaments of the ankle. In children in whom the disease appears at, or after, the end of the second year, this weakness in the joints is a very prominent symptom, and is often found where the limbs are perfectly straight and well formed. The following case illustrates this peculiarity. It is interesting besides as an example of rickets occurring as a sequel of inherited syphilis. "Frederick W., aged two years "and a half. Nineteen teeth. Began to snuffle soon after birth. Was vaccinated at the age of thirteen weeks, and an eruption then appeared all over body except chest; spots also were seen surrounding the anus. This has continued off and on till within the last three months. At seven months two lower incisors appeared. Could not walk before the age of thirteen months and a half. Child very auEemic look- ing ; striking pallor of face : very light flaxen hair. Tongue covered with a thinnish coating of white fur ; red, round, medium- sized papillae scattered all over dorsum. Bowels usually confined ; motions offensive. Strains often at stool. Does not sweat about head, but used to do so till very lately. Throws off bed-clothes at night. Does not care about playing; prefers to sit quietly. Head large : antero-posterior diameter very long. Fontanelle the size of a threepenny bit. When stripped the body generally is seen to be exceedingly pale. Child in tolerably good condition : totters as he wallvs. ISTo enlargement of ends of bones ; limbs straight ; joints relaxed, knees loose, and ankles yield under the weight of the body. Ends of ribs not visible to the eye, but can be felt to be nodular. Chest not deformed. No spots on skin, but a scar of old ulcer by the side of anus. Spleen not enlarged." All joints in the body are sharers in this ligamentous weakness, for it is not confined to the articulations of the limbs. The fibrous bands which connect the vertebrae with each other and with the sacrum, the sacrum with the pelvis, are alike affected ; and it is a conjunction of all these various lesions, combined with the soften- ing of the bones, and the weakness of the muscles, which produces the inability to walk, and the difficulty of holding the body upright, which are so characteristic of the disease. The general symptoms continue while these changes are going on. The perspiration is profuse, and the tenderness increases in 108 RICKETS. proportion to the softening of the bones. The appetite may re- main rav^enous, but more oftener it diminishes, and the child shows a disgust for food, or only exhibits a craving for beer, and the more tasty articles of diet. Sickness frequently occurs at this time, for attacks of gastric derangement often complicate the disease, and aggravate it. In these cases there is a sour smell from the breath, the vomited matters are acid, the bowels either become constipated, or there is diarrhoea with green, slimy, offensive stools, showing the participation of the intestinal mucous tract in the derange- ment. The emaciation increases ; the fat disappears, and the muscles get more and more flabby and wasted. The loss of power in the muscles is, however, greater than can be accounted for by the wasting; and if the disease be severe, the child may be incapable of supporting himself in the slightest degree. The face gets old-looking ; the eyes are large and staring, but somewhat deficient in speculation ; and the general expression is placid, although rather languid. The respiration is quick and laborious, and if there be much softening of the ribs, and conse- quent recession of the chest walls, the child's whole faculties appear to be concentrated upon the performance of the respiratory act. Such a child will give little trouble to his attendants ; in fact, the little creature has no breath to spare for idle lamentations, and cannot afford to cry. The abdomen is very large, and often appears enormously dis- tended when compared with the narrowed and distorted chest. This enlargement of the belly is due to depression of the dia- phragm and diminished capacity of the thorax, which force down the liver and spleen below the level of the ribs ; to increased shallowness of the pelvis; to the flabby condition of the abdom- inal muscles favoring the accumulation of flatus generated b_y the digestive derangement ; and in some cases to actual increase in size of the liver and spleen. The enlargement of the liver and spleen, when it occurs, is usu- ally combined with enlargement and induration of the lymphatic glands all over the body. The superficial glands may be felt in the groins, the armpits, and the sides of the neck, as hard round freely movable bodies, varying in size from a pin's head to a sweet-pea. The size of the spleen may be greatly increased : the liver, however, is seldom much enlarge 1, but its edges are harder INTELLECT — COMPLICATIONS. 109 and sharper than in health. There is at the same time extreme emaciation and anaemia, with often a little anasarca, so that the child has the peculiar " waxy, greenish-yellow tint which is some- times seen in the anoemia of young women," ^ The oedema is sometimes general and decided ; but there is never any increase in the white corpuscles of the blood. With regard to the intellect most writers have declared that it is precocious. Sir W. Jenner, however, opposes this view. " Chil- dren, the subjects of extreme rickets, are almost always deficient in intellectual capacity and power. They are not idiots ; they show no signs of idiocy ; they resemble rather children of low intellectual capacity and power much younger than themselves." He explains the source of the error by the fact, that rickety children separated in consequence of their physical defects from other children, are necessarily thrown very much into the society of adults, and therefore catch "their tricks of expression, their phrases, and even some, perhaps, of their ideas." These children are also very late in talking. They appear to be incapable of picking up new words with the I'eadiness exhibited by healthy children of ordinary cleverness. Apart from all the physical changes produced by the disease, the behavior of a rickety child is very characteristic, and is of itself almost sufficient to warrant a diagnosis. The quiet, the repose about him, strike the observer at once. Such a child, if able to support himself, will sit for hours, his legs stretched out straight before him on the floor, perfectly contented if only allowed to remain unnoticed. All that he wants is to be let alone. A healthy child delights in movements ; a rickety child is only happy when at rest ; his greatest pleasure consists in inaction. To look at him we are irresistibly reminded of the other term of life, for he appears to have anticipated at least one consequence of the weight of years, and to have combined the patient endurance of old age with the face and figure of a child. Complications. — The state of extreme debility to which a child suffering from advanced rickets is reduced naturally favors the occurrence of secondary diseases in general ; and it is usually to one of these that death is to be directly attributed, although, in some cases, the intensity of the general disease may be of itself ' Jenner, Medical Times and Gazette, May 12, 1860, p. 465. 110 RICKETS. sufficient to carry off the patient. Measles, whooping-cough, and scarlatina are very liable to occur, and to prove fatal ; but there are certain other diseases which are especially predisposed to by rickets, viz : — Catarrh and bronchitis. Diarrhoea. Laryngismus stridulus. Convulsions. Chronic hydrocephalus. To catarrh and bronchitis are due a very large proportion of the deaths in this disease, and Sir W. Jenner explains very fully the cause of this great mortality. At all ages bronchitis is an extremely fatal disease. The mucus which is thrown into the tubes impedes the entrance of air; but unless air can enter freely into the vesicular structure of the lung, mucus cannot be expelled. In coughing to expel the mucus, the lung must be filled with air to the utmost; the contained air is then prevented from escaping by closure of the glottis, and at the same time pressure is brought to bear upon the lungs by the muscles of expiration. The glottis is then suddenly opened, and the air is driven out, carrying with it the mucus which obstructed the tubes. The forced respiration seen in persons suffering from bronchitis is merely the effort made to draw in the air past the obstructing mucus. A second impediment to the entrance of air into the lung is found also in the healthy child. It arises from the natural flexibility of the lower part of the thoracic parietes, which yield to a certain extent in inspiration before the pressure of the external air. In advanced rickets, however, this natural flexibility is greatly increased by the abnormal softening of the ribs, so that even when the lungs are healthy each inspiration is only effected by a distinct laborious effort. Now add bronchitis to this condition, and the impediment is extreme. Air cannot enter deeply into the lungs ; mucus cannot be expelled; the air, however, in the lungs can be, and is expelled ; there is, consequently, collapse, and the child dies — not properly speaking from the collapse, but from that which caused the collapse, viz., the inability of the inspired air to pass the obstructing mucus. The extent to which the ribs are softened, and the amount of their recession in inspiration, are therefore of extreme importance DIARRHCEA — LARYNGISMUS AND CONVULSIONS. Ill as regards the prognosis of broncliitis when it occurs in rickety children. Diarrhoea. — Eicketj chiklren are especially liable to attacks of purging. This may be accounted for partly by their extreme sen- sitiveness to changes of temperature, and partly by the unhealthy condition of the alimentary canal, which always precedes and accompanies the disease, and which a very slight additional irrita- tion would easily aggravate into diarrhoea. These attacks are exceedingly dangerous. We know that even healthy children, seized with profuse purging, rapidly lose flesh, and soon become exhausted. A few hours are sufficient, if the drain is severe, to cause a marked change in their appearance ; their features quickly lose the roundness of youth, and assume instead the pinched, drawn characters of age. Rickety children, already enfeebled, are still less able to withstand the depressing effects of the disorder, and fall victims to it all the more readily in proportion to the degree to which their strength has been previously reduced. Laryngismus stridulus and convulsions are not uncommon com- plications of rickets. The first, especially, is almost always asso- ciated with rickets as its cause. Whether it is, as Dr. Gee suggests,^ that the convulsive tendency and the rickety state are both due to the same condition of general mal-nutrition, or that the convul- sions are a secondary result of the rickety constitution, the fact re- mains that in rickets the special and the general convulsive attacks are frequent, and are often combined. Out of fifty cases of laryn- gismus, noted by Dr. Gee, forty-eight were rickety, and of these nineteen had general convulsions. Out of one hundred and two children in whom general convulsions occurred, forty-six were rickety. This connection is exceedingly important, as regards the treatment of these attacks. Most of the children in whom this convulsive tendency is marked have carpo-pedal contractions. As dentition is backward in all these cases, the laryngismus and the convulsions are frequently attributed to teething. The teeth, however, are quite innocent of any share in the production of these complications. They are backward as a consequence of the arrest of growth of bone which is one of the characteristics of the dis- ease. When the teeth do appear they are often cut with remark- ' See an elaborate paper by Dr. Gee in St. Bartholomew's Hospital Reports, vol. iii. 1867. 112 EICKETS. able ease, and whereas the child had been formerly subject to con- vulsions, with or without apparent cause, the commencement of dentition is accompanied by no such phenomena ; the removal of the rickety condition, as shown by the evolution of the teeth, being coincident with the disappearance of the spasmodic tendency. Chronic Hydrocephalus occasionally complicates the disease, and is most common, according to Dr. Merei,' between the ages of eight and eighteen months. The fluid may be in the lateral ventricles, in the arachnoid sac, or in both.^ It often appears to be a merely mechanical effusion, the serosity being thrown out to fill up the space left when the cranial cavity becomes enlarged without any corresponding increase in the size of the brain. In these cases the convolutions are perfectly natural, and show no signs of pressure. On account of the altered shape of the skull, hydrocephalus is often suspected where it does not really exist. The differences be- tween the ordinary rickety head, and the skull expanded by fluid iu its cavit}^, have already been pointed out. (See page 99.) Besides the complications which have been mentioned, tubercular formation may occur in rickety children. This, however, is not a special complication of the disease, and is comparatively rare. When death results from the intensity of the general disease, without the occurrence of any of these complications, the child becomes weaker and weaker; he loses all power of supporting himself, and can hardly move. The diflftculty of respiration, owing to the softened state of his ribs, absorbs all his attention. The face gets livid, or leaden-colored; the perspirations are extreme; the tenderness is so great that he cannot bear to be touched ; the softening of the bones, and the consequent deformities, continue, although sometimes the bones seem to get brittle, and fractures may occur unless the child is moved with very great care. The appetite becomes completely lost; the body generally is much wasted, although the belly remains full and distended ; and at last the child dies exhausted or asphyxiated. If the disease terminate favorably, the symptoms gradually subside, and finally disappear. The tenderness becomes less marked ; the bones cease to soften ; the child aj^pears more lively, and takes an interest in what passes around him. As the softening ' Disorders of Infantile Development and Rickets, 8vo., 1855. 2 Dr. Gee, loc. cit. FAVORABLE TERMINATION — PATHOLOGY. 113 of the ribs diminishes, his respiration grows less laborious, and he will then begin to amuse himself with his toys. The appetite im- proves, and gets less capricious ; the bowels are more regular, and the stools healthier-looking. The wasting ceases ; the child begins to gain flesh, while the belly decreases in size, and becomes less prominent. The head-sweats are less noticed, and his sleep at night is more tranquil, although for a long time he will continue to throw off the bed-clothes at night unless restrained. Dentition recom- mences, and goes on rapidly and easily. The deformities of the bones gradually diminish ; the bones get very much straighter than would be expected from their former distortion, become exceed- ingly thick and strong, and the enlargement of the ends of the long bones becomes very remarkably reduced. The muscles also begin to be more developed, and increase rapidly in size. The increase in length of the bones, however, is not rapid, and the child remains more or less stunted, seldom when full grown reaching the average height. The rapidity with which dentition proceeds during recovery from rickets is sometimes very striking, and is well illustrated by the following case: "Geo. P., at the age of two years, had but twelve teeth, and could not stand. The chest was much deformed, the ends of the long bones were enlarged, and the legs were very thin and flabby. Treatment was begun on November 29. On January 2-4 of the following year the boy could walk across the room steadying himself by the different articles of furniture, and by May 16 could walk well and firmly without any assistance. The teeth reappeared as follows : By April 7 he had cut the two upper canines, and by May 16 the two lower canines; by May 30 three back molars had appeared, and on the following day, June 1, the last remaining tooth pierced the gum. The treatment con sisted in careful regulation of his diet; in the administration of alkalies with drop doses of tinct. opii, to improve the condition of his digestive organs ; and afterwards when the motions wei'e per- fectly healthy, in iron wine with half-drachm dose of cod-liver oil." Pathology. — Rickets is a general disease, and affects very widely the tissues of the body. Its influence is most manifest in the bones, which are always implicated, but we find in addition,. changes in the brain, liver, lymphatic glands, spleen, muscles^ and often of every organ in the body. Eickets affects the bones in three different ways. 8 114 RICKETS. It interferes with their growth, not only temporarily, but per- manently ; for children who have been thus affected never, as Mr. Shaw has pointed out, grow into average sized adults. It interferes with their development, perverting the process of ossification, and rendering the calcareous deposit irregular and incomplete. Indeed, according to Sir W. Jenner, it is not true ossification at all, but rather petrifaction, such as we see occasion- ally taking place in enchondromata. But besides its influence over the growth and development of bone, rickets produces equally serious changes in bone already completely ossified. It softens and consumes the osseous tissue, so that the bones lose in density, in weight, and in firmness; they yield under the pressure of a finger, and can be cut "like carrots with a knife.'" This softening is due to the removal of the lime salts, which enter the blood in a soluble form, and are excreted by the kidneys. Some pathologists have attempted to explain this absorption of lime by the excessive formation of the alimentary canal of an acid which has been variously stated as lactic, oxalic, phosphoric, and hydrochloric. The acid, whatever it may be, enters the blood, and so assists in the abduction of lime from the bones. This, however, is mere hypothesis. Since change probably takes pkice besides the loss of the earthy matter of the bones, for in some of Lehman's and Marchand's experiments the bones yiekled no gelatin on boiling. Anatomical characters. — The enlargement of the ends of the long bones is a real hypertrophy. "In rickets," says Sir W. Jenner, " there is an exaggeration of the conditions we find in the first stages of ossification in the healthy subject ; the completion of the process only is stayed. There is great development of the spongy tissue of the head of the bone, and of the epiphysis, and also of that layer of cartilage in which the primary deposit of calcareous mat- ter takes place. The layer of cartilage in which the cells are arranged in linear series, instead of being half a line, is from a quarter to half an inch in breadth."- While, however, great pre- parations are thus made for the process of ossification, the perform- ance of that process is extremely irregular and inadequate. The advancing bone, instead of moving up into a regular line into the ' Trousseau, Clinique Medicale. 2 Medical Times and Gazette, March 17, 1860, p. 261. MORBID CHANGES IN BOXES. 115 cartilage, consolidating as it advances, as we see in normal ossifi- cation, strikes up at different points, leaving the cartilage at other points still uncalcified, and these may remain untouched far below, forming specks of cartilage completely surrounded by bone. In addition to this, the cartilage cells become ossified before the matrix, being converted into lacunas and. imperfect canaliculi. " This takes place," says KoUiker, " by a thickening of the wall, and, at the same time, a formation in it of canalicular cavities," so that at last a vacant space resembling an almost perfect lacuna is all that is left of the cavity of the cell. The usual deposition of granular calcareous particles is absent from the matrix at the bor- der of ossification ; the changes in the cartilage cell can therefore be more distinctly observed. According to Virchow, the abnormal condition of rickety bone consists " not in a process of softening of the old bone, but in the non-solidification of the layers of new bone as they form. The old layers of bone are consumed by the formation of medullary spaces in the normal manner, and the new layers which are formed remain soft. Isolated masses of lime are also scattered about in sufficient numbers to give a dotted appearance to a section of the cartilage, and — to add to all the irregularities — we find medullary spaces, not only just below the margin of calcification — where they ought to be — but also far beyond the border of calcification — where they ought not to be ; and these spaces are filled with a soft slightly fibrous tissue, with vessels running up into them. Changes also take place in the flat bones, and in the shafts of the long bones. On section we see that the meshes of the spongy tissue are dilated, and that the cavities are filled with a greasy, gelatinous bloody matter, looking, says Trousseau,' "like pale red gooseberry jam." This pulp contains colorless nucleated cells, with one, or sometimes two, nuclei, a few blood corpuscles, and a large quantity of free fat. The periosteum is a bright rose-color from injection with blood, thicker than natural, and intimately adherent to the bone which is itself more vascular and less pol- ished looking than it ought to be. The pulp fills up the diploe of the flat bones, and in the shaft of the long bones is found filling the medullary canal and the meshes of the cancellated tissue and ' Clinique Medicale. 116 RICKETS. separating the lamellge of the more compact part from one another. At the same time the tissue itself becomes softer. As the disease advances the outer and inner tables of the fiaL bones become thin, soft, and elastic, so as to yield under the pres- sure of the fingers. The bones have a bluish appearance from the color of the pulp which fills up their diploe being seen through the semi-transparent bony shell. The periosteum now increases in thickness, and, according to M. Gu^rin,^ a red gelatinous matter, similar to that which clogs the diploe and the meshes of the can- cellated tissue, is deposited between it and the body of the bone. This gelatinous matter gradually thickens and acquires the consist- ence of cartilage, while at the same time the porosity of the bone is increased, the old tissue being gradually removed by interstitial absorption. The gelatinous matter lying beneath the periosteum is intimately adherent to it, coming away with it when that mem- brane is detached. "It is evidently," says Trousseau, "a product of periosteal secretion," and the process of its formation is analo- gous to what takes place in the production of callus thrown out to unite healthy bone after fracture; it resembles callus also in its power of becoming transformed into bony tissue much more solid and dense than the old bone. The medullary canal is narrowed by the thickening of its lining membrane, and by the deposit of matter like that which fills up the cancellar spaces. This narrow- ing is best marked at the most pronounced part of the curve, and should the curving be extreme, the canal may end abruptly at this point, opening externally under the periosteum. It would thus lorm an obtuse angle with the other part, from which it has been separated by the new tissue formed in the hollow of the curve. These curvatures in the shafts of the bones are incomplete frac- tures, such as take place in bending forcibly a stick of green wood. So long as the disease is in progress the bones lose more and more of their firmness, getting softer and softer, so that they yield before the slightest pressure — either the pressure of the air, as in the distortion of the ribs, or the weight of the body, as is the case with the limbs. When, however, the disease becomes arrested, consolidation commences, and the bones acquire greater firmness and consistency. The process of consolidation is compared by Trousseau to the calcification of callus in ordinai-y fractures. In ' Memoire sur le Rachitis. Paris, 1857. MORBID CHANGES IN BONES. 117 the long bones calcareous nuclei, the rudiments of new bony tis- sue, appear in the greasy gelatinous matter deposited beneath the periosteum at the circumference of the shaft. These enlarge and unite ; the layers of bone get thicker and thicker ; and the new tissue, thus acquiring consistence, hardens gradually into a com- pact substance like ivory. In the flat and short bones the effused matter is partially absorbed, so as to restore the normal spongy tissue. According to Dr. Yogel,' the occipital bone sometimes differs from the other bones of the skull in the changes which it undergoes. In the condition called cranio-tabes, which has already been described, spots are found in this bone where the osseous tissue is thin, transparent, of a yellowish-red color, and contains scarcely any spongy substance. By holding the bone against the light the extent of the thinning can be readily seen. "When looked at from the inside, depressions are found which correspond to the underlying convolutions of the brain. Dr. Vogel divides the pro- cess by which these changes take place into two stages : a first stage, in which there is deficient deposition of phosphates in the external bony layers all over the skull ; and a second stage, in •which absorption takes place in the softened parts where the pres- sure of the brain is felt. Sometimes the thinning of the bone is so extreme that the os- seous tissue almost entirely disappears in the affected spots ; the pericranium and the dura mater then come into contact, having between them merely relics of bone still unabsorbed. From the result of different analyses that have been made of rickety bone, it appears that the bone contains 79 parts of organic to 21 of inorganic matter; thus differing very much from the pro- portions found in healthy bone, where the inorganic matters are largely in excess of the organic, being as 63 to 37. The animal matter of rickety bone yields no gelatin on boiling, and at an advanced period of the disease, is said by Simon to yield neither gelatin nor chondrin. Schlonberger and Friedleben have obtained perfect gluten from rickety bone. The softening of the ribs, and consequent deformity of the chest, produce certain morbid conditions in the contents of the thoracic cavity. The influence exercised by the softened ribs upon the course and termination of bronchitis, has already been described ; ' Lehrbuch der Kinderkraukheitei], von Dr. Alfred Vogel. Erlangen, 1863. 118 EICKETS. but there are, besides, two special lesions of the lung, which are invariably present, and always in the same situation in every case of rickety chest-distortion. These lesions are emphysema and collapse. The emphysema occupies the whole length of the anterior border of each lung, extending backwards for about three-quarters of an inch from the free margin. The mode of its production is ex- plained in the following way : At each inspiration the ribs sink in, and the lateral diameter of the chest is narrowed at the part cor- responding to the line of union of the ribs with their cartilages. While, however, the lateral diameter is thus diminished, the antero- posterior diameter is increased by the thrusting forwards of the sternum. Air, therefore, is forced in excess into the lungs at that part so as to fill up the resulting space, and over-distension of the air vesicles is the result. Collapse of the lung is produced by the recession of the ribs during inspiration. The collapsed portion forms a groove just outside the emphysematous part, separating it from the healthy lung. This groove corresponds to the line of nodules which re- present the enlarged ends of the ribs, and which project inwards into the interior as much as, or even more than, they project exte- riorly. During inspiration the ribs sink in, and the nodules are forced against the lung beneath them, so that they compress the pulmonary lobules at those points, and close them against the advancing air. These two lesions are, therefore, quite independent one of an- other ; and although they invariably occur if there is much soften- ing of the ribs, yet they do not stand to one another in the relation of cause and effect. The collapse which is sometimes found to occupy the posterior and inferior parts of the lung, and occasionally some parts of the upper lobes, is the result of plugging of a tube with mucus. The mechanism of this has already been described. It is only found in bronchitis. Another result of the rickety chest is the circumscribed opacity on the visceral surface of the pericardium, known by the name of "white patch." This, although uncommon in children generally, is very common in rickety children. Its seat is usually the left ventricle, a little above its apex, just at the point where the heart at each beat comes in contact with the nodule of the fifth rib. In ALBUMINOID DEGENERATION. 119 this case friction against the bone is evidently the cause of the white patch, and this is a strong argument in favor of the "attri- tion theory" generally. The same thing is often seen on the spleen, which, rising and falling with respiration, is rubbed against a projecting rib nodule. It is distinguished from the result of embolism by not extending deeper than the fibrous coating of the organ. The pathological changes which take place as a result of rickets in the lymphatic glands, liver, spleen, and other internal organs, have also been described by Sir W. Jenner. They appear to be all of them affected with the same condition, which he calls albuminoid degeneration, and which corresponds very much to Virchow's amyloid degeneration, differing from it only in not giving the characteristic mahogany-brown color on the addition of a solution of iodine. All the organs on section show a pale, transparent uniform surface ; they are tough and solid to the feel, and are heavy out of proportion to their size. They are not all of them enlarged ; the liver and lymphatic glands are seldom much increased in size ; but whether enlarged or not, they exhibit the other peculiarities which have been described. This albuminoid degeneration is not found in all cases of rickets ; it is limited to those cases where the emacia- tion is marked ; but where it does occur, all the organs seem to be alike affected by it, and not merely one or two. The spleen varies very much in size. Sometimes it can just be felt below the ribs; sometimes it is very much enlarged. It may measure as much as eight inches from above downwards, and four inches from side to side. " Its substance," says Sir W. Jenner '*' is tough and elastic, and the thinnest sections can be cut with facility. The cut surface is remarkably transparent and smooth. It is not unlike what one might suppose would be its appearance if the whole organ were infiltrated with glue. Only a little pale blood can be expressed from the cut surface. Usually the organ is pale red, but occasionally it is dark purple. The more trans- parent any given part is, the paler it is; the more transparent parts are almost colorless. The splenic corpuscles are sometimes more readily seen than in a healthy spleen ; they may be mistaken for gray tubercles. I have never seen in the spleen of rickety children, the sago-like little masses so often present in the spleens of those who die of phthisis." 120 RICKETS. The thymus gland is often enlarged, and exhibits on section the usual pale transparent look from infiltration with the same albu- minoid substance as the other internal organs. The brain is usually larger than natural, and may also present the signs of albuminoid degeneration. Sometimes, however, this appearance is not seen, the increase being apparently due to a true hypertrophy. In a case noted by Dr. Gee,' this organ weighed fifty-nine ounces; it was of natural consistence, not toughened or hardened, and the gray and white matter appeared to retain their normal proportions. In another case, the brain weighed forty-two and a half ounces, and also seemed healthy, although of such unusual size. The voluntary muscles are small, pale, flabbj^, and soft, but do not owe this appearance to fatty degeneration. Sir W. Jenner did not succeed in detecting a single particle of olein in their fibres. Under the microscope their fibres are " singularly colorless, trans- parent, and soft," with the striae very indistinctly marked. The urine in rickets is pale. The amount of urea and uric acid is diminished; but there is increase in the amount of the earthy phosphates. This increase is stated to be greatest at the beginning of the bone softening, and to become less marked when the disease is further advanced, and the bones are undergoing distortion. Free phosphoric and lactic acids have been observed, and it is not uncommon to find a sediment of oxalate of lime. Phosphate of lime was in great excess in a case recorded by Mr. Solly. Diagnosis. — The early diagnosis of rickets is of great import- ance : few cases are so readily curable in their early stages, or so fatal if allowed to continue unchecked. Plumpness is no proof of the absence of rickets, for a child may be extremely fat, and yet rickety ; on the other hand, wasting is no proof of its presence, for a child may be reduced almost to a skeleton without presenting a single symptom of the disease. In a well-marked case of rickets the head elongated from before backwards ; the square, straight, prominent forehead ; the small face; the beaded ribs; the deformed chest; the tumid belly ; the twisted, distorted limbs; the immobility and quiet of the little creature as he sits — if he can sit — with bowed spine and head thrown back, gazing around him with vacant eyes; all these cha- Saint Bartholomew's Hospital Reports, vol. iii., 1857. DIAGNOSIS. 121 racteristic symptoms leave no room for doubt as to the nature of the disease. It is only when the disorder is at its very commencement, or appears first about the end of the second year, that it is so liable to be overlooked. A mild form of rickets, consisting merely in a little enlargement of the wrists and ankles, slight beading of the ribs, arrested or late dentition, and a large fontanelle, is exceedingly common, even in wealthy families. The parents from these signs alone never suspect disease, and indeed the plumpness of the child, which is often very considerable, is the subject of much admira- tion. The absence of teeth is looked upon as an innocent peculi- arity, and cases are quoted of relations, male and female, in whom the same tardy dentition was observed. It is not until some complication arises, or the disease enters a new phase, that any- thing is noticed to excite alarm. But late cutting of the teeth is never a natural condition. If, as Sir W. Jenner has observed, the ninth month passes away without the appearance of a tooth, the cause should be carefully inquired for, and will almost always be found in rickets. Lateness in walking much more frequently attracts the attention of parents, and children are often brought for advice on account of " weakness in the legs." In these cases, owing to the inability of the child to support himself, even for a moment, when held upon his feet, essential paralysis may be suspected. An examina- tion, however, will show that although there is no power of stand- ing, yet power of movement is by no means lost. The child draws up the legs when the soles of the feet are tickled, and the muscles, although weak, are not absolutely powerless. Other symptoms of rickets are also present. When the want of muscular power has increased to such a degree that the child is incapable of movement, the incapacity is general, and is not confined to one or more limbs. Besides, at this stage the deformities of bone are usually well marked, and the chest distortion is very great. Eelaxation of the ligaments, and consequent unnatural mobility of the joints, are almost always due to rickets. They are common results of the disease when it occurs after the end of the second year, and may be present although there is no osseous deformity, and very little enlargement of the ends of the bones. All the articulations are affected, but the knees and ankles seem to suffer 122 RICKETS. most, as tbey bear the weight of the body. The yielding of the ligaments of these joints may be so great as to make walking diffi- cult or even impossible, but where the relaxation is extreme there is usually combined with it more or less softening and distortion of the bones. In rickety children, before cutting for stone, the size of the pelvis should be carefully studied, for narrowness of the outlet may create great difficulty in removing the calculus. By noting the degree of stunting and distortion of the lower limbs, a fair guess may be made as to the degree to which the pelvis is likely to have suft'ered from arrest of development and softening of its bones. An examination jjer anum will, however, at once remove any doubts : by the finger introduced into the rectum we can readily explore the entire pelvic cavity, and the size and capacity both of the brim and of the outlet can by this means be satisfac- torily ascertained. Mollities ossium, which has been called the rickets of adults, appears to be a completely different disease : it goes on always from bad to worse ; re-ossification never takes place ; and it induces fatty degeneration of the bones — a condition never found in rickets. Prognosis. — The danger of rickets lies principally in the com- plications. As long as the disease remains simple, and the bone- softening is not extreme, the prognosis is very favorable. In estimating the danger of any particular case, attention should always be paid to two points : — The amount of chest distortion. The presence or absence of albuminoid degeneration of the spleen and glandular system generally. If the chest is much distorted, and the softening of the ribs is great, there is always cause for anxiety. Owing to the difficulty of respiration iu these cases, there is deficient aeration of the blood (shown by the lividity of the lower eyelid and of the mouth), and consequent deficient oxidation and removal of waste matter. The slightest catarrh, as has been before explained (see p. 110), adds a further obstacle to due aeration; and catarrhs are always liable to occur, however carefully chills may be guarded against, owing to the extreme sensitiveness of a rickety child to changes of tempera- ture. Under such circumstances the child's life is always in danger, for a slight cold, which in a healthy child would be scarcely worth notice, or which would be easily treated by domestic remedies, PROGNOSIS — CAUSES. 123 will be sufficient in a rickety child to cause fatal collapse of the lungs. If a child, the subject of this disease, begins to cough, no prognosis should be hazarded until the movements of the chest during respiration have been carefully watched; and here more useful information can often be gained by the eye than by the stethoscope. The danger is in direct proportion to the degree of recession of the ribs during inspiration. The danger of albuminoid degeneration of the glandular system is shown by the emaciation with which it is always accompanied. The weakness of the child in these cases reaches its height, and the impediment to the proper elaboration of nutritive material set up by such a condition of the glands forms a great obstacle to efficient treatment. These cases are usually fatal. On account of the danger of catarrh, those disorders in which it is a prominent symptom are of course especially formidable to rickety children. On this account measles and whooping-cougb are greatly to be dreaded. Of the other complications, diarrhoea is the most serious. Con- vulsions are not necessarily fatal, although they increase the gravity of the case. Sometimes, though rarely, laryngismus stridulus causes death. The combination of hydrocephalus with rickets is seldom attended with danger. No indication for prognosis can be derived from the age of the child. A slight degree of rickets is very common in infants of seven months old, and, when the causes which produced it are removed, it ceases as readily in them as in older children. The severity of the disease depends upon the intensity and the continu- ance of the causes of which it is the result. Causes. — Rickets is usually ranked amongst the diathetic dis- eases of childhood, but its claims to such a position are by no means indisputable. A diathesis is defined by Dr. Aitken,^ as "that character of the constitution which tends to the repeated expression of some form of ill-health, always in the same way." In other words, it is a constitutional predisposition to repeated manifestations of a certain invariable form of disease. Now, in rickets there is, strictly speaking, no constitutional predisposition. ' Science and Practice of Medicine, by "W. Aitken, M.D., Edinburgh, 2d edition, 1863, vol. i. p. 212. 124 RICKETS. It is tbe result of certain known causes, without whicli the disease cannot be produced, but under the influence of which any child whatever (with certain exceptions, to be afterwards noticed) will become rickety. That the disease occurs amongst the children of the rich as well as amongst the poor is no argument against this view, for wealth cannot buy judgment, and education is no guar- antee against foolish indulgence. We know that a child may be in reality starving, although fed every day upon the richest food, for he is nourished, not in proportion to the nutritive properties of the food he swallows, but in proportion to his capability of digest- ing what is given to him. If, therefore, he is supplied with food unsuited to his age, the result is the same, whether he live in a palace or a cottage. Cases occasionally occur where the mother, exhausted by chronic disease, or other depressing cause, bears children feeble at their birth, and who very rapidly become rickety. But these are not true cases of constitutional predisposition. The child is born suffering already from the effects of deficient nutrition in the womb. He is then at once suckled with poor watery milk, or is brought up by hand and stuffed with all the hurtful trash with which the ignorance of mothers prompts them to supply the deficiencies of their milk. The natural result of such imperfect nourishment follows, and rickets declares itself. But here the child can only be said to have been predisposed to rickets in the sense that he was born suffering from a condition which rickets is the final and most striking stage. Eickets does not produce malnutrition, but malnutrition produces rickets. The infant is not born weakly because he has a rickety predisposition, but he falls a victim to rickets because he was born weakly. It occasionally happens that a child is born suffering from the catarrh of whooping-cough, but he cannot be said to have a con- stitutional predisposition to pertussis because after the lapse of a certain time he begins to whoop. The disease was present at birth, although it had not at that time reached the spasmodic stage. So also in the case of early rickets, the disease really began in the womb, and only underwent further development after the entrance of the child into the world. Besides, for the full development of the disease, it is essential that the same causes by which nutrition was first rendered defec- tive should continue in operation. If measures are taken to im- CAUSES. 125 prove nutrition, this result does not follow, for when well cared for, and supplied with proper nourishment, the child in all cases becomes strong and healthy. Rickets is no disease which must run its course. By judicious treatment it may be stayed at any point of its career ; and the treatment required is merely food — • food which nourishes, and drugs which are not so much medicines as food under another name. Again, in the true diathetic diseases of children, as tubercle and syphilis, hereditary tendency plays a very important part, but in the case of rickets there is very little evidence of such a cause. Out of the thousands of rickety children there will no doubt be many, one or the other of whose parents was rickety before them ; but the same thing may be said of any other common disorder. It is always difficult where many conditions unite in the causation of a disease to separate the share which hereditary tendency takes in its production, but no special facts have yet been brought for- ward to show that rickety parents are more likely to have rickety children than parents who have been altogether free from the dis- ease — the other conditions remaining the same. Rickets, then, is not a diathetic disease in the sense in which tu- berculosis and syphilis are diathetic diseases. Before the altera- tions in structure actually occur there is nothing in the appearance of the child to indicate the disease from which he is about to suffer. It is acquired under the influence of certain causes, lasts as long as those causes continue in operation, and, unless the structural charges are so extensive, and the general strength so reduced, as to forbid recovery, passes off when the causes are removed. These causes must be looked for in all those conditions which interfere with the proper nutrition of the child. Ill health or weak constitution of the mother affecting the nutrition of the foetus in utero, and after birth of the child deteriorating the quality of the breast-milk; improper feeding generally, ill- ventilated rooms, damp, cold, dirt, want of sunlight, want of exercise. The con- tinued influence of these causes will produce the disease, or rather, will produce that unhealthy condition of the body of which rickets is the direct consequence. The preliminary stage, that which marks the commencement and progress of malnutrition, and in which the strength is being gradually reduced to the point at which rickets begins, may be long or short according to the de- gree of vigor of the child, and the degree of intensity with which 126 RICKETS. the causes operate, or may even be absent altogether. Its place may be taken by any disease which interferes seriously with the assimilative power, and causes sufficient impairment of the general strength. We thus get another set of causes, which may either act independently of the others, or may most powerfully intensify their influence. Thus rapidly recurring attacks of diarrhoea, chronic vomiting, measles, bronchitis, broncho-pneumonia, in fact, all the exhausting diseases, may have this effect. Too early weaning is sometimes stated to be a special cause of the disease. It is no doubt true that to deprive a young child of breast milk which he can digest, and to supply him instead with food which he cannot digest, is certain to be hurtful. In England, however, the tendency is rather to keep the child too long at the breast, to accustom him to look to that for his sole nourishment after the time when some additional food is required. In either case the supply of nutritive material is equally deficient, and the effect upon the health of the child must be equally unfavorable. The connection between syphilis and rickets is interesting; by some writers great importance is attributed to the influence of the former disease as a cause of rickets, while others have denied such influence altogether. That syphilitic infants do occasionally be- come rickety, no one who has been a close observer of children's diseases can venture to doubt. A child may become the subject of rickets after the disappearance of the syphilitic symptoms, or even while the body is yet covered by the specific rash. Such cases are, however, the exception, and are usually mild. The author has never as yet met with an example of severe rickets occurring in a syphilitic child. With regard to the influence of tubercle, rickety children may become tubercular, and a phthisical mother may bear rickety children; but a child in whom the tubercular diathesis is marked seldom, if ever, becomes rickety. It is also rare to find a case of rickets occurring in a family the other children of which are the subjects of tuberculosis. Prevention. — If any of the former children of the family have been rickety, especial attention must be paid to the diet and gene- ral management of the new-born babe. The mother may still suckle the infant during the first month, but after that time she should give up all idea of rearing the child from her own breast, and a wet nurse should be provided. If from circum- PREVENTION — TREATMENT. 127 stances this is impossible, the breast-milk must be limited to two meals a day ; the child being fed at other times upon ass's milk, or cow's milk and lime-water, as recommended in an earlier part of this volume. At the same time, all the other precautions so essential to perfect health must be carefully observed. Perfect cleanliness, warm clothing, fresh air, well-ventilated rooms, sun- light, are all indispensable. If the parents reside in a cold, damp situation, the child should, if possible, be removed to a neighbor- hood where the quality of the air is drier and more bracing. For full particulars as to the best method of preventing the occurrence of rickets the reader is referred to the section on the treatment of simple atrophy. If the management of the child be conducted ac- cording to the rules there laid down, rickets cannot occur, for the causes which produce the disease will not be in operation. Treatment. — In the treatment of rickets, our first care must be to endeavor to restore healthy nutrition. This can only be done by attention to diet and to general hygiene, taking care at the same time to correct any disordered condition of the alimentary canal which may be present to interfere with the proper digestion and assimilation of the food supplied. This is indispensable as a first step, for to give tonics while the causes which have produced the disease, and sustain it, continue in operation, is a course which can- not possibly be attended with any good result. In almost all cases the bowels will be found to be rather relaxed, two or three stools being passed in the course of the day, consist- ing of offensive, putty-like matter, mixed largely with mucus, often greenish, and occasionally streaked with blood, from the straining efforts with which they are evacuated. The fetor is due to decomposition of the undigested food. It is best to commence the treatment with a gentle laxative, such as a teaspoon ful of castor oil, or a small dose of rhubarb and soda, and the bowels having been thus relieved, alkalies should be given, with a little opium, in some aromatic water. The following prescription is useful in these cases, or some of the medicines ordered for a simi- lar condition of the bowels in the treatment of simple atrophy may be adopted : — ^.. Tinct. opii, n\^xij ; Sodse bicarb., gjss ; Sp. ammon. aromat., 5j > Syrupi ziiigib., §ss ; Aq. cinuamomi, ad 3iij. M. 5'j ter die. 128 RICKETS. The opium is of great use in diminishing the abnormal briskness of the peristaltic action of the bowels, and should never be omitted from the mixture so long as the stools present the appearances which have been described. Under such or similar treatment the motions will be found in a few days to assume a more healthy character, griping, if previously present, will be diminished, or will have altogether ceased, and the general condition of the patient will be much improved. At the same time the diet of the child must be regulated to suit the degree of debility to which he may be reduced, remembering that the greater his weakness, the more nearly does his digestive power resemble in degree that of a new- born infant. Full directions about diet have already been given in former chapter (see Treatment of Simple Atrophy), and need not here be repeated. It may, however, be remarked, that it will usually be found necessary very greatly to reduce the quantity of farinaceous matter which is being taken. Under the mistaken notion that such food is especially nutritious and easy of digestion, weakly children, whatever their age may be, are commonly made to depend for their support chiefly upon sago, arrowroot, tapioca, and similar articles of diet. The amount of this food must be therefore considerably restricted, according to the rules already laid down, and its place should be supplied by milk, gravy, strong beef-tea, minced meat once cooked, yelks of eggs lightly boiled, «Scc., according to the age and strength of the child. ^ Plenty of fresh air is indispensable to successful treatment of rickets. The child should be taken out regularly into the open air, and as he gets gradually stronger should pass more and more of his time out of doors. The qualit}'- of the air is of much im- portance, and sea-side places where the air is dry and bracing, as Lowestoft, Scarborough, Brighton, and Eastbourne, are especially to be recommended. Great attention must be paid to the clothing. The belly should be kept covered with a flannel bandage,- and the child should be dressed from head to foot in flannel or merino. Great cleanliness must be observed. The whole body should be well washed every morning with soap and warm water, and be sponged every evening with warm water ; and as he gets stronger, 1 See Chap. XL, Diets 5, 6, 7, 8, 10, 11, and 18. * The abdominal bandage has another use in retarding the too rapid descent of the diaphragm. This, when the bones are much softened, affords great relief. INTERNAL REMEDIES. 129 warm or tepid sponging with salt water may be used to the back and loins. The bed and bedding should be removed from the room every morning, and be freely exposed to the air ; the sheets must be changed frequently and must be carefully aired. The ventilation of the nurseries must be attended to, and at night a lamp placed in the chimney is useful to promote a free current of air. The influence of the preceding measures is usually most marked, and it is at this time that tonic medicines are so valuable. They ought not, however, to be given until, by suitable treatment, the motions have become healthy and the tongue clean. Iron is one of the most important medicines we have at our dis- posal. A good form for its administration is the following : — I^. Liq. ferri pernltratis, Acidi nitrici diluti, aa 3ss ; Syrupi zingiberis, §j ; lufusum calumbae, ad ^iij. M. 5U t^f e diagnosis of pulmonary phthisis is difficult or easy according' o the amount of disease, the stage which has been reached, and ' ne exact pathological condition which gives rise to the symptoms. AYe can readily detect consolidation, and can often determine the exact structural change to which consolidation is principally owing ; but whether or not it is entirely due to this cause — whether other structural alterations may not be present to complicate the case — is frequently a question of the greatest diffi- culty to determine. In all cases the great point to decide is the presence or absence of tubercle, for that may exist alone, or may accompany the other pathological conditions of the lung which have been described. When tubercle exists alone, disseminated through the lungs, it is often, owing to the obscurity of the physical signs, impossible at the first, or even after several successive examinations, to come to any positive conclusion as to the exact nature of the disease. To arrive at a diagnosis we must take into account the family history, the special history, the conformation of body, and especially the course of the physical signs. Thus, if a child, born of con- sumptive parents, and whose general build corresponds to the type which has been described as significant of the tuberculous diathesis, become languid and mopes ; if he has irregular attacks of febrile disturbance, loses flesh, has short, drj'- cough, and complains of vague pains and oppression about the chest, we should suspect DIAGNOSIS. 215 plithisis. If these symptoms have succeeded to an attack of measles or wtiooping-cough, our suspicions are strengthened ; but so long as percussion of the chest shows no dulness, and auscultation reveals nothing but harshness of respiration, with here and there dry rhonchi, there is nothing upon which to found a positive diag- nosis. If the dry sounds become replaced by submucous rhonchus, there is still nothing which may not be accounted for by ordinary catarrh attacking a weakly child. If, however, the dry rhonchi persist and become general, being heard from apex to base, and if this condition continues without improvement for several weeks, and without moist sounds replacing the dry rales, the case assumes a very much graver aspect, and the diagnosis of phthisis becomes almost a certainty. Such cases are, however, more common in the acute form of the disease. In chronic phthisis the tubercles have a greater tendency to become grouped at the apices, both lungs being affected. Here there is dulness on percussion, and the stethoscope reveals weak or bronchial breathi*"^, with often in- creased resonance of the voice or cry. The du. ]$s, however, to be trustworthy, must be well marked: slight sha^^os of variation from a healthy resonance being worthless as evidences of consoli- dation. Should the percussion dulness be distinct, and the breathing bronchial, with a slight crackle at the end of inspiration, tiiese signs occurring at both apices, and continuing unchanged for two or three weeks, become satisfactory evidence of tubercular consolidation. On the other hand, absence of dulness is no suffi- cient proof of the absence of aggravated tubercle, for the reso- nance may be due to emphysema. In cases where, from the ill-defined character of the physical signs, we had been obliged to reserve an opinion as to the condition of the apices, the occurrence of double pneumonia at those spots throws considerable light upon the difficulty, for inflammation coming on under such circumstances greatly increases the proba- bilities of tubercle. The thermometer is of little value in the diagnosis of pulmonary tubercle; a continued elevation of temperature shows the presence of tuberculosis, but this elevation is, according to Dr. Ringer's' in- vestigations, due rather to the general condition of the body than ' On the Temperature of the Body as a Meaus of Diagnosis in Phthisis and Tu- berculosis. London, 1865. 216 CHRONIC PULMONARY PHTHISIS. to the actual formation of tubercle in the organs, and affords, there- fore, no distinct indication of the presence of tubercle in the lungs. It may strengthen our suspicions, but that is all. In scrofulous pneumonia (pneumonic phthisis) we can generally succeed in discovering a distinct period at which the first symp- toms were noticed. A child, delicate, but in his usual health, is seized with an attack of vomiting, followed by fever, cough, and general chest symptoms. The strength is not much reduced, and the breathing is but little oppressed, although it may be rather more hurried than natural. If the child is seen early, no dulness may be found on percus- sion, but there is more or less coarse crepitation heard at a certain part of the chest, usually at one or the other apex — seldom at both if the disease is uncomplicated. The crepitation accompanies the expiration as well as the inspiration, and varies greatly in amount from day to day, sometimes more being heard, sometimes less, and sometimes for a short time it is completely absent. If any dulness is present, it is slight at first, and may not become more marked for several weeks; the breath-sounds are not necessarily altered in character. The temperature of the body rises at night to 102° or 103° Fahr,, falling in the morning to about its natural level.' After a time, often only after several weeks, the dulness becomes more marked, and then gradually increases in intensity and extent ; the respiration is bronchial or tubular ; and the coarse crepita- tion, persisting, is heard over the whole of the consolidated part, but varying in amount as before, and occasionally being replaced for a time by a rhonchus of larger size. Eventually cavities form ; the percussion-note is then often tubular, and there is cavernous respiration with gurgling. This pneumonia may affect any part of the lung, but it usually attacks the apex of one side, and is seldom found in both lungs — at any rate at first. It may last months or years. Here we get a series of signs and symptoms which differ very markedly from those found in simple acute pneumonia. When the case is seen early, the slight amount of weakness, the small dis- turbance in the relation between the pulse and the respiration, the fall of temperature in the morning, and the persistence of the phy- ' On some Anomalous Cases of Phthisis, by Sydney Ringer, M. D. Medical Times and Gazette, Feb. 29, 18(i8. DIAGNOSIS OF SCROFULOUS PNEUMONIA. 217 sical signs and the symptoms after the tenth or twelfth day, the time at which in simple lobar pneumonia resolution takes place ; all these peculiarities show that the case is not one of ordinary in- flammation of the lung. If the patient is seen for the first time at a later period, the disease may be distinguished from simple pneu- monia by the length of time during which it has lasted. It is often, however, dilBBcult to establish a distinct connection between the previous illness and the present symptoms, and the case may be one of simple pneumonia complicating an already existing disease. Under such circumstances, the fact of crepitation being heard over the whole of the consolidated surface instead of only at its circum- ference, the severity of the physical signs in comparison with the comparative mildness of the general symptoms, and the continu- ance of these, and of an elevated temperature, after the time when in an ordinary case resolution might be reasonably expected, will serve to furnish a distinction. Between commencing scrofulous pneumonia of the apices and gray tubercular formation, the diagnosis is much less easy. The definite period of commencement would lead us to suspect the former disease, but so long as there are no very positive physical signs it is necessary to reserve a decision. Later, when the dulness has become established, and all the signs of consolidation are found, the want of correspondence between the physical signs and the general symptoms, the limitation of the disease to one side, and the history of the case showing the absence of preliminary failure of health, will be sufficient grounds for the diagnosis of scrofulous pneumonia. It is, however, by no means uncommon to find scrofulous pneumonia occurring as a complication of tubercle, and the presence or absence of tubercle is therefore an important question to decide in every case of pulmonary phthisis. If the apices of the lungs are unaffected, tubercle may be excluded. If the pneumonia attacks only one apex the presence of tubercle is doubtful ; but if after several months the opposite apex still re- mains apparently free from disease, the only changes being an ex- tension of the physical signs on the side first affected, the case is probably one of uncomplicated scrofulous pneumonia. If both apices are the seat of inflammation, the presence of tubercle is probable, and if the double pneumonia succeed to 218 CHROXIC PULMONARY PHTHISIS. already suspected tuberculous disease of these parts, it goes far to confirm the previous suspicions. In fibroid phthisis the disease is limited to one side. The affected side is retracted, often considerably ; the front of the chest is flat- tened, the respiratory movement slight, and the heart more or less displaced. If the disease occupies the left side the heart is drawn upwards, if the right side the heart is drawn towards the middle line, Eeal elevation of the heart must not be confounded with apparent elevation through unnatural obliquity of the ribs occur- ring in long-chested children. There is dulness on percussion over the seat of disease — usually the middle third of the lung ap- proaching more or less to the apex. The note is often tubular, and there is unusual parietal resistance. Auscultation shows harsh, bronchial, or blowing respiration, with coarse rhonchus and increased resonance of voice, passing, as cavities form, into caver- nous respiration, with gurgling and pectoriloquy. A systolic basic murmur is sometimes present, produced probably by pressure. There is no febrile disturbance, on the contrary the temperature is unusually low. In extensive consolidation of the upper part of one side only, the other side giving no — not even the faintest — sign of disease, the diagnosis lies between scrofulous pneumonia and fibroid phthisis. The existence of retraction of the affected side, the altered position of the heart, and the absence of fever, exclude the former disease. It is distinguished from chronic pleurisy with retraction by the resonance at the base, and by the signs of cavity. Tubercle may exist in combination with this form of pulmonary phthisis, and should always be suspected "if the apex of the dis- eased lung is involved in the solidification." The probability is increased if there is moist crackling in the supra-spinous fossa, and "if, with the slightest dulness at the summit of the opposite lung, there is any moist crepitation, doubt is practically no longer possi- ble." The above sketch of fibroid phthisis is taken from a paper by Dr. Andrew Clark on that disease, read before the Clinical Society, Feb. 28, 1868. Dr. Clark's paper referred only to adults, but the disease is sometimes found in children of six or eight years and upwards. In its relation to them the subject has not as yet been thoroughly worked out, but there is no reason to believe that they are affected by it differently from their elders. It is not always easy to satisfy ourselves as to the existence of a DIAGNOSIS OF A CAVITY. 219 cavity in the lung, for, although present, it may give rise to no very positive signs, and, again, although absent, the physical signs usually indicative of excavation may be present. In infants, and children of three or four years old, the signs of a cavity are often very obscure, consisting merely in bronchial breathing with submucous rhonchus and bronchophon3^ Here no positive opinion should be hazarded. It must be remembered, however, that at such an age ulceration of the lung is a rare con- dition. In the case of older children a dull, tubular, or tympanitic per- cussion-note, with gurgling and bronchophonic resonance of the voice — signs usually indicative of a cavity — may be produced by dilated bronchi, and are occasionally very closely simulated in some cases of pleuritic effusion. In the case of this latter disease cavernous breathing, with large metallic bubbling rhonchus, and pectoriloquy, may be sometimes heard at the upper part of the affected side, and may then, if the disease is chronic, give rise to much hesitation, for excavation of the lung may be an accompani- ment of the empyema. If, however, the opposite side is perfectly healthy, and especially if ordinary vesicular breathing can be detected at any point, however limited, of the apex of the suspected lung, a cavity may be excluded.' Between the dilated bronchus and a cavity resulting from ul- ceration, the diagnosis is extremely difficult. The probabilities are in favor of dilated bronchi if the apex of the affected lung appears healthy, and if the cavernous signs are heard at about the middle of the lung, and give the idea of several small cavities lying in a horizontal or diagonal line.^ If the area over which the cavernous signs are heard gradually increases in extent, our suspicions point to a cavity, for dilated bronchi may remain unaltered for months. In all cases a careful examination of the sputum should be made with the microscope, if any expectoration can be obtained, to search for fragments of elastic tissue. Such fragments, if areolar, are conclusive evidence of ulcerative excavation.^ In cases, also, of empyema, with suspected cavity, the presence of fragments of elastic tissue in the sputum will at once decide the question in favor of a cavity. It is necessary, however, to make many exa- 1 Rilliet and Barthez, vol. iii. p. 680. 2 Dr. A. Clark, loc. cit. 3 Dr. A. Clark, iu Trausactlous of the Pathological Society of London, 1S55. 220 CHRO^riC PULMONARY PHTHISIS. minations of the same sputum before deciding against the presence of the elastic tissue. Prognosis. — Pulmonary phthisis is generally fatal sooner or later, but its course from bad to worse is not always uninterrupted. Great caution should therefore be exercised in giving a prognosis, for a child who is apparently in the greatest danger may suddenly begin to improve, and his more serious symptoms may for the time completely disappear. Such amendment is apt to excite amongst his friends hopes, seldom destined to be realized, of a complete recovery. This improvement often happens in cases where the local symp- toms are temporarily aggravated by a bronchitic attack, but it may also occur in cases of apparent uncomplicated gray tubercle, and it is not so very uncommon to find recovery taking place in cases which present all the characters of acute tubercular formation. When, however, the chronic disease is once fairly established, the apparent improvement is almost always speedily followed by a relapse, all the symptoms returning with increased severity. Pulmonary phthisis often lasts much longer than could be ex- pected from the character of the physical signs. A child may continue in the same state without much improvement, or aggrava- tion of his symptoms, for years, dying eventually of tubercular disease of some other organ, or even of a totally different com- plaint. It becomes, then, a question of much importance to decide in any given case upon the prospects of a lengthened course, and such decision will depend in a great measure upon the presence or absence of gray tubercle. Uncomplicated scrofulous pneumonia is often very sluggish in its course ; and if not extensive at first, may spread over the lung very slowly. It is, however, always liable to take on suddenly a more rapid course, and too great con- fidence should not be excited by the apparent inactivity of the disease. Fibroid phthisis is still slower in its progress : in such cases the prognosis, so far as that can be founded upon the anatomical cha- racters of the phthisis, is of all the varieties the least unfavorable. In the case of gray tubercle, either alone or complicating the other varieties of pulmonary phthisis, very little hope can be given. The most favorable change appears to be its complication with fibroid phthisis : by this means life is often prolonged for a considerable time. The presence of tubercle in other organs, CAUSES. 221 especially the bowels, is very unfavorable. Diarrhoea is not un- frequently the direct cause of death. Death may take place suddenly, without being preceded by any great aggravation of the symptoms. Usually, however, it is ushered in by increased severity of the cough, sensation of oppres- sion about the chest, lividity of the face, increasing weakness, and all the signs of exhaustion. In a certain proportion of cases rup- ture of the lung takes place, producing pneumothorax : this is seldom recovered from. Causes. — Of the causes of pulmonary phthisis, so far as that is the result of tubercle of the lung, nothing need be added to what •has already been stated with regard to tuberculosis. Scrofulous pneumonia may, however, arise quite independently of any of the causes there mentioned. Inflammation of the lung occurring in an unhealthy child is seldom simple. The deposit, instead of becoming absorbed, is apt to remain for a considerable time, then slowly to degenerate, and to cause ulceration and cavities, which spread until the whole lung, or the greater part of it, is rendered useless. Besides this there is, however, another means by which the same pathological condition may be set up. According to Dr. Andrew Clark,^ certain dead animal products inserted beneath the skin of a rabbit will produce deposits, first in the lungs, and afterwards in other parts of the body. When the animal is healthy these become absorbed : when he is unhealthy, or being healthy is kept in conditions unfavorable to health, the deposits are not absorbed, but excite secondary de- posits in other parts. The same thing will occur in the human subject : portions of septic matter, from whatever source, retained in contact with a living surface may become absorbed, and may give rise to " secondary deposits in the lungs, to ulceration in the bowels, to clottings in vessels, and to poisoning of the blood."^ Dr. Clark has shown that enlarged tonsils which retain their secre- tions are apt to become loaded with an offensive cheesy matter in a state of disintegration, and to give rise to a curdy, purulent discharge, streaked with blood. In the paper just referred to. Dr. Clark describes a case in which s-uch tonsils were, with an orchitis, the probable cause of fatal scrofulous pneumonia. The pulmonary ' Lectures delivered at the Royal College of Physiciaus, 18G6. 2 See a paper by Dr. A. Clark, in the Medical Times and Gazette, May 23, 1868. 222 CHKONIC PULMONARY PHTHISIS. deposits resulting from the transference of these septic matters to the lung undergo disintegration, excite secondary inflammation around them, and set up the pathological changes which have been described. In scrofulous children tonsils of the character referred to are not uncommon. They are, besides, subject to purulent discharges from the ears, nose, and vagina, to unhealthy ulcerations of the skin and mucous membranes, and to suppurations of the glands. It is possible that all of these may be sources from which absorp- tion can occur to give rise to pulmonary deposits. Treatment. — The directions already given in the preceding chap- ter, with regard to the prevention and treatment of tuberculosis, apply with equal force to the present disease. In the case of pul- monary phthisis there are, however, certain precautions which it is important to attend to. Thus, when the shape of the chest is elongated, and narrowed from before backwards, showing the small size of the lungs, every means must be taken, by exercises care- fully proportioned to the strength of the patient, to increase the capacity of the chest, and invigorate the muscles of respiration. This is effected in a great measure by general exercise ; but, be- sides this, the more special exercises, as the use of the dumb-bells and "of the " chest-expander," are particularly valuable. Drilling, fencing, and other amusements which promote the acquirement of a good' carriage, accustoming the child to throw back the shoulders and expand the lungs, are also of much service. The exertion should not, however, be too violent, or harm rather than good will result. BrQathlessness, or a feeling of oppression about the chest, are signs of labored pulmonary circulation, and should at once indicate repose. The child must be prevented from bending over a table in writing or drawing: he should be accustomed to stand at a desk, breast-high, while pursuing these occupations, so that the necessity for curving his body may be avoided. He should be taught fully to expand his chest, from time to time, by occasional deep inspirations ; and singing or reading aloud are also advisable. Fresh air is of the utmost importance, and daily exercise in the open air should never be neglected if the weather is not damp. If there is any keenness in the quality of the air, a respirator may be used to warm the air before it reaches the lungs. In scrofulous children who are subject to inflammations and suppurations, and to caries of bone, early attention must be paid TREATMENT — GENERAL AND SPECIAL. 223 to these derangements. The child must be kept scrupulously clean, and any discharges from the ears, nose, or vagina, should be at once treated by suitable applications. Where disease of bone is positively ascertained, Mr. Holmes recommends early removal of the whole of the diseased bone ; as internal remedies, such as cod- liver oil and tonics, although useful in improving the general health of the patient, yet appear to exercise no curative influence upon the local disease, and an operation becomes imperative.^ For cheesy tonsils. Dr. Andrew Clark^ advises, in addition to general tonic remedies, alkaline applications to the throat, and gargles of tannin and alum. The action of the skin must be promoted by daily sponging over the whole body with tepid water. When there is any reason to suspect consolidation of the lungs, cold baths must be forbidden. The shock produced by the first contact with the cold water at once drives the blood from the surface to the interior, and causes a sudden increase of the strain upon the vessels of the lungs, as well as of the other viscera. Pulmonary congestion may be pro- duced by this means, and the danger of hemoptysis increased. With regard to the question of climate, what has been said when speaking of tuberculosis applies equally well to the earlier stages of pulmonary phthisis. When, however, softening of the consolidating matter has taken place, and cavities have formed, a warmer climate is desirable ; but even in these cases there are great differences in different patients, and some will require a much less degree of heat than others. Unless there be great irri- tability of the bronchial mucous membrane dryness of the air is of extreme importance, as a dry air, although warm, still possesses bracing properties. If the lungs are very irritable, a certain amount of moisture is of service; and many places, both in Eng- land and abroad, are recommended for such cases. If, however, a suitable climate can be found in their own country, it is well not to send these patients too far from home ; invalids feel acutely the absence of home comforts, and in the last stage of the disease especially, when little good can be hoped for from travel, it is cruel to send them away merely to die. To improve the general condition of the patient the same mea- ' Lancet, 1865, vol. i. p. 59. 2 London Hospital Reports, vol. i., 1864. 224 CHRONIC PULMONARY PHTHISIS. sures must be adopted as have already been recommended for tuberculosis. Our first attention must be directed to the digestive organs, and afterwards, when these have been brought into a more healthy state, cod-liver oil, iron, and other tonics, will be of service. With regard to the special treatment of the lung affection : — so long as there is fever, with dry cough or scanty expectoration, and tightness or oppression of the chest, stimulant expectorants are inadmissible. No lowering measures should be employed, it is true ; but while, on the one hand, we should avoid all measures calculated to increase the depression of strength, we should not, on the other hand, be too eager to administer drugs the action of which would be to increase the irritation of a mucous membrane already in a state of active congestion. Opium, although it allays for the time the irritability of the bronchial tubes, is also unsuit- able, for it diminishes expectoration, and the secretions would, therefore, remain in the tubes to be a source of continued irrita- tion. In such cases we shall best relieve the engorged state of the lung by the administration of remedies tending to produce a copious secretion from the congested mucous membrane, as in the following mixture :' — IJ. Liquor ammonise acetatis, '^iv ; Potas. nitratis, 5j ; Potas. bicarbonatis, ^jss ; Sp. ffitheris nitrici, 5JS3 ; Aqufe carui ad §vj. M. 5SS tertii hora. At the same time the chest should be kept covered with hot lin- seed-meal poultices, frequently renewed ; and the child should be confined to his nursery or bed-room. After the cough has become looser, and the oppression of the chest has subsided, expectorants should be given with an alkali : — I^. Sp. ammonise aromat., Sp. cctheris nitrici, Viui ipecacuanhse, aa 3j ; Pot. bicarbonatis, 5J 5 Infusi calumbffi ad §vj. M. ^ss sexta hora ; and afterwards, when the secretion is free, easily brought up, and the fever has disappeared, an astringent may be prescribed, with expectorants and a little opium : — ' For a child of six or seven years old. COUNTER-IRRITATION. 225 5. Liq. ferri pernitratis, Acidi nitiici diluti, aa 5j 5 Tiiict. camph. c. opio, 3ij ; Oxymel scillae, §j ; Inf. calumbae ad ^vj. M. §ss ter die. On account of the derangement of the stomach, which is so apt to be produced by even small doses of the nauseating expectorants, such as ipecacuanha and squill, it is advisable to combine them with tonics when the state of the patient permits. In this way they are better borne by the stomach, and cause less impairment of the appetite. The alkaline mixtures should not be continued too long: when the secretion is quite free, as shown by the looseness of the cough, the ease of expectoration, and the absence of fever, astringents are required to dry up the secretion, and give tone to the relaxed mucous membrane. In cases where we have reason to believe the consolidation to be owing to unabsorbed pneumonic deposits, alkalies are also ex- tremely useful. Dr. Andrew Clark^ recommends a mixture con- taining bark, iodide of potassium, bicarbonate of potash and ammonia, until the urine is alkaline. If there is much anaemia, he substitutes infusion of calumba for the bark, and adds a few grains of citrate of iron to each dose. The inhalation of sprays of weak solutions of bicarbonate, nitrate, or chlorate of potash, seems to have a very useful effect in promoting expectoration. A solution of bicarbonate of potash, ten grains to the ounce, ma}' be inhaled in this way twice a day. At a later stage an astringent spray may be used, as three grains of tannin to the ounce of water. Counter-irritation in children must be used cautiously, and is seldom necessary. So long as there is fever, with dry cough, etc., hot linseed-meal poultices are the best applications; and these combined with the measures described above, soon relieve the more acute symptoms. Irritants applied to the chest appear to be most useful in cases where the consolidation is pneumonic in char- acter. In such cases a liniment of croton oil (5j in oj of linimentum saponis) may be rubbed into a limited spot twice a day till pustu- lation, and then once a day for a week. Dr. Buchanan states that he has used this method of counter-irritation to children under two years of age.^ So long, however, as there is much heat of skin, counter-irritants should not be employed. ' See Lancet, Oct. 20, 1866, p. 439. 2 Lecture I., On Diagnosis and Management of Lung Diseases in Children. Lancet, Feb. 1, 1868. 15 CHAPTER X. TUBERCULIZATION OF GLANDS. TtTBERCDLiZATiON OF LYMPHATIC Glands. — Of glands ID generaL Of Bronchial Glands or Bronchial Phthisis. — Symptoms — Produced by pressure on neigbboring organs — Pressure on veins — On nerves — Pliysical signs — Alterations in respiratory sounds produced by pressure on tracbea and broncbi — Modes of termination — Diagnosis. , Tuberculization of Mesenteric Glands or Mesenteric Phthisis (Tabes Mesen- tn-icus). — Symptoms — General — Local — Pressure on veins — Ascites usually tbe result of peritonitis — Perforation of bowel — Diagnosis — Only to be made by feeling the glands — Diagnosis from fecal accumulations — From tubercle of omentum. Anatomical Characters of Enlarged Tubercular Glands. Treatment. The lymphatic glands often become the seat of tubercle, not only those which are external, but also those occupying the thora- cic and abdominal cavities. In children, the lymphatic glands are exceedingly liable to become enlarged from neighboring irritation or inflammation, some irritating matters being conveyed into them by the lym- phatics coming from the inflamed part. This is well seen in the case of impetigo of the head or face, when the glands of the neck, or those under the chin — according to the seat of the eruption — become actively congested, serum is poured out, lymph is exuded, and the size of the glands is increased. In tuberculous children, active congestion of the glands tends to the formation of tubercle within them. If, then, after the cure of the primary disease the enlarged glands remain large, and this increase in size persists for a long time, without any tendency to diminish, they are probably tubercular.^ Such glands are oval or round, hard, uneven on their surface, and their outline is irregular. They are not tender, and the skin over them is colorless, and is ' Jenuer on Tuberculosis, Medical Times and Gazette, Oct. 26, 1861. BRONCHIAL PHTHISIS. 227 not adherent. Occasionally they inflame without evident cause : the skin then becomes red ; attaches itself to the gland beneath it ; an abscess forms, bursts, and the tuberculous matter is expelled ; after which the wound heals, or a small opening is left through which a discharge occurs from time to time. This spontaneous inflammation and suppuration of a chronically enlarged gland, should always lead us to suspect tubercle. Sometimes several glands become enlarged and unite, forming a mass, the separate parts of which are connected by thickened and condensed cellular tissue. Glandular enlargement, then, is always an indication of pre- existing inflammation of the part from which the lymphatic vessels which pass through the gland have taken their origin, and if this enlargement continues a long time, it is strong evidence of tubercle. The same cause produces tuberculization of the bronchial and mesenteric glands ; catarrhs or inflammatory affections of the lungs in the one case, and diarrhoea or intestinal irritation in the other, leading to the tuberculous condition. While, however, in the case of tuberculization of the external glands, no other ill effects follow than those due to impairment of function in the glands themselves, in the case of the bronchial and mesenteric glands, other evils are induced. These bodies — in- closed as they are in cavities, and in contact with compressible organs — when enlarged, produce by their pressure secondary dis- turbances, which vary according to the organ whose function is thus interfered with, and according to the more or less yielding material of which the walls of the cavity are composed. Enlarge- ment of the bronchial glands will thus produce more serious consequences — owing to the resisting parietes of the chest — than the same condition of the mesenteric glands which are confined by the more distensible wall of the belly. Tuberculization of the Bronchial Glands, or Bronchial Phthisis. — Tubercular disease of the bronchial glands is exceed- ingly common in consumptive children, as shown by post-mortem examination; but an amount of disease so great as to be detecta- ble during life, is a condition much less frequently met with. In order to afford signs of its presence, the disease of the glands must be sufficient to produce considerable enlargement; for unless their size is so much increased as to produce derangement of 228 TUBERCULIZATION OF GLANDS. function in neighboring organs, the lesion is one which cannot be satisfactorily diagnosed. Symptoms. — After a child has been sujQfering for some time from the general symptoms of tuberculosis, certain special symptoms be- gin to be noticed. These special symptoms may best be grouped according to the causes which produce them. Thus, the glands by their enlargement may press upon the bloodvessels, the nerves, and the air-passages. Pressure upon the superior vena cava, or upon either innominate vein, interferes with the return of blood from the head and neck. As a consequence, we find dilatation of the veins of those parts, and more or less lividity of the face, neck, and upper part of the chest. A certain amount of heaviness and stupor may be pro- duced by the interference with the return of blood from the brain ; and, if the pressure be great, or the quality of the blood much impoverished, puffiness, or even oedema of the face may be found, first appearing, and being most marked about the eyelids. If only one of the innominate veins is exposed to pressure, the symptoms are limited to one side only. Enlargement of the veins of one side of the face and neck, with a prominent jugular vein on that side, should always lead us to suspect bronchial phthisis. The venous engorgement is especially noticeable during coughing. If the congestion is very great, rupture of small vessels may take place, and bleeding occur from the nose or into the lungs. The former is common, but the latter is difficult to ascertain, for children almost invariably swallow blood coming up from the lungs. In a child the discharge of blood from the mouth during coughing, is seldom evidence of haemoptysis. It is almost always the result of epistaxis, the blood flowing down into the back of the throat through the posterior nares. When the nerves passing through the chest are compressed, one of the earliest indications of such pressure is a peculiar character of the cough. The cough becomes spasmodic, occurring irregu- larly in paroxysms like those of pertussis, lasting only a short time, and ending sometimes, although rarely, in a crowing inspira- tion. There is seldom any vomiting. Sometimes the cough is hoarse and dry ; at others it is moist with a rattling of mucus; at others again its quality is unchanged, and presents nothing to attract attention. The voice, like the cough, may be altered in character, but not usually, unless the disease is far advanced. It BRONCHIAL PHTHISIS — PHYSICAL SIGNS. 229 may become hoarse or thick, or even partially extinct, and these different conditions frequently alternate with one another. Violent attacks of dyspnoea occasionally occur, and may assume all the characters of asthmatic seizures; the face becomes livid, the countenance anxious, and the skin cool and damp. Asthma in young children not unfrequently owes its origin to this condi- tion of the bronchial glands. Attacks of spasm of the glottis sometimes are noticed; according to Dr. Ley/ laryngismus stridu- lus is constantly produced by this cause. Physical signs. — The enlarged glands are seated at the bifurca- tion of the trachea, and therefore behind the first bone of the sternum. On percussion there is dulness at that spot, which may extend to a variable distance on either side, and below. It some- times reaches from the sternal notch as far as the base of the heart. Occasionally there is dulness also between the scapulae, but this is not always found on account of the thickness of lung which lies between the glands and the posterior wall of the chest. If any enlarged glands lie underneath the anterior mar- gins of the lungs, a "crack-pot" sound may be heard on per- cussion over the first three ribs. This, however, on account of the natural pliancy of the chest- walls in children, is a common circum- stance, and is not necessarily a sign of disease. The auscultatory signs are due partly to the effects of pressure of the enlarged glands upon the trachea and bronchi ; partly to the unnatural distinctness with which the breath sounds are con- veyed to the surface, for an artificial medium of conduction is formed between the tubes and the wall of the chest. Pressure upon the lower part of the trachea produces during respiration a loud snore, which differs in character from the ordi- nary sonorous rhonchus, and may be frequently heard at a distance from the chest. It is sometimes intermittent. Upon either bron- chus pressure, if considerable, causes weakness of the respiratory sound in the corresponding lung, especially at the base, for a certain amount of collapse of the inferior lobes of the lung may take place with sinking in of the lower part of the thoracic wall at the side. If there is no pressure, but the glands adhere closely to the bronchi on one side, and to the chest-wall on the other, the breath- ' London Medical Gazette, 1834. 230 TUBERCULIZATION OF GLANDS. sounds are tubular with long ringing rhonchus, in front, and also, sometimes between the scapulae behind ; powerful quasi-pectorilo- quous bronchophony may also be produced.^ At the supra-spinous fossge the sounds may be weak, bronchial, or even cavernous, and these different conditions may alternate irregularly with one another. A hum is sometimes heard over the position of the descending vena cava from pressure upon the vein ; and compression of the pulmonary artery produces a systolic mur- mur heard at the second left interspace. The symptoms of bronchial phthisis are blended with those of the general disease, and are often masked by more prominent symptoms due to the same disease of other organs, especially of the lungs. The combination of pulmonary with bronchial phthisis is very common, and the physical signs of the former disease are often perverted and exaggerated by this condition of the glands, as has already been described. Softening of the enlarged glands may take place, and a commu- nication be set up with the lung, producing pneumothorax; or with a large vessel, giving rise to fatal hemorrhage. These methods of termination are, however, rare. Death usually takes place with aggravation of the preceding symptoms, and is not unfrequently hastened by accompanying pulmonary phthisis. Diagnosis. — •In a well-marked case the signs of pressure upon the veins, the dulness over the first bone of the sternum extending to a variable distance on each side, and the paroxysmal cough, point conclusively to bronchial phthisis. Before any signs of pressure exist, and before the size of the glands is increased sufficiently to give rise to alteration of the per- cussion-note, the only symptoms observable are those of tubercu- losis, and present nothing characteristic. The first symptom leading to suspicion is usually the peculiarity in the cough. This is distinguished from the cough of pertussis, which it so much resembles, by the absence of crowing, and of the terminal vomit- ing, or glairy expectoration. Such a cough, if unaccompanied by the auscultatory signs of pulmonary disease, is very distinctive of enlarged bronchial glands. The absence of these auscultatory signs is very important in the diagnosis, as a morning cough of very similar character is occasionally heard in cases of pulmonary ' Walshe on Diseases of the Lungs. Art. Bronchial Phthisis. MESENTERIC PHTHISIS — SYMPTOMS. 231 phthisis with excavation of the lung, and is sometimes also a cha- racteristic of broncho-pneumonia. If in the interval of the fits of coughing there is anything approaching to an asthmatic seizure, or the slightest percussion-clulness at the top of the sternum, little doubt can remain as to the nature of the disease. Alteration in the quality of the voice often accompanies the characteristic cough. If there is doubt in any case, the occurrence of signs of venous pressure at once changes our suspicions into certainty. Mesenteric Phthisis. — Tubercular disease of the mesenteric glands, or tabes mesenterica, is very far from being a common dis- ease ; at any rate it is rare to find enlargement of these glands so great as to be discoverable by the touch, and unless they can be felt, it is impossible to say with anything approaching to certainty that they are enlarged at all. Unless enlarged, their influence upon general nutrition is probably insignificant, for although they may not be quite healthy, yet they are no doubt sufficiently so to carry on their functions with more or less completeness, and there- fore if no increase in size can be discovered, their consideration may be passed over, as far as regards prognosis or treatment of the patient. Symptoms. — The general symptoms are those belonging to the general disease, for the mesenteric glands are only one of many organs the seat of tubercle, although they may be more profoundly affected than other parts of the body. There is usually emacia- tion, as there is in all cases where tubercle is present, but it is not more marked than when other organs are more prominently affected. The appetite is good, sometimes unusually keen. Thirst is moderate. The tongue is pale, clean, and often slimy-looking, and there may be diarrhoea, especially if, as often happens, tuber- cular ulceration of the bowels is a complication of the disease. Vomiting is a rare symptom. The local symptoms are the only ones of any value in the detec- tion of tabes. The belly is at first unchanged in shape, and even as the disease advances does not necessarily become more promi- nent. On the contrary, the abdominal wall is often retracted, and when swollen it may be soft and easily depressed, although it is apt to become tense at times from the accumulation of flatus in the bowels. The wall may also be tense when the size of the glands is very considerably increased. The degree of tension of the parietes is very important, as regards the detection of the en- 232 TUBERCULIZATION OF GLANDS. largement. If the tension be very great, a moderate enlargement may escape notice, owing to the resistance of the abdominal walls, which will not allow the glands to be reached by the finger ; and a tumor which can be easily felt at one visit may at the next be completely concealed by the abdominal inflation, so as to be no longer detectable by the touch. The situation of the tumor is about the umbilicus; the swelling is irregular to the feel, and hard. Its size varies, but may be as large as a foetal head. When the mass is large, it can best be de- tected by pressing the abdominal wall inwards towards the spinal column. When small, Sir William Jenner^ recommends that the parietes should be grasped by the fingers and thumb of one hand, or between the fingers of the two hands, and pressure thus be made laterally, from the sides towards the centre, so as to seize the tumor between the fingers. By this means a swelling the size of a nut can be felt, if the wall is flaccid. The glands are sometimes slightly movable, if the enlargement is not sufficiently great to involve the mesentery in the swelling. There is usually more or less tenderness on pressure, but the tenderness is not necessarily a sign of inflammation of the dis- eased glands, for it is found in cases where no trace of inflammation is discoverable on a post-mortem examination. When the glands reach a considerable size, they may press upon neighboring parts, so as to produce secondary derangements. Thus, pressure upon the nerves may cause cramps in the legs. Compression of the large venous trunks may give rise to oedema of the lower limbs and dilatation of the abdominal veins. If this venous dilatation be very marked, the superficial veins being seen to ramify upon the abdominal wall, and to join the veins of the chest-walls, tabes should always be suspected in the absence of chronic peritonitis or enlargement of the liver. Ascites is not necessarily a result of the tuberculization of these glands, and is rarely produced by direct pressure unless the portal vein is compressed by enlargement of the glands occupying the hepatic notch. It may, however, be produced in a different way : thus, friction of the enlarged glands against the peritoneum lining the abdominal wall may cause inflammation of that membrane. In these cases there is some fever, with increase of abdominal ' Lecture on Tuberculosis. Medical Times and Gazette, Oct. 18G1. MESENTERIC PHTHISIS — DIAGNOSIS. 233 tenderness and colicky pains. The belly becomes tense from gaseous distension of the intestines; and indistinct fluctuation is often felt from adhesion of the bowels one to another, with the addition of a little serous effusion between the coils. Vomiting is not constant, and diarrhoea, if previously present, is not interfered with. The amount of ascites is in these cases not very great, and the sj'mptoms of peritonitis generally are far from being well marked. Adhesion may take place between an enlarged mesenteric gland and a coil of intestines : when the gland softens, perforation of the bowel may result. The course of the disease is slow, but its duration is difficult to estimate, on account of the obscurity of the earlier symptoms. It seems to occur more frequently in boys than in girls, and is seldom found in children under three years of age : most commonly between the fifth and the tenth years. The children do not neces- sarily die ; they sometimes recover. Diagnosis. — The diagnosis of tabes mesenterica can only be made satisfactorily by the sense of touch. If we can hold the mass between the finger and thumb, proof of its presence is indisputable, and this proof is the only one which leaves no doubt upon the mind. Enlargement of the belly is no evidence of the glandular disease, for flatulent distension is in children a common accompani- ment of ill health, and in tabes the abdominal wall is more often retracted than expanded. Wasting, again, is found in almost all chronic diseases tubercular or otherwise ; and diarrhoea is a symp- tom by no means confined to tabes. These symptoms may be present, but they are not a result of the tubercular lesion of the glands, and either alone or combined are useless as indications of the^disorder under consideration. If, as has been said, the superficial veins are distinctly seen to ramify on the abdominal wall, and to join similiar veins on the thoracic parietes, tabes should be suspected, but nothing more than suspicion is allowed by such evidence. Any interference with the portal circulation will produce the same result, and when the abdo- minal wall is tense it is difficult to exclude hepatic disease. Even when by direct exploration the existence of a tumor in the belly has been ascertained, we have still to satisfy ourselves that the tumor is formed by enlarged mesenteric glands. The disease may be simulated by fecal accumulation in the colon, or by tubercular masses attached to the omentum. 234 TUBERCULIZATION OF GLANDS. Fecal accumulations are distinguished by the absence of tender- ness; by the situation of the tumor, which usually occupies the transverse or descending colon instead of the umbilical region ; and by the shape of the mass which is elongated, the long axis being in the direction of the long axis of the bowel in which it is contained. In doubtful cases, a positive opinion should be re- served until the effect upon the swelling of a good injection has been tried. For a child of four years old, an enema^ of a pint or more of soap and water, or thin gruel, containing half an ounce of oil of turpentine and four ounces of olive oil, should be thrown up the bowel by a good syringe. The injection should be retained for a few minutes by firm pressure upon the anus, and then be allowed to escape. If the tumor is due to fecal accumulation, a quantity of pale, brittle lumps will be discharged with the re- turning fluid, and the swelling previously noticed in the belly will be found to have disappeared. If tuberculized glands are the cause of the tumor, the evacuation of gas and fecal matter will only make the presence of the enlargement more manifest, by re- moving the tension of the abdominal wall, and allowing of more efficient exploration of the cavity of the belly. In these cases an enema of sufficient quantity to distend the bowel is of more value than any number of aperients. It is well, also, to remember that fecal accumulation having once occurred, there is great liability to a second collection of the same kind, therefore for some time afterwards a careful watch should be kept over the condition of the bowels. Between tubercular masses attached to the omentum and tuber- cular mesenteric glands the distinction is often very difficult, par- ticularly if the seat of the tumor happens to be the umbilical region. When their seat is the omentum the masses are more superficial, are less nodular, and have better defined edges than is the case where the glands themselves are diseased. They are usually also more freely movable. In a case mentioned by MM. Eilliet and Barthez,'' a cancerous pancreas offered some resemblance to the tumor of tabes mesente- rica, but was distinguished, amongst other signs, by the presence of vomiting, jaundice, and abdominal pains. ' Jenner on Tuberculosis, Meiiical Times and Gazette, Oct. 1861. * Maladies des Enfauts, vol. iii. p. 817. ANATOMICAL CHARACTERS, 235 Anatomical characters of enlarged tubercular glands. — The forma- tion of tubercle usually begins in the centre of the gland, and from this point the morbid change spreads gradually towards the circumference. Occasionally, however, several distinct points of tubercle are seen at different parts of the same gland ; these may increase in size, and approach one another until the whole gland is converted into tubercular matter. The color of the diseased gland is usually yellow, but sometimes a gray point is-seen in the centre, surrounded on every side by the yellow mass. The glands are not all equally affected. Some remain perfectly healthy while others are diseased ; some which are diseased remain small, while others undergo- considerable enlargement. The alteration in these glands consists, according to Yirchow,* in a great increase of their cell elements, with not unfrequently hypertrophy of the connective tissue. The cells become large, round, tough, transparent, finely granular, and contain one or two large nuclei. They have a great tendency to undergo degeneration by fatty change. A gland so altered is seen at first as a large spongy-feeling body ; its color is reddish, passing, where the fat change is much advanced, into a dirty, opaque-white color. If there is much hypertrophy of the connective tissue the gland be- comes very hard. After a time the whole gland becomes thick, tough, anaemic-looking, and dry, quickly transforming into a yellow, opaque, cheesy mass. The capsular vessels become much enlarged, and the capsule itself thicker and divisible into two layers. After a time the glands soften ; the softening process usually begins at the centre, although isolated points at the circumference may first undergo this change. These, on section of the gland, are sometimes seen to be connected by prolongations of softening with the softened centre. Evacuation of the liquefied matter may eventually take place, a communication being formed with some neighboring organ. The tubercle sometimes becomes cretaceous, as it does in other organs. In bronchial phthisis the glands lying at the bifurcation of the trachea are usually the most enlarged. Those accompanying the ' See Gulstonian Lectures on the Nature aud Affiuities of Tubercle, by Regiuald Southey, M. D. Oxon. London, 18(37. 236 • TUBERCULIZATION OF GLANDS. bronchial tubes into the interior of the lung are less increased in size, although thej may be seen larger than natural as far as the third or fourth division of the bronchial tubes. A mass formed of these enlarged glands nnay occupy the anterior mediastinum, extending from the base of the heart to the top of the sternum. In mesenteric phthisis the glands often unite to form an irregu- lar nodular mass as large as the fist, or even larger. The mass is situated in front of the vertebral column. If the mesentery is involved, the tumor is fixed ; if the mesentery is free, the mass can be moved a little to one side or the other. Treatment. — On account of the readiness with which the lymph- atic glands, both internal and external, become enlarged in tuber- culous and scrofulous children, it is of great importance to remove as quickly as possible any local irritations, the continuance of which would lead to the glandular disease. All purulent dis- charges, skin eruptions, and ulcerations of the skin and mucous membranes must therefore receive prompt attention. "Little colds" must not be neglected, as disease of the bronchial glands is produced by pulmonary irritation ; and the danger of tubercular enlargement of the glands of the mesentar}^ is an additional reason for keeping a careful watch over the condition of the stomach and bowels. In bronchial and mesenteric phthisis the general measures to be employed are the same as those already recommended for the treatment of tuberculosis. Cod-liver oil is said to be of especial value in these cases, and should be given with the precautions previously enjoined. In the case of bronchial phthisis, counter- irritation should always be adopted, either in the form of pustula- tion with croton oil, or, for children of six or seven years old, by the application of a blister of the size of a two-shilling piece, which must be kept open for some time. The counter-irritant should be applied to the upper part of the sternum in front, and between the scapulae behind, alternately. The internal use of iodide of iron is also strongly advocated. The syrup of the iodide may be made use of, or a mixture containing half a grain of iodide of potassium, and five grains of potassio-tartrate of iron, in half an ounce of distilled water, three times in the day. The quantity of the iodide of potassium may be gradually increased. For mesenteric phthisis, the ointment of iodide of lead may be rubbed into the belly twice a day, and iodide of iron should be TREATMENT. • 237 given internally as recommended above. Should peritonitis occur, hot linseed-meal poultices applied to the belly, and opium given cautiously by the mouth, form the best remedies. The diarrhcea which is so frequent an accompaniment of the glandular disease should be arrested as rapidly as possible. For the treatment oi this complication the reader is referred to the chapter on tubercu- losis, and to that on chronic diarrhoea. Small enemata of warm starch containing five or ten drops of tinct. opii are very useful in these cases. Unfortunately, the diarrhcea is, in many instances, the result of accompanying tubercular ulceration of the bowels ; if so, all our efforts will prove of little avail in retarding the fatal termination. CHAPTER XI. DIET OF CHILDEEN IN HEALTH AND DISEASE. Diet in Health. — From birth to six months old — From six to twelve months — From twelve to eighteen months — From eighteen months to two years — After two years. Diet in Disease. — In simple atrophy — In chronic diarrhoea — In chronic vomiting — In rickets — In mucous disease — In tuberculosis and pulmonary phthisis. On account of the importance of the subject of diet in relation to children, both in health and disease, the maintenance of their health, and the treatment of their several disorders, being mainly dependent upon a proper regulation of their food, it has been thought advisable to devote a chapter especially to this subject. Directions upon this matter, to be of any service at all, must be plain, minute, and exhaustive. Nothing should be left to the dis- cretion of the attendants. The articles of food, the quantity to be given, the hours at which the meals are to be taken, and, when necessary, the exact method in which the food is to be prepared, should be all accurately stated and written down, or mistakes will almost certainly be committed. In the following pages will be found dietaries, carefully arranged and tabulated, suitable to infants and children, both in health and disease. It should be stated, however, that the quantities given below are not intended to be invariable. It would be impossible to lay down rules which would be found suitable to all children. Some require and can digest much more than others ; the quanti- ties, therefore, must be adapted in each particular case to the re- quirements and capabilities of the child. The amounts of farina- ceous food ordered can, however, seldom be exceeded with safety. Diet in Health. 1. from birth to six months old. Diet 1. If the child be suckled, and the breast-milk be found in all respects suitable : — No other food. FROM BIRTH TO SIX MONTHS OLD. 239 The child should take the breast alternately every two hours for the first six weeks; afterwards, every three hours, except between 11 P. M. and 5 or 6 A. M. In cases where the secretion of milk is slow to be established, and the quantity drawn is insufficient to supply the wants of the infant, the following food may be given as an addition to the breast- milk, until the secretion becomes sufficiently abundant: — One tablespoonful of fresh cream. Two tablespoonfuls of whey. Two tablespoonfuls of hot water. This mixture must be taken from a feeding-bottle. The whey is made fresh in the house by adding one teaspoonful of prepared rennet to a pint of new milk. The coagulated casein is removed by straining through muslin. Diet 2. If the infant be brought up by hand : — Kew milk and lime-water, in equal proportions. Three to four ounces, sweetened with a teaspoonful of sugar of milk are to be given at first every two hours from a feeding-bottle. The proportions of milk and lime-water must be varied accord- ing to the age of the infant. From six weeks to three months one-third of lime-water may be used ; and from three to five months this quantity should be re- duced to one-fourth. Diet 3. If the infant be partially suckled, the breast-milk being poor and scanty : — The breast must be given only twice a day. For the other meals, the child must be fed upon milk and lime- water as directed in Diet 2. Up to the age of six months the milk should be warmed by dipping the bottle containing it into hot water. After the age of six months it may be boiled if convenient. New unskimmed milk should always be used. If the milk has been previously skimmed, a teaspoonful of cream must be added to each meal. In all cases where the child is artificially fed, the utmost atten- tion should be paid to the cleanliness of the feeding-bottle. 240 DIET IN HEALTH. 2. FROM SIX TO TWELVE MONTHS OLD. Five meals in the day. Diet 4. First meal, 7 A.M. One teaspoonful of baked or boiled flour carefully prepared with a teacupful of milk. ^Second meal, 10.30 A. M. Third meal, 2 P.M. A breakfastcupful of milk alkalinized, if necessary, by fifteen drops of the saccharated solution of lime.^ Fourth meal, 5.30 P.M. Same as the first. Flth meal, 11 P.M. Alkalinized milk, as before. For the second meal, twice a week, may be given the yelk of one egg, beaten up with a teacupful of milk. The method of preparing boiled flour is given on page 46. Chapman's "entire wheaten flour" should always be used. It is much to be preferred for children to the ordinary wheaten flour, containing as it does the phosphates of the wheat, and the cerealin, a peculiar body which changes starchy matters into dextrine. The barked flour may be varied from time to time with the same quantity of some other farinaceous food, or of Liebig's " food for infants" (Mellin's).^' If there be constipation, a teaspoonful of fine oatmeal can be used instead. Diet 5, {For a Child about ten months old.) First meal, 7 A.M. A dessertspoonful of pearl-barley jelly, dissolved in a break- fast cupful of milk, and sweetened with loaf-sugar. Second meal, 10.30 A. M. A breakfast cupful of milk, alkalinized, if necessary, by fifteen drops of the saccharated solution of lime.^ 1 The solution of lime need only be used in cases where discomfort has been noticed after the milk meal. « Seepage 48. ' See note 1. FROM SIX TO TWELVE MONTHS OLD. 241 Third meal, 2 P. M. The yelk of one egg beaten up in a teacupful of milk. Fourth ?nea?, 5.30 P.M. Same as the first. Fifth meal, 11 P. M. Same as the second. Pearl-barley boiled for six hours forms, on cooling, after the water has been strained off", a jelly which dissolves readily in warm milk. Diet 6. {To alternate with the i^receding?) First meal, 7 A.M. Half a teaspoonful of Cadbury's cocoa essence,^ boiled for ^ one minute in a breakfastcupful of milk. Second meal, 10.30 A. M. A breakfastcupful of milk alkalinized, if necessary, by fifteen drops of the saccharated solution of lime. Third meal, 2 P. M. A teacupful of beef-tea"^ (half a pound of meat to the pint). A rusk. Fourth meal, 6.30 P. M. A dessertspoonful of pearl-barley jelly, dissolved in a break- fastcupful of milk, and sweetened. Fifth meal, 11 P. M. Same as the second. • In Cadbury's Cocoa two-thirds of the fatty matter are removed. It is there- fore more digestible than the ordinary cocoas, and far better adapted for an infant's diet. 2 Beef-tea is to be made in the following way. Put half a pound (or a pound, according to the strength required) of rump-steak, cut up into small pieces, into a covered copper saucepan with one pint of cold water. Let this stand by the side of the fire for four or five hours, and let it then simmer gently for two hours. Skim well and serve. The meat used should be as fresh as possible — the fresher the better — and should be cleared beforehand of all fat or gristle. If this precaution be neglected, a greasy taste is given to the beef-tea which cannot be afterwards removed by skimming. The saucepan used should be made of copper or tin. Iron saucepans should not be used unless enamelled. In re-warming beef-tea which has been left to cool, care must be taken to warm the tea up to the point at which it is to be served, and no higher. It should on no account be allowed to boil. 16 242 DIET IN HEALTH. It is advisable, as a rule, to avoid giving intermediate meals, and therefore the meals should be made sufficiently large to satisfy all reasonable demands. If the child requires food before 7 A. M., on waking from sleep, a little milk may be given him. A healthy child, between ten and twelve months old, will re- quire from a pint and a half to a quart of milk in the twenty-four hours. 3. from twelve to eighteen months old. Diet 7. First meal, 7.30 A. M. A rusk, or a slice of stale bread, well soaked in a break- fastcupful of new milk. Second meal, 11 A. M. ^ A drink of milk ; a plain biscuit or slice of thin bread-and- butter. Third meal, 1.30 P. M. A teacupful of good beef-tea (a pound of meat to the pint), or of beef-gravy, with rusk ; A good tablespoonful of light farinaceous puddihg. Fourth meal, 6 P. M. Same as the first. Fifth meal, 11 P. M. (if required). A drink of milk. Diet 8. {To alternate with the preceding^ First meal, 7.30 A. M. The yelk of a lightly-boiled egg ; A slice of thin bread-and-butter ; A cupful of new milk. Second meal, 11 A. M. A drink of milk ; A slice of thin bread-and-butter. Tliird meal, 1.30 P. M. A mealy potato, well mashed with a spoon, moistened with two tablespoonfuls of good beef gravy ; A cupful of new milk. FROM TWELVE TO EIGHTEEN MONTHS OLD. 243 Fourth meal, 6 P. M. A rusk, or slice of stale bread, well soaked in a breakfast- cupful of milk. Fifth meal, IIP. M. (if required). A drink of milk. The fifth meal at 11 P. M. should never be given unnecessarily. The sooner a child becomes accustomed to sleep all night without food the better. When, however, he wakes in the morning, re- freshed by his night's rest, he should never be allowed to remain fasting for an hour or more until his breakfast is prepared. A drink of milk, or a thin slice of bread-and-butter, should be given at once. Some children will take larger quantities than others at one meal ; but if the meals are made very large, their number must be reduced in proportion. Many children between twelve and eighteen months old, will be found to do well upon only three meals a day, as in the following: — Diet 9. • First meal, 8 A.M. One teaspoonful of baked flour ; One teaspoonful of fine oatmeal ; Three-quarters of a pint to a pint of fresh milk ; A little white sugar. Second meal, 1 P.M. The same, with the addition of the yelk of one egg. Third meal, 5 P. M. Same as the first. In this diet the baked flour and the oatmeal are first beaten up till smooth, with four tablespoonfuls of cold water, and are then boiled. The milk and sugar are then added, and the mixture is boiled till it thickens. For the second meal, the yelk of Qgg is stirred up in the sauce- pan and boiled with the rest. If the child requires anything early in the morning, or at 11 P. M., he may take a drink of milk, or a thin slice of bread-and- butter. A healthy child of a year to eighteen months old will usually take between two and three pints of milk in the four and twenty hours. 244 diet in health. 4. from eighteen months to two years old. Diet 10. First meal, 7.80 A. M. A breakfastcupful of new milk ; A rusk or a good slice of stale bread. Second meal, 11 A. M. A cup of milk. Third meal, 1.30 P. M. Underdone roast mutton, pounded in a warm mortar, a good tablespoonful ; One well mashed potato moistened with two or three tablespoonfuls of gravy. For drink, milk and water or toast- water. Fourth meal, 6 P. M. A breakfastcupful of milk ; Bread-and-butter. After the age of eighteen months it is well to omit the meal at 11 P.M. A healthy child of eighteen months old should sleep from 6 P. M. to 6 A. M. without waking. Diet 11. {For a child of the same age.) First meal, 7.30 A. M. A breakfastcupful of new milk ; The lightly-boiled yelk of one egg ; A thin slice of bread-and-butter. Second meal, 11 A. M. A cup of milk Third meal, 1.30 P.M. A breakfastcupful of beef-tea (a pound of meat to the pint), containing a few well-boiled asparagus-heads, when in season, or a little thoroughly stewed flower of broccoli ; A good tablespoonful of plain custard pudding. Fourth meal, 6 P. M. A breakfastcupful of milk ; Bread-and-butter. These diets can be given on alternate days. DIET IN SIMPLE ATROPHY. 245 Between tlie ages of two and three years the same diets may be continued. Meat can, however, be given every day, and a little well-stewed fruit may be occasionally added. The morning and evening meals should always consist princi- pally of milk. Diet in Disease. DIET IN simple ATROPHY. For a child of two or three months old, brought uj) by hand, weakly and emaciated, in ivhom milk with lime-water excites griping and flatulence, with occasional attacks of vomiting and purging} In these cases we can often succeed in rendering the milk and lime-water digestible by adding an aromatic. Thus, to half-a-pint of cold milk add a teaspoonful of caraway-seeds or chopped cinnamon, inclosed in a small muslin bag, and boil for five minutes. The bag is then withdrawn, and the lime-water, and milk-sugar, are afterwards added as usual. If this do not succeed, one of the diets given below can be tried. Diet 12. The child is to be fed every three hours from a feeding-bottle with the following, in alternate meals : — 1. One teacupful of Liebig's food for infants (Mellin's), dissolved in a teacupful of new milk and water (equal parts), with the addition of one tablespoonful of cinnamon or dill-water. 2. A teacupful of fresh whey containing a teaspoonful of cream. If the amount of milk given above cannot be digested, as often happens, the proportion of water used to dilute the milk may be increased to two-thirds ; or in some of the meals the milk may be altogether omitted, using instead barley-water, or equal parts of barley-water and weak chicken-broth, in which the Liebig^s food can be dissolved. In the above cases Dr. Meigs^ recommends the following: — Diet 13. A scruple of gelatine (i. e., a square inch of the gelatine cake) is soaked in cold water and is then boiled for ten or fifteen minutes ' In all these cases a wet-uurse should be provided if possible. 2 Meigs and Pepper on Diseases of Children. Pliiladelphia, 1870. 246 DIET IN DISEASE. in half-a-pint of water until it dissolves. To this, at the termina- tion of the boiling, is added, while stirring, three ounces of milk, and a teaspoonful of arrowroot, the latter having been previously mixed into a paste with a little cold water. Lastly, just before re- moval from the fire half an ounce of cream is stirred up with the rest, and the whole is sweetened with loaf sugar. Of this food three or four ounces or more can be given every two or three hours from a feeding-bottle. The above diets are suitable to all infants suffering from simple atrophy due to improper feeding. It will, however, be necessary to vary the quantities somewhat according to age. Thus, a child of six months old will usually be able to take a teaspoonful of Liebig's food for infants, dissolved in milk more or less diluted for each meal. For a child of the same age. Dr. Meigs' food may be strength- ened by increasing the quantity of milk to six or ten ounces, and of cream to one or two ounces. DIET IN CHRONIC DIARRHCEA. For a child of twelve months old, luho can hear milk: purging not very severe. Diet 14. A teaspoonful of Liebig's food for infants (Mellin's) every three hours, dissolved alternately in milk and water (equal parts), and in equal parts of weak veal broth and barley water. If no milk at all can be digested, a good diet is the following : — Diet 15. First meal, 7 A. M. One teaspoonful of Liebig's food for infants (Mellin's), dissolved in a teacupful of veal broth and barley water (equal parts). Second meal, 11 A. M. One tablespoonful of cream in a teacupful of fresh whey. Third meal, 2 P. M. The unboiled yelk of one egg beaten up with fifteen drops of brandy, a tablespoonful of cinnamon water, and a little white sugar. Fourth meal, 5 P. M. Six ounces of beef-tea (a pound to the pint). DIET IN CHRONIC DIARRH(EA. 247 Fifth meal, 11 ^.M. Same as the first. After a week or ten days a little milk can be introduced into the diet, beginning cautiously, and only once in the day. Thus, for the first meal milk may be substituted for the veal broth and be added to the barley-water and Liebig's food. If this be found to agree, the same change may be made in the fifth meal. Another, consisting partially of milk, for a child of twelve months old : — Diet 16. First meal, 7 A. M. One teaspoonful of Cadbury's cocoa essence boiled for one minute with a teacupful of milk. Second meal, 10 A. M. A teacupful of beef-tea (a pound to the pint). Third meal, 2 P.M. A teacupful of milk alkalinized with fifteen drops of saccha- rated solution of lime. Fourth meal, 5 or 6 P.M. The yelk of one Qgg beaten up with brandy and cinnamon water, as in Diet 16, or beaten up with a teacupful of veal broth and barley-water (equal parts). Fifth meal, 11 P. M. One teaspoonful of Liebig's food for infants (Mellin's) dissolved in a teacupful of warm milk. If the child be much reduced by the purging, the diet should be simpler in character and the meals should be smaller, more fre- quently repeated, as in the following : — Diet 17. {For a weakly child of twelve months old.) First meal, 7 A. M. Four ounces of whey with a teaspoonful of cream. Second meal, 9.30 A. M. Four ounces of veal broth (half a pound to the pint). Third meal, noon. A teaspoonful of pearl barley jelly, dissolved in four ounces of whey. 248 DIET IX DISEASE. Fourth meal, 2. SO "P. M.. Four ounces of milk and lime-water (equal parts) witli a tablespoonful of cinnamon- water. Fifth meal, 5 P. M. One teaspoonful of Liebig's food for infants (Mellin's) dis- solved in four ounces of barley-water. Sixth meal, 9 P.M. Same as the second. During the night whey or barley-water may be given. If the purging be very severe, all regular meals should be dis- continued, and the child be supplied with any of the above foods in quantities of one tablespoonful every quarter of an hour. Milk, however, is seldom found to agree. Diet 13 will often succeed in these cases. DIET IN CHRONIC VOMITING. In this disorder the food must be given in minute quantities, one teaspoonful in many cases being all that can be retained at one time. This may be repeated every ten minutes. Choice may be made from the following: — Diluted whey with cream, as in Diet 1, Milk and lime-water with cinnamon-water. One teaspoonful of Liebig's food for infants (Mellin's) dis- solved in four ounces of milk and water (equal parts), or in equal parts of weak veal broth and barley-water. Dr. Meigs' food. {Diet 13.) Whatever the food may be, it should be given cold or hot, not tepid. If the vomiting be only occasional and not severe, Diet 17 may be tried, suiting the quantities to be given at one time to the de- gree of irritability of the stomach. \ DIET IN RICKETS. Here the kind of diet will depend in a great measure upon the condition of the alimentary canal. In almost all cases it will be found that farinaceous food has been supplied in excessive quan- tities, and the amount will have to be considerably reduced. If the bowels are relaxed, with loose, slimy, offensive motions, Diets 15 and 16 will be suitable. If the motions are healthy, Diets 5, 6, DIET IN MUCOUS DISEASE. 249 7, 8, 10, 11, may be made use of, according to the age of the child. If the child be sixteen or eighteen months old, the following is of service : — Diet 18. First meal, 7.30 A. M. One or two teaspoonfuls of Liebig's food for infants (Mel- lin's) dissolved in a breakfastcupful of milk. Second meal, 11 A. M. A breakfastcupful of milk alkalinized by fifteen drops of the saccharated solution of lime. Third meal, 2 P. M. A good tablespoonful of well pounded mutton chop with gravy, and a little crumbled stale bread ; Or, a good tablespoonful of the flower of broccoli well stewed'with gravy until quite tender ; A little dry bread ; For drink, milk and water. Fourth meal, 6 P. M. Same as the first ; Or (if no meat has been given) the lightly-boiled yelk of one Qgg ; A little thin bread-and-butter ; Milk and water. DIET IN MUCOUS DISEASE. (Farinaceous food is as much as possible to be avoided.) Diet 19. {For a Child about seven years of age and upwards) Breakfast, 8 A. M. Three-quarters of a pint of fresh milk alkalinized by twenty drops of the saccharated solution of lime; A thin slice of well-toasted bread. Dinner, 12. A small mutton chop without fat, broiled ; A little well-boiled spinach or French beans, according to season : 250 DIET IN DISEASE. A thin slice of well-toasted bread ; Half a wineglassful to a wineglassful of sound sherry, diluted with twice its bulk of water. Tea, 4 P. M. Same as breakfast. Supper, 7 P. M. A breakfastcupful of beef- tea (a pound to the pint). Diet 20. {For the same) Breakfast, 8 A. M. Half-a-pint of new milk, alkalinized with fifteen drops of the saccharated solution of lime ; A thin slice of cold roast beef or mutton ; A thin slice of well-toasted bread. Dinner, 12. A little boiled sole or turbot (without melted butter). A thin slice of stale bread. A large wineglassful of claret, diluted with an equal bulk of water. Tea, 4 P. M. A poached egg on a thin slice of dry toast. Milk and water. Supper, 7 P. M. Three-quarters of a pint of alkalinized new milk. Diet 21. {For the same) Breakfast, 8 A. M. One teaspoonful of Oadbury's cocoa essence boiled for one minute in half a pint of milk; A slice of thin dry toast. Dinner, 12. The wing of a roasted or boiled fowl ; A little well-boiled flower of cauliflower, or well-stewed celery ; A slice of thin dry toast or stale bread ; A claretglassful of ligrht bitter ale. DIET IN TUBERCULOSIS AND PHTHISIS. 251 rea,4:F.M. Half-a-pint of alkalinized milk; A lightly boiled egg ; A slice of thin dry toast. Supper, 7 P. M. A breakfastcupful of beef tea (a pound to the pint); A thin slice of dry toast. It would be unnecessary to occupy space by giving more diets of the same kind. The above will serve as illustrations of the kind of food to be recommended. Two of the meals should always consist of milk. For the other meals selection should be made from the followinor : — Meats: — Eoast beef; roast or boiled mutton; roast or boiled fowl (without sauces) ; roasted pheasant, turkey, lark, snipe. No spiced or salted or preserved meats can be allowed. Fish: — Boiled cod, turbot, mackerel, or sole; raw oysters. Eggs : — Boiled or poached. Soup : — Clear turtle ; beef or veal tea. Vegetables : — Cauliflower ; spinach ; turnip greens ; asparagus ; young French beans ; lettuce or celery (stewed). For drink : — Sound sherry or claret (not burgundy), diluted with water; light bitter ale; toast-water; milk and water. DIET IN TUBERCULOSIS AND PULMONARY PHTHISIS. In these diseases farinaceous food, and indeed all fat-forming material, is of value ; but usually the capability of digesting such food is not very great, as in almost all such cases there is a ten- dency to acid dyspepsia. In arranging the diet, therefore, the greatest attention must be paid to the capabilities of the child, so that no more be given him than he is able readily to digest. Diet 22. (For a Child of seven years and up)wards) Breakfast, ^ AM. Half-a-pint of new milk alkalinized with fifteen drops of the saccharated solution of lirne ; A lightly boiled egg ; Thin bread and butter. 252 DIET IN DISEASE. Dinner, 12 or 1 P. M. A slice of roast beef or mutton with gravy ; A mealy potato well mashed ; Milky farinaceous pudding ; For drink, half a wineglassful of dry sherry, diluted with twice its bulk of water. , Tea, 4 or 5 P. M. A teaspoonful of chocolate or cocoa boiled with half-a-pint of milk ; Thin bread-and-butter, or a rusk. Supper, 7 or 8 P. M. Half-a-dozen raw oysters ; Bread-and-butter. The ordinary cocoa is to be preferred for the third meal, if it can be digested. If it seem too heavy, Cadbury's cocoa essence may be used in stead. Diet 23. {For a Child of the same age) BreaTcfast, 8 A.M. Alkalinized new milk, as much as desired ; A rusk, or bread-and-butter. Dinner, 12 or 1 P. M. A slice of boiled leg of mutton ; A well-boiled carrot or turnip; A spoonful of savory omelet ; For drink, dry sherry and water, as before. Tea, 4 or 5 P. M. Bread and milk. Su'pim; 7 or 8 P. M. A small basin of tapioca soup, or of clear turtle soup. Diet 24. {For the same age.) Breakfast,^ AM. Bread and milk; or, cocoa and milk, as in Diet 22. Dinner, 12 or 1 P. M. Koast or boiled fowl ; DIET IN TUBERCULOSIS AND PHTHISIS. 253 A mealy potato ; Sherry and water ; For dessert, a good buncli of sweet grapes. Tea, 4 or 5 P. M. A liglitly-boiled Q^g ; Thin bread-and-butter : Half-a-pint of milk ; Or, the egg may be beaten up raw with the milk. Supper, 7 or 8 P. M. ' A basin of stronor beef-tea. OBEX. ABDOMEN, in mesenteric phthisis, 231 large in infants, 22 cause of, in rickets, 108 Abdominal bandage, 52, 73, 75 disease, cvy in, 22 muscles motionless in respiration, 22 pain may prevent sucking, 51 Abundant secretion of breast-milk, 30 Accumulation offlatus, causing big belly, 23 fecal matter, 23 may be mistaken for enlarged mesenteric glands, 233 Acidity, treatment of, 56 Acute diarrhoea, 39 treatment of, 56 in rickets, 131 in inherited syphilis, 153 diseases, dangers of, 18 secondary, 18 indigestion, 39 treatment of, 59 Admission into body of acaris lumbri- coides, 172 Advantage of putting child early to breast, 41, 42 Age of milk of importance in choosing wet-nurse, 42 Air, change of, in mucous disease, 168 rickets, 128 tuberculosis, 197 Albuminates, their value in nutrition, 32 Albuminoid degeneration in rickets, 123 Alcohol in mucous disease, 163 Alkalies, their value in artificial feeding, 44 in chronic tuberculosis, 201 in mucous disease, 164 Alkaline sprays for unabsorbed pneu- monic deposit, 225 Aloes in chronic vomiting, 92 mucous disease, 165 Alum in mucous disease, 167 Analysis of bone in rickets, 117 Anatomical characters of chronic diar- rhoea, 69 of enlarged tubercular glands, 235 Anatomical characters — of pulmonary phthisis, 210 of rickets, 114 of tubercle, 185 Ani, prolapsus, treatment of. 182 Aphthje, 39 difficulty of sucking from, 51 treatment of, 58 Appearance of a rickety child, 109 tongue in mucous disease, 157 Aperients for infants, 53 Appetite in chronic diarrhoea, 62 wasting children, 37 to improve, in chronic tuberculosis, 200 Applications, external, 24 Areolar fragments of elastic tissue 'in sputum, 219 Aromatics, value of, for infants, 55, 81 Arrest of growth of bone in rickets, 105 Articulations in rickets, 106 Artificial feeding, 44 Ascaris lumbricoides, 170 admission of, into body, 172 description of, 170 migrations of, 172 symptoms of 176 treatment of, 180 Ascites, a cause of big belly in infants, 22 in tabes mesenterica, 232 Ass's milk, 44, 90 Asthmatic seizures in bronchial phthisis, 229 Astringents for chronic diarrhoea, 81 Astringent sprays for pulmonary phthi- sis, 225 Atrophia lactantium. See Diarrhoea, chronic. Atrophy, simple, from insufficient nour- ishment, 29 Auscultation of chest in infants, 207 Auscultatory signs in bronchial phthisis, 229 of chronic pulmonary phthisis, 207 of fibroid phthisis, 218 of scrofulous pneumonia, 216 256 INDEX. BAKED flour, mode of preparation, 77 Sandage, elastic, to loose joints in rickets, 130 Bandage, flannel, to belly, 52, 73, 75 Baths, cold, 27 danger of, in phthisis, 223 hot, 26 mercurial, 150 mustard, 26 warm, for constipation, 54 colic, 57 convulsions, 58 Belly, large, in rickets, 108 Bending of ribs in rickets, 102 Big belly, causes of, 22 Bilious attacks in mucous disease, 158 Bismuth in acute indigestion, 59 in chronic diarrhoea, 81 Blisters for bronchial phthisis, 236 inadmissible for infants, 26 Blood, expectoration of, by infants, 228 in stools, 62 Blowing breathing, value of, 208 Boiled flour, 46 Bone, analysis of, in rickets, 117 caries of, 197 deformities in rickets, 98 in rickets, ossification of, 114 Bones, flat, in rickets, morbid changes in, 115 . of face, arrest of development of, 99 reconsolidation of, in rickets, 116 Bothriocephalus latus, 171 Brain, enlargement of, in rickets, 120 Breathing, harsh, in pulmonary phthisis, 209 importance of watching, in infants, 22 in bronchial phthisis, 229 in pulmonary phthisis, 208 in rickets, 108, 113 weak, in pulmonary phthisis, 209 Breast, pigeon, in rickets, 101 tuberculosis, 189 Bridge of nose flattened in inherited syphilis, 135, 142 Bronchi, dilated, diagnosis of, 219 Bronchial breathing, value of, 209 phthisis, 227 anatomical characters of, 235 alterations of voice in, 228 asthmatic seizures in, 229 auscultatory signs of, 229 blisters in, 236 cough in, 228 diagnosis of, 230 engorgement of veins in, 228 epistaxis in, 228 hsemoptysis in, 228 hoarse voice in, 229 laryngismus stridulus in, 229 pressure on nerves in, 228^ Bronchial phthisis — pressure on trachea in, 229 pressure on veins in, 228 rupture of vessels in, 228 symptoms of, 228 termination of, 230 treatment of, 236 venous hum in, 230 Bronchitis, difficulty of sucking in, 51 in rickets, 110 treatment of, 131 Butter, excess of, in milk, 30 Buttocks, eruption on, in inherited sy- philis, 136 CAFE-AU-LAIT tint of face, in inhe- rited syphilis, 137 Calomel in chronic vomiting, 92. inherited syphilis, 149, 154 Capsicum, tincture of, in chronic diar- rhea, 82. Care required during dentition, 74 Caries of bone, early removal of, 197 Carpo-pedal contractions in rickets. 111 Casein of cow's milk, coagulability of, 33, 44. Catarrh in rickets, 110 danger of, 123 treatment of, 131 Causes of chronic diarrhoea, 66 pulmonary phthisis, 221 tuberculosis, 193 vomiting, 88 large belly in infants, 22 mucous disease, 159 refusal of breast by infants, 51. rickets, 123 simple atrophy, 29 Cavernous breathing, value of, 209 Cavities in lung, anatomical characters of, 212 cicatrization of, 213 diagnosis of, 218 Cerebral aflections, cry in, 22 sinuses, thrombosis of, 63 Cestode worms, 169, 171 Change of air in pulmonary phthisis, 223 in mucous disease, 168 rickets, 128 tuberculosis, 197 Changes, morbid, in flat bones in rickets, 115. Characters, anatomical, of chronic diar- rhoea, 69. of enlarged tubercular glands, 235 of pulmonary phthisis, 210 of rickets, 114 of tubercle, 185 Chest, deformities of, in rickets, 101 INDEX. 257 Chest- examination of, in infants, 206 expander, the, 199 shape of, in tuberculosis, 189 Chronic diarrhoea. See Diarrhcea. hydrocephalus in rickets, 112 interstitial keratitis, 140 pulmonary phthisis. See Phthisis. tuberculosis. See Tuberculosis, vomiting. See Vomitiiuj. Cicatrices, linear, in inherited syphilis, 137 Cicatrization of cavities in the lung, 213 Cirrhosis of lung, a form of, 213 Clavicle, deformity of, in rickets, 103 Cleanliness of feeding bottle, importance of, 45, 48, 55. Cleft palate, an obstacle to sucking, 51 feeding bottle for cases of, 51 Climate, change of, in mucous disease, 168 in pulmonary phthisis, 223 in rickets, 128 in tuberculosis, 197 Coagulabilityof casein of human milk, 33 Consolidation of bone in recovery from rickets, 116 of lung, chronic, rare in infants, 204 Conduction of laryngeal sounds to chest, 208 Constipation in infants, cause of, 36. enemata for, 54 treatment of, 53 warm bath for, 54 in mucous disease, 159 Contraction of brows in infants, 20 Convulsions, reflex, iufrequency of in wasted children, 20 from indigestion, 39 treatment of, 58 from worms, 176 in rickets. 111. treatment of, 132 Corrosive sublimate in inherited syphi- lis, 149. Coryza, syphilitic, 134 Cough in bronchial phthisis, 228 pulmonary phthisis, 204 worms, 174 Counter-irritants, 26 in bronchial phthisis, 236 in chronic diarrhcea, 79 in pulmonary phthisis, 225 precautions in using, 26 Cowhage for worms, 180 Cow's milk, iudigestibiiity of, 47, 57 Crackpot percussion note, 229 Cracks on skin in inherited syphilis, 135 Cramps of legs in tabes mesenterica, 232 17 Cranio tabes, 100, 117 Cream in artificial feeding, 45, 48 Cretaceous change in tubercle, 187 Croton oil as a counter-irritant, 225 Cry in inherited syphilis, 138 infants, characters of, 22 Curvature of spine in rickets, 100 Cysticercus cellulose, 173 DAMP, danger of, to children, 74 Danger of bronchitis in rickets, 123 damp to children, 74 rickets after chronic diarrhcea, 85 of vomiting and diarrhoea in in- herited syphilis, 138 Death in rickets from intensity of gene- ral disease, 112 mode of, in bronchial phthisis, 230 in pulmonary phthisis, 205 Debility of stomach a cause of vomitin?, 94 ^ Decay of teeth in rickets, 100 Deep inspirations in the treatment of phthisis, 222 Deficiency of butter in milk of syphilitic mothers, 151 Deformities of bone in rickets, 98 chest, 101 clavicle, 103. femur, 104 humerus, 103 pelvis, 103 radius and ulna, 103 scapula, 103 skull, 99 spine, 100 tibia, 104 Delayed symptoms of inherited svphilis, 140 Demeanor of a rickety child, 109 Dentition, care required during, 74 in chronic diarrhoea, Hi) in inherited syphilis, 138 in rickets, 100 in tuberculosis, 187 progress of, no guide to weaning, 49 Derangement, digestive, accompanying worms, 174 in mucous disease, 158, 159. in rickets, 107 treatment of, 127 Description of worms, 169 Development of taenia solium, 171 Diagnosis between rickety skull and hydrocephalus, 99 of bronchial phthisis, 230 chronic diarrhoea, 70 fibroid phthisis, 218 inherited syphilis, 141 mucous disease, 161 pulmonary phthisis, 214 258 INDEX. Diagnosis — rick«ts, 120 scriit'iilous pneumonia, 21G tabwi luesenteiica, 233 tnliercle of lung, 214 tubercnlosis, 191 vomiting, 89 worms, 177 Diarrhoea, acute, 39 treatment of, 58 danger of in inherited syphilis, 138, 146 in rickets, 111 treatment of, 131 clironic, 60 abdominal pain, in, 62 anatomical characters of, 69 appearance of tears in, 65, 72 appetite in, 62 astringents in, 81 bad feeding a cause of, 66 blood in stool in, 61, 62 causes of, 66 complications of, 63 conviulsions in, 63 counter-irritation in, 79 danger of rickets after, 85 dentition in, 66 diet in, 72, 76, 246 diagnosis of, 70 dry skin in, 61 exanthemata in, 63 flannel bandage in, 75 green stools in, 62, 72 congestion of lungs in, 63 influence of dentition on, 74 mode of death in, 64 nitrate of silver in, 82 oedema in, 63 pain in belly in, 62 pneumonia in, 63 prevention of, 72 prognosis of, 71 secondary, 60, 68 serous effusions in, 63 stimulants in, 83 stools, characteis of 61, 62 symptoms of, 60 thrombosis of cerebral sinuses, 63 tongue in, 62 tonics in, 84 treatment of, 75 ulceration of bowels in, 62, 69 variations in intensity of, 62 warmtli in treatment of, 75 Diet after weaning, 51 general directions upon, 24, 238 in chronic diarrhoea, 76, 246 pulmonary phtiiisis, 251 tuberculosis, 199, 251 vomiting, 80, 248 Diet- mucous disease, 162, 249 rickets, 127, 248 Diets, tabulated, 238 Diflerences between gray and yellow tubercle, 186 Dilated bronchi, diagnosis of, 219 Diminished nervous excitability in chronic disease, 19 Diphtheria a cause of defective nutrition, 18 Discharges from ears in scrofulous chil- dren, 222 from nose in inherited syphilis, 135 Diseased bone, importance of early re- moval of, 197 Displacement of liver and spleen, 23, 108 Disseminated miliary tubercles, diag- nosis of, 214 physical signs of, 209 Drilling, use of in expanding chest, 222 Dulness on percussion of chest, value of, 206 Dumb-bells, use of, 199 Dyspnoea in bronchial phthisis, 229 EARLY symptoms of rickets, 95 Ecthyma, syphilitic, 136 Effusions, serous, in chronic diarrhoea, 63 Elastic bandage to loose joints in rickets, 130 tissue, fragments of, in sputum, 219 Emaciation in chronic diarrhoea, 64 tuberculosis, 190 vomiting, 87 mucous disease, 157 rickets, 108 Emphysema in rickets, 118 Empyema with suspected cavity, 219 Enemata, astringent, 81 for constipation, 54 in diagnosis of fecal accumulations, 234 Enlargement of liver and spleen, 23, lOS lymphatic glands in rickets, 108, 119 lymphatic glands in tuberculosis, 226 mesenteric glands, 231 spleen in rickets, 108, 120 cervical veins in bronchial phthisis, 228 Epistaxis in bronchial phthisis, 228 Epithelial structures, rapid growth of, in scrofulous diathesis, 187 Error, common, of mothers in feeding in- fants, 31, 34 Eruptions on skin in inherited syphilis, 135 INDEX. 259 Examination of belly in tabes mesen- terica, 231 of chest in infants, 206 liver, 23 spleen, 24 stools in cases of wastinpr, 34, 61 Exciting causes of tuberculosis, 193 Exercise in chronic tuberculosis, 198 Exhaustion, signs of, in infants, 22 Expectorants in pulmonary phthisis, 224 Expectoration, rarity of, in young chil- dren, 204 Expression of infants, importance of noting, 20 in rickets, 109 External applications, 24 in chronic diarrhoea, 79 vomiting, 91 Eyelids, lividity of, 21 FACE, color of, 21 in inherited syphilis, 137 Fall of hair in inherited syphilis, 137 Farinaceous foods, 46 to be avoided in mucous dis- ease, 162 Fatality of bronchitis in rickets, 110, 123 Fats, their use in nutrition, 32 Feeding, artificial, 44 bottle, 45 importance of cleanliness of, 45, 48, 55 for cleft palate, 51 Fecal accumulations, diagnosis of, 233 Femur, deformities of, in rickets, 104 Fencing useful to strengthen chest, 222 Fibroid phthisis, 213 diagnosis of, 218 physical signs of, 218 prognosis of, 220 symptoms of, 218 First suckling, time of, 42 Fissures on skin in inherited syphilis, 137 Fits, inward, 38 of coughing in bronchial phthisis, 228 in pulmonary phthisis, 204 of screaming in infants, 36 Flannel bandage to belly, 52, 73, 128 underclothing for rickety children, 128 Flat bones, morbid changes in, in rickets, 115 Flattened bridge of nose in inherited syphilis, 135, 142 Flatulence, 36 treatment of, 55 Flatus, accumulation of, causing big belly, 23 Flour, baked, n\ode of preparing, 77 boiled, 46 Flow of milk, abundant, 42 Fontanelle, importance of noting state of, 22 in exhaustion, 22 in inherited syphilis, 138 in rickets, 99 in tubercular children, 187 Food, Liebig's, for infants, 48, 47 improper, a cause of chronic diar- rho3a, 66 a cause of chronic vomiting, 89 Foods required for perfect nutrition, 32 Freckles as evidence of tubercular dia- thesis, 187 Frequency of stools in chronic diarrhoea, 60,62 Frequency of suckling, 43 Fresh air, in the treatment of rickets, 128 Frictions, 24 in rickets cannot always be borne, 25 mercurial, in inherited syphilis, 150 of use after cold bath, 27 Furrows, M. Jadelot's, 21 GALVANISM to increase lacteal secre- tion, 41 Genal line, 21 General behavior of .rickety children, 109 management of infants, 52 Genito-crural nerve, stimulation of, 19 Glands, bronchial, tuberculization of, 227 lymphatic, tuberculization of, 226 mesenteric, tuberculization of, -31 Good figure, best mode of forming, 196 uur?e, test of, 31, 41 Granulations, gray, 185 conversion of, into yellow, 185 seat of, in lungs, 210 yellow, 185 Gray granulations, 185 powder in inherited syphilis, 149 Green stools, cause of, 61 Griping from cold feet, 76 pain, treatment of, 54 Growth of bone, arrest of, in rickets 105 Gymnastic exercises in chronic tubercu- losis, 199 in pulmonary phthisis, 222 HABITUAL constipation in infants, treatment of, 53 Haemoptysis in bronchial phthisis, 228 rarity of, in children, 204 260 INDEX. Hair, fall of, in inlierited syphilis, ]37 growth of, in scrofulous children, 187 Hand, method of bringing up infants by, 44 Hardening system, the, 196 Harsh respiration, 209 Heart, displacement of, in fibroid phthi- sis, 218 Hoarse voice in bronchial phthisis, 228 in infants, 22 in inherited syhilis, 138 Hot bath, 26 in colic, 57 in constipation, 54 in convulsions, 58 method of giving, without ex- citing alarm, 26 Humerus, deformity of, in rickets, 103 Hunger, sign of, in infants, 43 Hydrocephalus, chronic, in rickets, 112 spurious, 88 treatment of, 94 IMPROPER food a cause of chronic diarrhoea, 66 Incontinence of urine in mucous dis- ease, 157 Increased peristaltic action of bowels, 61 Indigestibility of cow's milk, 33, 47 Indigestion, acute, 39 treatment of, 59 Infants, examination of chest in, 206 general management of. 52 secondary diseases in wasting, 18 Infiltrated yellow tubercle, 210 Influence of soils on phthisis, 196 Inhalations in pulmonary phthisis, 225 Inherited syphilis, 133 appearance of first symptoms, 134 chronic interstitial keratitis, 140 complexion in, 137 coryza in, 135 cry in, 138 delayed symptoms, 140 dentition in, 138 diagnosis of, 141 diarrhoea in, danger of, 138, 146 diarrhoea in, treatment of, 153 diet in, 151 disease of liver in, 139 disease of spleen, 140 disease of thymus gland, 134 ectliyma, 136 erythema, lo5 fall of hair in, 137 flattened bridge of nose in, 135, 142 Inherited syphilis — fontanelle in, 138 infection after birth, 144 influence of parent in produc- ing, 142 local applications in 153 local peritonitis in, 140 mercurial inunctions in, 150 mercurial baths, 150 mucous patches, 137 treatment of, 154 necrosis of nasal bones, 135 nodes, 138 notched teeth, 141 perforation of septum nasi, 136 prevention of, 146 prognosis in, 145 relapses in, 141 skin eruptions in, 135 symptoms of, 133 tonics in, 155 treatment of, 147 ulcerations, linear, 137 vomiting in, 139, 146 wasting in, 138 Injections in chronic diarrhoea, 82, 83 Innominate vein, pressure on, in bron- chial phthisis, 228 Inoculation, syphilitic, by vaccination, 144 Inoculability of tubercle, 194, note Inspirations, deep, in treatment of phthisis, 222 Inspissation of tubercle, 213 Intellect in rickets, 109 Internal remedies, 27 Inward fits, 38 Iodide of iron in inherited syphilis, 155 in tuberculization of glands, 236 of lead ointment in tabes meseu- terica, 236 Iron in chronic tuberculosis, 202 Irritation of digestive organs in inherited syphilis, 139, 146, 149, 153 TADELOT'S traits, 21 t) Joints, mobility of, in rickets, 106 Jugular veins, distension of, in bronchial phthisis, 228 KERATITIS, chronic interstitial, 140 Kcilliker's views on ossification of rickety bone, 115 LABIAL line, 21 Large belly in rickets, causes of, 108 in weakly children, causes of, 23 IXDEX, 261 Laryngeal sounds, conduction of, to chest, 209 Laryngismus stridulus in bronchial phthisis, 229 in inherited syphilis, 138 in rickets, 111 treatment of, 132 Laryngitis, cry in, 22 Late talking iii rickets, 109 walking in rickets, 121 Lateral curvature of spine in rickets, 101 Liebig's food for infants, 48, 77 in chronic diarrhoea, 76 vomiting, 90 Ligaments, relation of, in rickets, 106 Lime, saecharated solution of, 199 Lime-water, to dilute cow's milk, 44 Linear cicatrices, 137, 142 ulcerations in inherited syphilis, 137 Liniment for habitual constipation, 53 Lips, lividit}' of, 21 Lithotomy in rickety children, 104, 106, 122 ' Liver disease in inherited syphilis, 139 enlarged, a cause of big belly, 23 enlargement of, in rickets, 108 mode of examining, 24 Lividity of lips and eyelids, 21 Local applications in inherited syphilis, 153 peritonitis in inherited syphilis, 140 Looseness of joints in rickets, 106 Lung complication of rickets, 110 treatment of, 131 examination of, in infants, 206 Lymphatic glands, enlargement of, in rickets, 119 tuberculization of, 226 MALFORMATION of permanent teeth from syphilis, 141 Maternal suckling, 41 Maw's feeding bottle, 45 Measles, a cause of refusal of breast, 51 Meat for young children, 51 raw, for chronic diarrhoea, 83 Mechanism of chest deformity, in rickets, 101 Medicated milk in treatment of inherited syphilis, 148 Mercurial treatment of inherited syphilis, 147 Mesenteric disease, infreqnency of, 23 phthisis. See Tabes mesenterica. Method of suckling, 42 Migration of worms, 175 Milaria in rickets. 96 Miliary tubercle, 185 disseminated, physical signs of, 209 diagnosis of, 214 Milk abundant, behavior of child when, 31 age of, importance of, in choosing wet nurse, 42 cow's, sometimes indigestible, 33, 47 human, and cow's milk compared, 33 medicated, in treatment of inherited syphilis, 148 of syphilitic mothers, 150 scanty, behavior of child when, 31 to increase secretion of, 41 Miscarriage a common result of syphilis, 133 Mobility of joints in rickets, 106, 121 Moist air in phthisis, 223 MoUities ossium, distinction from rick- ets, 122 Motionless belly in respiration, 22 Movement of nares in respiration, 22 unequal, of two sides of chest, 22 Mucous disease, 156 causes, 159 diagnosis, 161 diet in. 162, 249 treatment of, 162 patches, 137 treatment of, 154 Mucuna prurieus, 180 Muscles, voluntary, in rickets, 120 Mustard bath, 27 NARES, movement of, in respiration, 22 Nasal bones, necrosis of, 135 furrow, 21 obstruction a cause of refusal of breast, 51 Necrosis of nasal bones in inherited syphilis, 135 Nematode worms, 169 Nervous sensibility diminished in wasted children, 20 Nettlerash a sign of indigestion, 37 Nitrate of silver in chronic diarrhoea, 82 Nodes in inherited syphilis, 138 Non-mercurial treatment of inherited syphilis, 148 Notching of permanent teeth in inherited syphilis, 141 Nurse, a good, test of, 31, 41 Nux vomica in rickets, 130 CULO-ZYaOMATIC furrow, 21 (Edema of face in bronchial phthisis, 228 of feet and hands in chronic diar- rhoea, 63 of lower limbs in tabes mesenterica, 232 IV 262 INDEX. Oil of male fern in treatment of tape- worm, 181 use of, as an external application, 25 Opium in chronic diarrhoea, 81 in pulmonary phthisis, 224 Ossification of bone in rickets, 114 Over-feeding of infants, 32, 34 Oxidation of tissues interfered with by starches, 32 Oxyuris vermicularis, 168 symptoms of, 176 treatment of, 179 PAIN indicated by expression of face in infants, 20 in belly, 21 in cliest, 20 in head, 20 Parasitic stomatitis, 37 treatment of, 58 Patches, mucous, 137 Pathology of pulmonary phthisis, 210 rickets, 114 tuberculosis, 185 Pelvis, arrest of growth of, in rickets, - 106 deformity of, in rickets, 103 Percussion, broad, 207 Perforation of bowel in mesenteric phthisis, 233 of septum nasi in inherited syphilis, 135 Pericardium, white patch on, in rickets, 118 Peristaltic action of bowels, increased, 61 Peritonitis a result of tabes mesenterica, 233 local, in inherited syphilis, 140 Perspirations in rickets, 96 Pertussis, a cause of mucous disease, 160 Perverted ossification of rickety bone, 114 Phthisis, bronchial. See Bronchial phthisis. different conditions included under name of, 203 fibroid, anatomical characters of, 213 diagnosis of, 218 prognosis of, 220 influence of soils on, 196 mesenteric. See Tabes mesenterica pulmonary, 202 anatomical characters, 210 auscultation of chest, 207 causes, 221 diagnosis, 214 hffinioptysis in, 204 pliysical signs, 205 Phthisis, pulmonary — prognosis, 220 symptoms, 204 treatment, 222 Pigeon-breast in rickets, 101 in tuberculosis, 189 Pleurisy, death from, in inherited syphi- lis, 139 Pneumonia, a cause of refusal of breast, 51 in chronic diarrhoea, 63, 71 scrofulous, 210 anatomical characters of, 210 diagnosis of, 216 symptoms of, 216 temperature in, 216 without symptoms, 19 Pneumonic deposits unabsorbed, treat- ment of, 225 Pneumothorax, a result of pulmonary phthisis, 205 Pomegranate bark in treatment of tape- worm, 181 Pony exercise in chronic tuberculosis, 198 Portal vein, pressure on, 232 Potash, chlorate of, for aphthse, 58 Precautions against cold, 73 Pregnancy of mother a reason for wean- ing, 50 Premature weaning sometimes neces- sary, 50 Preparations of mercury in treatment of inherited syphilis, 149 Pressure of air the cause of chest dis- tortion, 102, 189 on nerves of chest by enlarged bronchial glands, 22*^ on superior vena cava, 228 on trachea, 229 on veins in abdominal cavity, 232 Prevention of diarrhoea, 72 inherited syphilis, 146 rickets, 126 tuberculosis, 195 Prognosis in chronic diarrhoea, 71 inherited syphilis, 145 pulmonary phthisis, 221 rickets, 122 Prolapsus ani, treatment of. 183 Pulmonary phthisis. See Phthisis. tubercle in infants, 209 diagnosis of, 214 Purgative enemata, 64 for habitual constipation in infants, 53 Pus in stools. RADIUS and ulna, deformities of in rickets, 103 Rash, sypliilitic, 135 INDEX, 263 Raw meat in treatment of chronic diar- rlicea, 83 Recousolidation of bone in rickets, 116 Recovery in chronic diarrhoea, 65 in rickets, 113 Red-gum, 37 Reflex convulsions, 20 rare in cachectic children, 20 Refusal of breast by infants, causes of, 50 Relapses in chronic diarrhoea, 62 in inherited syphilis, 141 Relaxation of ligaments in rickets, 106 Respiration, harsh, 209 in bronchial phthisis, 229 in pulmonary phthisis, 208 in rickets, 108 weak, 209 Respirator, use of, in phthisis, 199 Retraction of nipple an obstacle to suck- ling, 50 Rickets, 95 albuminoid degeneration in, 119 analysis of bone, 117 anatomical characters, 114 arrest of growth of bone in, 105 breathing in, 108 catarrh and bronchitis in, 110 treatment of, 130 causes of, 123 chronic hydrocephalus in, 112 climate for, 128 collapse of lung in, 110, 118 complications of, 109 convulsions in, 111 treatment of, 132 danger of, after chronic diarrhoea, 85 danger of bronchitis in, 123 deformities of bone in, 97 demeanor of child in, 109 diagnosis of, 120 diarrhoea in, 111 treatment of, 131 diet in, 128, 248 early symptoms of, 95 enlargement of ends of bones in, 97 enlargement of liver and spleen in, 108 general symptoms of, 107 tenderness in, 96 insidious commencement of, 18, 95 intellect in, 109 laryngismus stridulus in. 111 treatment of, 132 lithotomy in, 104, 106, 122 malaria in, 96 mode of death in, 110, 112 morbid changes in bones, 97, 113 in flat bones, 115 not a diathetic disease, 123 nux vomica in, 130 ossification of bone in, 114 Rickets — pathology of, 114 pigeon-breast in, 101 prevention of, 126 prognosis in, 122 recovery in, 112 shape of chest in, 101 skull in, 98 softening of bones, 98 splints, use of, 130 sweating in, 96 talking late in, 109 tannin in treatment of, 130 tonics, time of giving, in, 129 treatment of, 127 walking late in, 121 white patch on pericardium in, 118 white patch on spleen in, 119 Rules for choosing nurse, 41 SALIVA, secretion of, 32 Salts, their value in nutrition, 32 Santonine, in treatment of worms, 180 occasional effects of, 180 Scaly eruptions in inherited syphilis, 136 Scapula, deformities of, in rickets, 103 Schneiderian membrane, mucous patches on, 135 Screaming fits in children, 36 Scrofulous diathesis, type of, 187 pneumonia. See Pneumonia. Sea-air in rickets, 128 in tuberculosis, 197 Second dentition a cause of mucous dis- ease, 161 Secondary acute diseases common in wasted children, 19 peculiarities of, 20 Septum nasi, perforation of, 135 Serous effusions in chronic diarrhoea, 63 Shampooing in chronic tuberculosis, 199 in rickets, 130 Shape of chest in rickets, 101 in the tubercular diathesis, 189 Sickness from acidity, treatment of, 59 Sign of hunger in infants, 43 Silver, nitrate of, in chronic diarrhoea, 82 Simple atrophy, 29 causes of, 29 symptoms of, 34 treatment of, 40 Size of liver, to estimate, 23 of spleen, 24 Skin, tint of, in chronic diarrhoea, 61 in inherited syphilis, 137 Skull, shape of, in rickets, 98 Slimy tongue, a sign of mucous disease, 157 Smile during sleep, of infants, 36 264: INDEX. Snuffling in syphilis, 134 Soap suppository for constipation, 53 to be used for washing infants, 52 Softening of mesenteric glands, 233 of pneumonic deposit, 212 of tubercle, 212 of tubercular glands, 235 Soils, influence of, in phthisis, 196 Somnambulism in miicous disease, 157 Sour smell of breath in chronic vomiting, 87 Spasmodic cough in bronchial phthisis, 229 Spine, deformities of, in rickets, 100 Spleen, albuminoid degeneration of, 120 enlargement of, in inherited syphi- lis, 140 method of examining, 24 Sprays, alkaline, 225 astringent, 225 Spurious hydrocephalus, 88 diagnosis of, 89 treatment of, 94 Sputum, elastic tissue in, 219 Stethoscope, use of, in examining infants, 208 Stethoscopic signs in pulmonary phthisis, 208 Stimulant expectorants in phthisis, 224 Stimulants, 28 indications for giving, 22 Stomach, irritability of, 57 in inherited syphilis, 139, 146 Stools, blood in, cause of, 61, 02 character of, in chronic diarrhoea, 61, 62 examination of, in cases of wasting, 34, 61 pus in, 62 Stripping children for examination, 22 Strophulus a sign of indigestion, 37 Suckling, first time of, 42 frequency of, 42 Sugar as a substitute for cod-liver oil, 202 its use in nutrition, 32 of milk in artificial feeding, 44 Superficial veins of abdominal wall en- larged, 232 of face, enlargement of, 228 Supraspinous fossa, duluess at, 206 Symptoms of bronchial phthisis, 228 of chronic diarrhoea, 60 of chronic pulmonary phthisis, 204 of chronic tuberculosis, 188 of chronic vomiting, 86 of inherited syphilis, 133 of mucous disease, 156 of rickets, 96 of simple atrophy, 34 of worms, 174 Syphilis and rickets, connection between, 126 inherited. See Inherited syphilis. miscarriage a result of, 134 secretion of milk in, 151 Syphilitic coryza, 135 Syrup of iodide of iron in inherited sy- philis, 155 System, the hardening, 196 TABES MESENTERICA, abdomen in, 23, 231 anatomical characters of, 236 ascites in, 232 cramps of extremities in, 232 diagnosis of, 233 peritonitis as a result of, 233 pressure on veins in, 232 symptoms, 231 tenderness of belly in, 232 treatment of, 236 Tjenia medio-canellata, 171 solium, 171 Talking late in rickets, 109 Tannin in treatment of rickets, 130 Tears a good sign in chronic diarrhoea, 65,72 Teeth, care required during cutting of, 74 early decay of, in rickets, 100 late appearance of, in rickets, 100 permanent malformation of, 141 Teething in chronic diarrhoea, iiio in inherited syphilis, 138 in rickets, 100 in tuberculosis, 187- Temperature, changes of, a cause of di- arrhoea, 74 precautions against, 73 in scrofulous pneumonia, 216 in tubercular ulceration of bowels, 71 in tuberculosis, 191 Tenderness, general, in rickets, 96 of belly in tabes meseuterica, 232 Test of a good nurse, 31, 41 Thermometer in diagnosis of mucous dis- ease, 161 of pulmonary phthisis, 216 of tubercle of bowels, 71 of tuberculosis, 191 Thighbone, deformities of, in rickets, 104 Thorax, shape of, in rickets, 101 tuberculosis, 189 Thrombosis of cerebral sinuses, 63 Thrush, 37 a cause of refusal of breast, 51 treatment of, 5 value of, in prognosis, 37 Thymus gland, disease of, in inherited syphilis, 134 in rickets, 120 IXDEX, 265 Tibia, deformities of, in rickets, 104 Time of first suckling, 42 Tint of skin in chronic diarrhoea, 61 inherited sypliilis, 137 Tissue, elastic, in sputum, 219 Tongue in acute indigestion, 39 chronic diarrhoea, 62 chronic vomiting, 87 mucous disease, 51 Tongue-tie an obstacle to sucking, 51 rarity of, 51, note Tonics, 27 in inherited syphilis, 155 rickets, 129 Tonsils, cheesy, 221 treatment of, 223 Trachea, pressure on, in bronchial plitlii- sis, 229 " Traits," M. Jadelot's, 21 Treatment, general, of wasting, 24 of acidity of stomach in infants, 54 of aphthae, 58 of bronchial phthisis, 236 of catarrh in rickets, 130 of chronic diarrlioea, 75 phthisis, 222 tuberculosis, 197 of chronic vomiting, 89 of cheesy tonsils, 223 of colic in infants, 57 constipation in infants, 53 of convulsions from indigestion, 58 in rickets, 132 of diarrhoea in inherited syphilis, 153 in rickets, 131 of inlierited syphilis, 147 of laryngismus stridulus, 132 of mucous disease, 162 of prolapsus ani, 183 of rickets, 127 of simple atrophy, 40 of spurious hydrocephalus, 94 of tabes mesenterica, 236 of thrush, 58 of vomiting in inherited syphilis, 153 from acute gastric catarrh, 86 of worms, 179^ Tricocephalus dispar, 170 treatment of, 180 Tubercle in rickets, 112 infiltrated yellow, 210 inoculability of, 194, note miliary, 185, 209 of lung, 210 complicating scrofulous pneu- monia, 212 diagnosis of, 217 physical signs of, 206 treatment of, 222 Tubercles, seat of, in lung, 209 I Tiiberculizah'on of glands, 226 I bronchial glands, 227 of mesenteric glands, 231 Tuberculosis, chronic, 184 causes of, 193 diagnosis of, 191 diet in, 199, 251 exercise in, 198 pigeon-breast in, 189 prevention of, 195 symptoms of, 188 temperature in, 191 treatment of, 197 Tuberculous ulceration of bowels, 70 Tumor, seat of, in tabes mesenterica, 232 Turpentine in treatment of convulsions, 58 in treatment of tapeworm, 181 Type of scrofulous diathesis, 187 tuberculous diathesis, 187 ULCERATION of bowels, symptoms of, 62 tuberculous, 70 of mucous membrane of nose, 135 Ulcerations, linear, in inherited syphilis, 137 Unsuitable food a cause of simple atro- phy, 31 Urine, incontinence of, in mucous dis- ease, 157 Urine in rickets, 120 Urticaria a sign of indigestion, 37 VACCINATION as a means of commu- nicating syphilis, 144 Value of aromatics for infants, 55, 81 stethoscopic signs in infantile phthi- sis, 208 Value of thermometer iu diagnosis of tuberculosis, 191 Varieties of breast-milk, 30 Vein, portal, pressure on, 232 Veins, pressure on, in tabes mesenterica, 232 Vena cava, superior, pressure on, 228 Venous engorgement of face and neck, 228 Vernois and Becquerel,MM.,on woman's milk, 30 Virchow's views on bone disease in rick- ets, 115 Vocal vibration in infants, 206 Voluntary muscles in rickets, 120 Vomiting, chronic, 86 alkalies in, 92 bowels in, 87 causes of, 88 diagnosis of, 89 diet in, 39, 89 266 INDEX. Vomitiug, chronic — emetics in, 93 mode of death in, 88 prussic acid for, 92 sour smell of breath in, 87 spurious hydrocephalus in, 88 stimulants in, 94 tongue in, 88 warmth, importance of, in, 91 danger of, in inherited syphilis, 138, 146 in acute indigestion, 39 in inherited syphilis, treatment of, 153 "IITALKINCt, lateness of, in rickets, 121 T T Warm bath for constipation, 54 Warmth in chronic dianhoea, 75 vomitiug, 91 in inherited syphilis, 152 Wasting, causes of, 17 from overfeeding, 32 in inherited syphilis, 138 in rickets, 113 not always present, 120 Weak respiration, 209 Weanini:, dentition no guide to, 49 method of, 50 Weaning — premature, sometimes necessary, 50 time of, 49 Wet nurse, rules for choosing, 41 test of a good, 31 White patch on pericardium in rickets, 118 on spleen in rickets, 119 Whitlow in inherited syphilis, 137 Whooping-cough a cause of mucous dis- ease, 160 Woman's milk, 30 Worms, 169 appearance of tongue in, 195 ascaris lumbricoides, 170 bothriocephalus latus, 171 convulsions from, 175 diagnosis of, 177 migrations of, 175 oxyuris vermicularis, 169 symptoms, 174 taenia medio-canellata, 171 solium, 171 treatment of, 179 tricocephalus dispar, 170 yELLOW granulations, 185 A New American Work on Children-Just Issued. A TRE4TISE ON^E DISEASES OF INFANCY AND CHILDHOOD. By J. LEWIS SMITH, M.D., Curator to tho Nursery and Child's Hospital, New York ; Physician to the Infants' Hospital, Ward's Island ; Professor in Bellevue Hospital Medical College, New York. In one large and handsome octavo volume o/"620 pages : extra doth, $4 75 ; leather, $5 75. It is in many respects one of the best works on infantile disease we have met with. The latest views are clearly discussed iu it, and it has a special advantage in being one of the most reli- able guides as regards practice with which we are acquainted. Indeed, we do not hesitate to place it first on the list in this respect. In our opinion, iu uo class of cases is the so-called "re- storative treatment of disease" so essential as in the young, and we know of no systematic woi-k in which this fact is so thoroughly recognized as in Dr. Smith'.s. — Brit, and For. Med.-Chirurg. Revieio, Oct. 1S70. The excellence of this book is one explanation of our not having reviewed it sooner. Taking it up from time to time, we have been freshly inte- rested in its various chapters, and so been led to defer writing our opiuion of it. It is one of those works with which we are happily becoming fami- liar, as coming to us from time to time from across the Atlantic, which contain all that is good in European works of the same kind, together with much that is original, both in reflection and ob- servation. It is astonishing how well the Ameri- can writers succeed in gleaning, and yet giving a fresh character to their books. This work is an illustration, and pervading every chapter of it is a spirit of sound judgment and common sense, without which any work on any department of the practice of medicine is, to use the mildest word, defective. We are sorry that we cannot give further ilhi.>'tralions of the excellence of this book. — London Lancet, Sept. 4, 1S69. After an examination of this book, we think we are not mistaken iu welcoming its writer as a new better form a notion of the industry and good judgment of its author by au extended perusal of it, that we have concluded to simply refer them to the book itself — St. Louis Med. and Surg. Jotirnal, May 10, 1S69. Most heartily do we wish the work the success it so richly deserves. — Am. Journ. o/Obstet., *c., May, 1869. The work before us is a valuable addition to the text-books of the subject. While it covers the gronnd of the recognized principles and treat- ment of the diseases of childhood and infancy, it teems with a freshness of suggestion and resource which will insure it a place in every physician's lihrnvy. —LeavemoortJi Med. Herald, May, 1S69. The remarkable faculty of bringing out salient points and stating concisely other less impiu'tant facts, enables him to crowd within a small com- pass a vast amount of practical information. The attention given to the treatment of the various maladies, as well as the presentation of all the recently accepted pathological views, make it one of the most valuable treatises, within its present compass, that can bo placed in the hands of any seeker after truth. The volume as a whole will still further establish for the writer a permanent and enviable reputation as a careful observer, an impartial interpreter, a safe and trustworthy ad- viser, and a modest and untiring student. — N. Y. Med. Record, March 1.9, 1869. We have perused Dr. Smith's book with not a little satisfaction; it is indeed an excellent work ; well and correctly written ; thoroughly up to the authority in medical literature on the diseases of modern ideas; concise, yet complete iu its mate- children. The sources of his information are rial. We cannot help welcoming a work which copious, and he seems to have made careful use I will be worthy of reliance as a text-book for med- of them. We had intended to support these opi- ical students and younger physicians in their iu- nions by qnotations, but the range of the work is j vestigations of disease in children. — Boston Med. so comprehen.sive, and our readers can so much I and Surg. Journal, March 4, 1S69. New and Enlarged Edition— Just Issued. LECTURES~ON THE DISEASES OF IISTFAN^OY XED CHILDHOOD. By CHARLES WEST, M. D., Physician to the Hospital for Sick Children, &c. Fourth American, from the Fifth Enlarged and Improved London Edition. In one neat octavo volume o/656 large pages : extra cloth, $4 50; leather, $5 50. Of all the English writers on the diseases of children, there is no one so entirely satisfactory to us as Dr. West. For years we have held his opinion as judicial, and have regarded him as one of the highest living authorities in the difli- cult department of medical science in which he is most widely known. His writings are charac- terized by a sound, practical common sense, at the same time that they bear the marks of the most laborious study and investigation. We com- mend it to all as a most reliable adviser on many occasions when many treatises on the same sub- ject will utterly fail to help us. It is supplieinted out. We is so creditable to the country as to be tlatlering to must congratulate the student upon the completion our national pride. —Ame7-ioan MedicalJournal. of this Atlas, as it is the most convenient work of I H ARTSHORNE {HENRY), M. D., Professor of Hygiene, etc., in the University of Pennsylvania. A HAND-BOOK OF HUMAN ANATOMY AND PHYSIOLOPxY, for the use of Students, with 176 illustrations. In one volume, royal 12mo. of .312 pages; extra cloth, $1 75. {Now Ready.) QHARPEY ( WILLIAM), M.D., and Q CAIN {JONES §• RICHARD). HUMAN ANATOMY. Revised, with Notes and Additions, b}- Joseph Lkidy, M.D., Profe.ssor of Anatomy in the University of Pennsylvania. Complete in two large octavo volumes, of about i;H(ld pages, with 611 illustrations; extra cloth, $6 00. The very low price of this stand.ird work, and its completeness in all departments of the subject, should command for it a place in the library of all anatomical students. ALLEN {J. M.), M.D THE PRACTICAL ANATOMIST; or. The Student's Guide in the Dissecting Room. With 266 illustrations. In one very handsome royal 12mo volume, of over 600 pages; extra cloth, $2 00. One of the most useful works upon the subject ever written. — Medical Examiner. Henry C. Lea's Publications — (Anatomy). |^/L5<9iV [ERASMUS], F.R.S. A SYSTEM OF HUMAN ANATOMY, General and Special. A new and revised American, from the lat^t and enlarged English edition. Edited by W. H. Go- BRECHT, M. D., Professor of General and Surgical Anatomy in the Medical College of Ohio. Illustrated with three hundred and ninety-seven engravings on wood. In one large and handsome octavo volume, of over liOO large pages; extra cloth, $4 00; leather, $5 00. The publisher trusts that the well-earned reputation of this long-established favorite will be more than maintained by the present edition. Besides a very thorough revision by the author, it has been most carefully examined by the editor, and the efforts of both have been directed to in- troducing everything which increased experience in its use has suggested as desirable to render it a complete text-book for those seeking to obtain or to renew an acquaintance with Human Ana- tomy. The amount of additions which it has thus received may be estimated from the fact that thi' present edition contains over one-fourth more matter than the last, rendering a smaller type and an enlarged page requisite to keep the volume within a convenient size. The author has not only thus added largely to the work, but he has also made alterations throughout, wherever there appeared the opportunity of improving the arrangement or style, so as to present every fact in its most appropriate manner, and to render the whole as clear and intelligible as possible. The editor has exercised the utmost caution to obtain entire accuracy in the text, and has largely increased the number of illustrations, of which there are about one hundred and fifty more in this edition than in the last, thus bringing distinctly before the eye of the student everything of interest or importance. or THE SAME AUTHOR. THE DISSECTOR'S MANUAL; or, Practical and Surgical Ana- tomy. Third American, from the last revised and enlarged English edition. Modified and rearranged by William Hunt, M. D., late Demonstrator of Anatomy in the University of Pennsylvania. In one large and handsome royal 12mo. volume, of 682 pages^ with 154 illustrations; extra cloth, $2 00. fJEATH [CHRISTOPHER], F. R. C. S., -'-'- Teacher of Ofjerative Surgery in University College, London. PRACTICAL ANATOMY: A Manual of Dissections. From the Second revised and improved London edition. Edited, with additions, by W. \V. Kt;i;,'<, M. D., Lecturer on Pathological Anatomy in the Jefferson .Medical College, Philadeipiiia. In ope handsome royal 12mo. volume of 578 pages, with 247 illustrations. Extra cioth, $3 50; leather, $4 00. {J list Ready.) TTODGES, [RICHARD M.), M.D., -*-* Late Demonstrator of Anatomy in the Medical Department of Harvard University. PRACTICAL DISSECTIONS. Second Edition, thoroughly revised. In one neat royal 12mo. volume, half-bound, $2 00. {Just Issued.) The object of this work is to present to the anatomical student a clear and concise description of that which he is expected to observe in an ordinary course of dissections. The author ha« endeavored to omit unnecessary details, and to present the subject in the form which many years' experience has shown him to be the most convenient and intelligible to the student. In the revision of the present edition, he has sedulously labored to render the volume more worthy of the favor with which it has heretofore been received. -MAC USE [JOSEPH). SURGICAL ANATOMY. By Joseph Maclise, Snrgeon. In one volume, very large imperial quarto ; with 68 large and splendid plates, drawn in the best style and beautifully colored, containing 190 figures, many of them the size of life; together with copious explanatory letter-press Strongly and handsomely bound in extra cloth. Price $14 00. As no complete work of the kind has heretofore been published in the English language, the present volume will supply a want long felt in this country of an accurate and comprehensive Atlas of Surgical Anatomy, to which the student and practitioner can at all times refer to ascer- tain the exact relative positions of the various portions of the human frame towards each other and to the surface, as well as their abnormal deviations. Notwithstanding the large size, beauty and finish of the very numerous illustrations, it will be observed that the price is so low as to place it within the reach of all members of the profession. We know of no work on surgical anatomy which refreshed by those clear and distinct dissections, can compete with It. — Lancet. The work of Maclise on surgical anatomy is of the highest value. In some respects it is the best publi- cation of its kind we have seen, and is worthy of a place in the library of any medical man, while the student could scarcely make a better investment than this.— r^e Western Journal of Medicine and Surgery. No such lithographic illustrations of surgical re- gions have hitherto, we think, been given. While the operator is sliown every vessel and nerve where an operation is contemplated, the exact anatomist is which every one must appreciate who has a particle of enthusiasm. The English medical press hat 4ujte exhausted the words of jiraise, in lecoramending this admirable treatise. Those who have any curiosity to gratify, in reference to the perfectibility of the lithographic art in delineating the complex merlian- ism of the human body, are invited to examine onr specimen copy. If anything will induce surgeons and students to patronize a book of such rare value and everyday importance to them, it will be a survey of the artisti'cal skill exhibited in these fac-similes of nature— B<'.«t()» Med. and Surg. Journal. HORNER'S SPECIAL .\N.\TOJIY AND HISTOLOGY. I In 2 vols. 8vo , of over 1000 pages, with more than Eighth edition, extensively revised and modified. | 300 woodcuts ; extra cloth, 6 00 Henry C. Lea's Publications — (Physiology). IXTARSHALL {JOHN), F. R. S. •*■'■*- Professor of Surgery in University College, London, &c. OUTLINES OF PHYSIOLOGY, HUMAN AND COMPARATIVE. With Additions by Francis Gurney Smith, M. D., Professor of the Institutes of Medi- cine in the University of Pennsylvania, Ac. With numerous illustrations. In one large and handsome octavo volume, of 1026 pag#s, extra cloth, $6 60 ; leather, rai.sed bands $7 60. (Just Issued.) ern physiological science, both hnman and compara- tive, with which we are acquainted. To speak of this work in the terms ordinarily used on such occa- sions would not be agreeable to ourselves, and would fail to do justice to its author. To write such a book requires a varied and wide range of knowledge, con- siderable power of analysis, correct judgment, skill in arrangement, and conscientious spirit. It must have entailed great labor, but now that the task has been fuldUed, the book will prove not only invaluable to the student of medicine and surgery, but service- able to all candidates in natural .science examinations, to teachers in schools, and to the lover of nature gentv- rally. In conclusion, we can only express the con- viction that the merits of the work will command for it that success which tlie ability and vast labor dis- played in its production so well deserve. — London Lancet, Feb. 2-2, 1868. If the possession of knowledge, and peculiar apti- tude and skill in expounding it, qualify a man to write an educational work, Mr. Marshall's treatise might be reviewed favorably without even opening the covers. There are few, if any, more accomplished anatomists and physiologists than the distinguished professor of surgery at University College; and he has long enjoyed the highest reputation as a teacher of physiology, possessing remarkable powers of clear exposition and graphic illustration. We have rarely the pleasure of being able to recommend a text-book so unreservedly as this. — British Med. Journal, Jau. 2.5, 1868. In fact, in every respect, Mr. Marshall has present- ed us with a most complete, reliable, and scientific work, and we feel that it is worthy our warmest commendation. — St. Louis Mtd. Reporter, Jan. 1S69. This is an elaborate and carefully prepared digest of human and comparative physiology, designed for the u.se of general readers, but more especially ser- viceable to the student of medicine. Its style is con- cise, clear, and scholarly; its order perspicuous and exact, and its range of topics extended. The author and his American editor have been careful to bring to the illustration of the subject the important disco- veries of modern science in the various cognate de- partm<-uts of investigation This is especially visible iu the variety of interesting information derived from the Jei.artments of chemistry and physics. The great amount and variety of matter contained in the work is strikingly illustrated by turning over the copious index, covering twenty-four closely printed pages in double columns — Silhnian's Jotirnal, Jan. 1869. We doubt if there is in the English language any compead of physiology more useful to the student than this work. — St. Louis Med. ahd Surg. Journal, Jan. 1S69. It quite fulfils, in our opinion, the author's design of making it truly c'^jfcafiOTiaiihits character — which is, perhaps, the higliest commendation that can be asked. — Am. Journ. Med. Sciences, Jan. 1869. We may now congratulate him on having com- pleted the latest as well as the best summary of mod- rfARPENTER {WILLIAM B.), M.D., F.R.S., V>' Examiner in Physiology and Comparative Anatomy in the University of London. PRINCIPLES OF HUMAN PHYSIOLOGY; with their chief appli- cations to Psychology, Pathology, Therapeutics, Hygiene and Forensic Medicine. A new American from the last and revised London edition. With nearly three hundred illustrations. Edited, with additions, by Francis Gurney Smith, M. D., Professor of the Institutes of Medicine in the University of Pennsylvania, Ac. In one very large and beautiful octavo volume, of about 900 large pages, handsomely printed; extra cloth, $5 60 ; leather, raised bands, $6 50. We doubt not it is destined to retain a strong hold on public favor, and remain the favorite text-book in our colleges. — Virginia Medical Journal. With Dr. Smith, we confidently believe "that the present will more ihan sustain the enviable reputa- tion already attained by former editions, of being one of the fullest and most complete treatises on the subject in the English language." We know of none from the pages of which a satisfactory knowledge of the physiology of the human organism can be as well obtained, none better adapted for the use of such as take np the study of physiology in its reference tof the institutes and practice of medicine. — Am. Jour. Med. Sciences. The above is the title of what is emphatically the great work on physiology ; and we are conscious that it would be a useless effort to attempt to add any- thing to the reputation of this invaluable work, and can only say to all with whom our opinion has any influence, that it is our authority. — Atlanta lied. Journal. JOY THE SAME AUTHOR. PRINCIPLES OF COMPARATIYE PHYSIOLOGY. New Ameri- can, from the Fourth and Revised London Edition. In one large and handsome octavo vohnne, with over three hundred beautiful illustrations Pp. 762. Extra cloth, $6 00. As a complete and condensed treatise on its extended and important .subject, this work becomes a neces.sity to student.* of natural science, while the very lovr price at which it is offered places it within the reach of all. J^IRKES {WILLIAM SENHOUSE), 31. D., A MANUAL OF PHYSIOLOGY. A new American from the third and improved London edition With two hundred illustrations. In one large and hand- some royal l2mo. volume. Pp. 686. Extra cloth, $2 25 ; leather, $2 75. It is at once convenient in size, comprehensive in | lent guide in the study of physiology in its most ad- design, and concise in statement, and altogether well adapted for the purpose de.signeJ. — St. Louis Me'l. and Surg, -fournal. The physiological reader will llnd U a inost excel- vauced and perfect form. The author has shown himself capable of giving details sutflciently ample in a Condensed and eoueeutraied shape, on a science in which it is necessary at once to be correct and not lengthened — Edinburgh Med. and Surg Journal. Henry C. Lea's Publications — (Physiology). T)ALTOy {J. C), M. D., -'-^ Professor of Physiokigy in the College of Physicians and Surgeons, New York, T THE SAME AUTHOR. MANUAL OF CHEMICAL PHYSIOLOGY. Translated from the German, with Notes and Additions, by J. Cheston Morris, M. D., with an Introductory Essay on Vital Force, by Professor Samuel Jackson, M. D., of the University of Pennsyl- vania. With illustrations on wood. In one very handsome octavo volume of 336 pages extra cloth. $2 25. fpODD {ROBERT B.), M. D. F.R.S., and ^0 WMAN ( W.), F. R. S. THE PHYSIOLOGICAL ANATOMY AND PHYSIOLOGY OF MAN. With about three hundred large and beautiful illustrations on wood. Complete in one large octavo volume of 950 pages, extra cloth. Price $4 75. 10 Henry C. Lea's Publications — {Chemistry). -nRANDE ( WM. T.), D. C.L., and JIAYLOR {ALFRED S.), M.D., F.R.S. CHEMISTRY. Second American edition, thoroughly revised by T>r. Taylor. In one hJindsome 8vo. Volunae of 764 pages, extra cloth, $5 00 ; leather, $6 00. (Lately Issued.) ■ From Dr. Taylor s Preface. "The reviaion of the second edition, in consequence of the death of my lamented colleague, has devolved entirely upon myself. Every chnpter, and indeed every page, has been revised, and numerous additions made in all parts of the volume. These additions have been restricted chiefly to subjects having some practical interest, and they have been made as concise as possible, in order to keep the book within those limits which may retain for it the character of a Student's Manual ''—London, June 29, 1867. A book that has already so established a repnta- ' This second American edition of an excellent trea- tion, as has Brande and- Taylor's Chemistry, can tise on chemical science is not a mere republication hiiidly need a notice, save to mention the additions from the English press, bnt is a revision and en- and improvements of the edition. Doubtless the largement of the original, under the supervision of ■W'Tk will long remain a favorite text-book in the ihe surviving author. Dr. Taylor. The favorable school:', as well as a convenient book of reference for opinion expressed on the publication of the former all.— jv! Y. Medical Gazette, Oct. 12, 1867. ! edition of this work is fully sustained by the present revision. In which Dr. T. has increased the size of For this reason we hail with delight the Tepnblica- ; the volume, by an addition of sixty-eight pages.— .ilm. tion, in a form which will meet with general approval | jQ^im. Med. Sciences, Oct. 1S67. and copimand public attention, of this really valna- WivnnnoK im Crfmi^^trt op tup STrnps-r — hie standard work on chemistry— more particularly : ^ ^he Handbook in I^hemistrt of the feTrnBNT.— as it has been adapted with such care to the wants of Fo>- c earness of language, accuracy of description, the Leneral public The well known scholarship of extent of information and freedom from pedantry ts authors, and their extensive researches for many and mysticism no other text-book comes into corn- years in experimental chemistry, have been long ap- Vetnion with it.-The Lancet. preciatedinthescientific world, but in this work they The authors set out with the definite purpose of have been careful to give the largest possible amount writing a book which shall be intelligible to any of information with the most sparing use of technical educated man. Thus conceived, and worked out in terras and phraseology, so as to furnish the reader, the most sturdy, common-sense method, this book "whether a student of medicine, or a man of the gives in the clearest and most summary method world, with a plain introduction to the science and possible all the facts and doctrines of chemistry.— jjractice of chemistry." — Journal of Applied Chem- Medical Times. istry, Oct. 1S67. DLING{W1LLIA3T), Lecturer on Chemistry, at St. Bartholomew's Ilo.spitul, i-e. A COURSE OF PRACTICAX CHEMISTRY, arranged for the Vse of Medical Students. With Illustrations. From the Fourth and Revised London Edition. In one neat royal 12mo. volume, extra cloth. $2. {Just Jssved.) Asa work for the practitioner it cannot be excellwl It is written plainly and concisely, andgivesina very small compass the information required by the busy piactitioner. It is essentially a work for the physi- cian, and no one who purchases it will ever regret the outlay. In addition to all that is usually given in coi^nection with inorganic chemistry, there are most valuable contributions to toxicology, animal and or- gauic chemi.^try, etc. The portion.s devoted to a dis- cussion of these subjects are very excellent. In no work can the physician find more thai is valuable and reliifble in regard to mine, bile, milk, bone, uri- nary calculi, tissue composition, etc. The work is small, reasonable in price, and well published. — Richmond and Louisville Med. Journal, Dec. 1S69. jyOWMAN {JOHN E.),M. D. PRACTICAL HANDBOOK OF MEDICAL CHEMISTRY. Edited by C. L. Bloxam, Professor of Practical Chemistry in King's College, London. Fifth American, from the fourth and revised English Edition. In one neat volume, royal 12mo., pp. 351, with numerous illustrations, extra cloth. $2 25. (Now Ready.) , The fourth edition ofi this invaluable text-book of Medical Chemistry was published in England in 'Octo- ber of the last year. The Editor has brouaht down the Handbook to that date, introducing, as faraswiis compatible with the necessary conci-seness of such a work, all the valuable discoveries in the science f>Y THE SAME AUTHOR. INTRODUCTION TO PRACTICAL CHEMISTRY, INCLUDING ANALYSIS. Fifth American, from the fifth and revised London edition. With numer- ous illustrations. In one neat vol., royal 12mo., extra cloth. $2 26. (Now Ready.) which have come to light since the previous edition was printed. The work is indispensable to pvpry student of medicine or enlightened practitioner. It is printed in cU-ar type, and the illiisirations are numerous and intelligible. — Boston Mtd. and Snrg. Journal. One of the most complete manuals that has for a long time been given to the medical student. — Athen(Bum. We regard it as realizing almost everything to be desired in an introduction to Practical Chemistry. It is by far the best adapted for the Chemical student of any that has yet fallen iu our way. — British and Foreign Medico-'Ohirurgical Revieio. The best iutrodnetory work on the subject with which we are acquainted. — Edinburgh Monthly Jour. (IRAHAM {THOMAS), F.R.S. THE ELEMENTS OF INORGANIC CHEMISTRY, including the Applications of the Science in the Arts. New and much enlarged edition, by Henry Watts and Robert Bridges, M. D. Complete in one large andhandsoiue octavo volume, of over 800 very large pages, with two hundred and thirty-two wood-cuts, extra cloth. $5 50. KNAPPS TECHNOLOGY ; or Chemistry Applied to the Arts, and to Manufactures. Wilh American additions, by Prof. Walter R. Johnson. In two very handsome octavo volumes, with 500 wood engravings, extra cloth, ^ij 00, Henry C. Lea's Publications — {ChemiHtrxj^ Pharmacy, ((;c.). 11 JprOWNES {GEORGE}, Ph. D. A MANUAL OP ELEMENTARY CHEMISTRY; Theoretical and Practical. With one hundred and ninety-seven illustrations. A new American, from the tenth and revised London edition. Edited by Robert Bridges. M. D. In one lari^e royal 12mo. volume, of about 860 pp , extra cloth, *2 75 ; leather, S.'? 2.5. (Ji/xt Issitfd^ Some years having elapsed since the appearance of the last American edition, and several revisions having been made of the work in England during the interval, it will be found very greatly altered, and enlarged by about two hun Ired and fifty pages, containing nearly one half more matter than before. The editors, Mr. Watts and Dr. Bence Jones, have labored sedulously to render it worthy in all respects of the very remarkable favor which it has thus far enjoyed, by incorporating in it all the most recent investigations and discoveries, in so far as is compatible with its design as an elementary text-book. While its distinguishing ch.iracteristics have been pre- served, various portions have been rewritten, and especial pains have been taken with the department of Organic Chemistry in which late researches have accumulated so many new facts and have enabled the subject to be systematized and rendered intelligible in a manner formerly impossible. As only a few months have ehipsed since the work thus p:issed through the ban Is of Mr. W.itts and Dr. Bence Jones, but little has remained to be done by the American editor. Such additions as seemed advisable have however been made, and especial care has been taken to secure, by the closest scrutiny, the accuracy so essential in a work of thi-i nature. Thus fully brought up to a level with the latest advances of science, and presented at a price within the reach of all, it is hoped that the work will maintain its position as the favorite text- book of the medical student. This work is so well kuowa that it eeems almost superlluous for us to speak about it. It has been a favorite text-book with medical stuJeuts fur years, and Its popularity has iu no respect dimini'shed. Whenever we have been cousuUed by medical stu- dents, as has frequently occuired, what treatise on chemistry they should procure, we have always re- commeudrd Fownes', for we regarded it as the best. There is no work that combines so many excelleu- ces. It is of convenient size, not prolix, of plain perspicuous diction, contains all the most recent discoveries, and is of moderate price. — Gincinnati Med. Repertory, Aug. 1S69. Large additions have been made, especially in the department of organic chemistry, and we know of no other work that has greater claims on the physician, pharmaceutist, or student, than this. We cheerfully recommend it as the best text-book on elementary chemistry, and bespeak for it the careful attention of students of pharmacy. — Ohicago Pliarmaeist, Aug. 1869. The American reprint of the tenth revised and cor- rected Euglish edition is now issued, and represents the present condition of the science. No comments are necessary to insure it a favorable reception at the hands of practitioners and students. — Boston Med. and Surg. Journal, Aug. 12, 1S69. It will continue, as heretofore, to hold the first rank as a text-book for students of medicine. — Chicago Med. Examiner, Aug. 1869. , This work, long the recognized Manual of Chemistry, appears as a tenth edition, under the able editorship of Bence Jones and Henry Watts. The chapter on the General Principles of Chemical Philosophy, and the greater part of the organic chemistry, have hfpa rewritten, and the whole work revised in accordance with the recent advances in clieraical knowledge. It remains the standard text-hook of chemistry. — Dub- lin Quarterly ./nuriial, Feb. 1869. There is probably not a student of chemistry in this country to whom the admirable manual of the late Profe.ssor Fownes is nftknown It has achievpd a success which we believe is entirely without a paral- lel among scientific text-books in our language. This success has arisen from the fact that there is no En- glish work on chemistry which combines so many excellences. Of convenient size, of attractive form, clear and concise, in diction, well illustrated, and of moderate price, it would seem that every requisite for a student's haud-bonk has been attained. The ninth edition was published under the joint editor- ship of Dr. Bence Jones and Dr. Hofraann; the new one has been superintended through the press by Dr. Bence Jones and Mr. Henry Watts. It i« not too much to say that it could not possibly have been in better hands. There is no one in England who can compare with Mr. Watts in experience as a compiler in chemical literature, and we have much pleasui* in recording the fact that his reputation is well sus- tained bv this, his last undertaking. — T/ie Clumical News, Fe'b. 1869. Here is a new edition which has been loog watched for by eager teachers of chemistry. In its new garb, and under the editorship of Mr. Watts, it has resumed its old place as the most successful of text-books.— Indian Medical Gazette, Jan. 1, 1869. ATTFIELD {JOHN), Ph.D. Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, Ac. CHEMISTRY, GENERAL, MEDICAL, AND PHARMACEUTICAL ; Including the Chemistry of the British Pharmacopoeia. Adapted to the Requirements of American Practice of Medicine and Pharmacy. In one handsome volume. (Preparing.) It contains a most admirable digest of what is spe- cially needed by the medical student in all that re- lates to practical chemistry, and constitutes for him a sound and useful text-book on the subject We commend it to the notice of every medical, as well as pharmaceutical, student. We only regret that we had not the book to depend upon in working up the subject of practical and pharmaceutical chemistry for the University of London, for which it seems to us that it is exactly adapted. This is paying the book a high compliment. — Tlie Lancet. Dr. Attfield's book is written in a clear and able manner; it is a work sMi^ewerJ.? and without a rival ; it will be welcomed, we think, by every reader of the 'Pharmacopoeia,' and is quite as well suited for the medical student as for the pharmacist. — The Oliemi- ctil News. A valuable guide to practical medical chemistry, and an admirable companion to the "BritisTi Phar- . macopojia " It is rare to find so many qualities com- bined, and quite curious to note how much valuable information finds a mutual interdependence. — Medi- cal Tiriien and Gazette. It is almost the only book from which the medical student can work up the pliarmacopojial ehomi'try required at his examinations. — The Pharmaceutical Journal. At page 3.50 of the current volume of this journal, we remarked that " there is a sad dearth of [medical] students' text-books in chemistry." Dr. Attfield's volume, just published, is rather a new book than a second edition of his previous work, and more nearly realizes our ideal than any book we have before seen on the subject.— T/ie Briti.'/h Medical Journal. The introduction of new matter has not destroyed the original character of the work, as a treatise on pharmaceutical and medical chemistry, but has sim- ply extended the foundations of these special dep;»rt- ments of the science.— T/te Ohemiat and Druggist. We believe that this manual has beou already adopted as the class-book by many of the professors in the public schools throu^out the United Kingdom. ... In pharmaceutical chemistry applied to the pliar- macoproia, we know of no rival. It is, therefore, p;ir- liciilarly suited to the medical student. — The Medical Press and Circular. 12 Henry C. Lea's Publications — {Mat. Med. and Therapeutics). pARRISH [ED WARD), Professor of Materia Medica in the Philadelphia College of Pharmacy. A TREATISE ON PHARMACY. Designed as a Text-Book for the Student, and as a Guide for the Physician and Pharmaceutist. With many Formulae and Prescriptions. Third Edition, greatly improved. In one handsome octavo volume, of 850 pages, with geveral hundred illustrations, extra cloth. $5 00. The immense amount of practical information condensed in this volume may be estimated from the fact that the Index contains about 4700 items. Under the bead of Acids there are 312 refer- ences; under Emplastrum, 36; Extracts, 159; Lozenges, 25; Mixtures, 65; Pills, 56; Syrups, 131; Tinctures, 138; Unguentum, 57, Ac. We have examined this large volume with a good deal of care, and find that the author has completely exhausted the subject upon which he treats ; a more complete work, we think, it would be impossible to ♦find. To the student of pharmacy the work is indis- pensable ; indeed, so far as we know, it is the only one of its kind in existence, and even to the physician or medical student who can spare five dollars to par- chase it, we feel sure the practical information he will obtain will more than compensate him for the outlay. — Canada Med. Journal, Nov. 1864. The medical student and the practising physician will find the volume of inestimable worth for study and reference. — San Francisco Med. Press, July, X864. When we say that this book is in some respects the best which has been published on the subject in the English language for a great many years, we do not wish it to be understood as very extravagant praiwe. In truth, it is not so much the best as the only book. — The London Chemical News. An attempt to furnish anything like an analysis of Parrish's very valuable and elaborate Treatise on Practical Pharmacy would require more space than we have at our disposal. This, however, is not so mnch a matter of regret, inasmuch as it would be difficult to think of any point, however minute and apparently trivial, connected with the manipulation of pharmaceutic .substances or appliances which has not been clearly and carefully discussed in this vol- ume. Want of space prevents our enlarging further on this valuable work, and we must conclude by a simple expression of our hearty appreciation of its merits. — Dublin Quarterly Jour, of Medical Science, August, 1864. OTILLE {ALFRED), M.D., A^ Professor of Theory and Practice of Medicine in the University of Penna. THERAPEUTICS AND MATERIA MEDICA; a Sj^stematic Treatise on the Action and Uses of Medicinal Agents, including their Description and History. Third edition, revised and enlarged. In two large and handsome octavo volumes of about 1700 pages, extra cloth, $10; leather, $12. {Just Issued.) T>r. Stille's splendid work on therapeutics and ma- teria medica. — London Med. TiTnes, April 8, 186.5. Dr. Still6 stands to-day one of the best and most honored representatives at home and abroad, of Ame- rican medicine ; and these volumes, a library in them- selvos, a treasure-house for every studious physician, assure his fame even had he done nothing more. — The Western Journal of Medicine, Dec. 1868. We regard this work as the best one on Materia Medica in the English language, and as such it de- serves the favor it has received. — Am. Journ. Medi- cal Sciences, July 1868. We need not dwell on the merits of the third edition of this magnificently conceived work. It is the work on Materia Medica, in which Therapeutics are prima- rily con.sidered — the mere natural history of drugs being briefly disposed of To medical practitioners this is a very valuable conception. It is wonderful how much of the riches of the literature of Materia Medica has been condensed into this book. The refer- ences alone would make it worth possessing. But it is not a mere compilation. The writer exercises a good judgment of his own on the great doctrines and points of Therapeutics. For purposes of practice, Stille's book is almost unique as a repertory of in- formation, empirical and scientific, on the actions and uses of medicines. — London Lancet, Oct. 31, 1868. Through the former editions, the professional world is well acquainted with this work. At home and abroad its reputation as a standard treatise on Materia Medica is securely established It is second to no work on the subject in the English tongue, and, in- deed, is decidedly superior, in some respects, to any other. — Pacific Med. and Surg. Journal, July, 1868. Still6's Therapeutics is incomparably the best work on the subject.— JV. Y. Med. Gazette, Sept. 26, 1868. Dr. Stmt's work is becoming the best known of any of our treatises on Materia Medica. . . . One of the most valuable works in the language on the subjects of which it treats. — N. Y. Med. Journal, Oct. 1868. The rapid exhaustion of two editions of Prof. Stille's scholarly work, and the consequent necessity for a third edition, is sufficient evidence of the high esti- mate placed upon it by the profession. It is no exag- geration to say that there is no superior work upon the subject in the English language. The present edition is fully up to the most recent advance in the science and art of therapeutics. — Leavenworth Medi- cal Herald, Aug. 1S68. The work of Prof. Still6 has rapidly taken a high place in professional esteem, and to say that a third edition is demanded and now appears before us, .sufii- ciently attests the firm position this treatise has made for itself. As a work of great re.'^earch, and scholar- ship, it is safe to say we have nothing superior. It is exceedingly full, and the busy practitioner will tind ample suggestions upon almost every important point of therapeutics. — Cincinnati Lancet, Aug. lSt>8. G RIFFITH [ROBERT E.), M.D. A UNIVERSAL FORMULARY, Containing the Methods of Pre- paring and Administering Officinal and other Medicines. The whole adapted to Physicians and Pharmaceutists. Second edition, thoroughly revised, with numerous additions, by Robert P. Thomas, M.D., Professor of Materia Medica in the Philadelphia College of Pharmacy. In one large and handsome octavo Tolume of 650 pages, double-columns. Extra cloth, $4 00; leather, $5 00. Three complete and extended Indexes render the work especially adapted for immediate consul- tation. One, of Diseases and their Remedies, presents under the head of each dise.ase the remedial agents which have been usefully exhibited in it, with reference to the formulaB containing them — while another of Pharmaceutical and Botanical Names, and a very thorough General Index afford the means of obtaining at once any information desired. The Formulary itself is arranged alphabetically, under the heads of the leading constituents of the prescriptions. We know of none in our language, or any other, so comprehensive in its details. — London Lancet. One of the most complete works of the kind in any language. — Kdinfmrgh Med. ./immal. We are not cognizant of the existence of a parallel work. — London Med. Gazette. Henry C. Lea's Publications— (3/a/. 3Ied. and Therapeutics). 13 jp ERE IRA {JONATHAN), M.D., F.R.S. and L.S. MATERIA MEDICA AND THERAPEUTICS; being an Abridg- ment of the late Dr. Pereira's Elements of Materia Medica, arranged in conformity wi7h the British Tharmaeopoeia, and adapted to the use of Medical Practitioners, Chemists and Druggists, Medical and Pharmaceutical Students, Ac. By P. J. Farre, M.D., Senior Physician to St. Bartholomew's Hospital, and London Editor of the British Pharma!copoeia ; assisted by Robert Bentley, M.R.C.S., Professor of Materia Medica and Botany to the Pharmaceutical Society of Great Britain; and by Robert WaringTon, F.R.S. , Chemical Operator to the Society of Apothecaries. With numerous additions and references to the United States Pharmacopoeia, by Horatio C. Wood. M.D., Professor of Botany in the University of Pennsylvania. In on© large and handsome octavo volume of 1040 closely printed pages, with 236 illustrations, extra cloth, $7 00; leather, raised bands, $8 00. {Lately Published.) The task of the American editor has evidently been no sinecure, for not only has he given to us all that is contained in the abridgment useful for our pur- poses, but by a careful and judicious embodiment of over a hundred new remedies has increased the size of the former work fully one-third, besides adding many new illustrations, some of which are original. We unhesitatingly say that by so doing he has pro- portionately increased the value, not only of the con- densed edition, but has extended the applicability of the great original, and has placed his medical coun- trymen under lasting obligations to him. The Ame- rican physician now has all that is needed in the shape of a complete treatise on materia medica, and the medical student has a text-book which, for prac- tical utility and intrinsic worth, stands unparalleled. Although of considerable size, it is none too large for the purposes for which it has been intended, and every medical man should, in justice to him.self, spare a place for it upon his book-shelf, resting assured that the more he consults it the better he will be satisfied of its excellence.— .y. Y. MeA. Record, Nov. 13, 1866. It will fill a place which no other work can occupy In the library of the physician, otudeut, and apothe- cary. — Boston Med. and Surg. Journal, Nov. 8, 1866. Of the many works on Materia Medica which have ttppeared since the issuing of the British Pharmaco- poeia, none will be more acceptable to the student and practitioner than the present. Pereira's Materia Medica had loug ago asserted for itself the position of being the most complete ^ork on the subject in the English language. But Its very completeness stood in the way of its success. Except in the way of refer- ence, or to those who made a special study of Materia Medica, Dr. Pereira's work was too full, and its pe- rusal required an amount of time which few had at their disposal. Dr. Farre has very j udiciously availed himself of the opportunity of the pubHcatir>n of the new Pharmacopoeia, by bringing out an abridged edi- tion of the great work. This edition of Pereira is by no means a mere abridged re-issue, butcitntains ma- ny improvements, both in the descriptive and thera- peutical departments. We can recommend it as a very excellent and reliable text-book. — Edinburgh Med. Journal, February, 1866, The reader cannot fail to be impressed, at a glance, with the exceeding value of this work as a compend of nearly all useful knowledge on the materia medica. We are greatly indebted to Professor Wood for his adaptation of it to our meridian. Without his emen- dations and additions it would lose much of its value to the American student. With them it is an Ameri- can book.— Pcrei/fc Medical and Surgical Journal, December, 1866. TJLLIS {BENJAMIN), M.D. THE MEDICAL FORMULARY: being a Collection of Prescriptions derived from the writings and practice of many of the most eminent physicians of America and Europe. Together with the usual Dietetic Preparations and Antidotes for Poisons. The whole accompanied with a few brief Pharmaceutic and Medical Observations. Twelfth edi- tion, carefully revised and much improved by Albert H. Smith, M.D, In one volume 8vo. of 376 pages, extra cloth, $3 00. {Now Ready.) This work has remained for some time out of print, owing to the anxious care with which the Editor has sought to render the present edition worthy a continuance of the very remarkable favor which has carried the volume to the unusual honor of a Twelfth Edition. He has sedu- lously endeavored to introduce in it all new preparations and combinations deserving of confidence, besides adding two new classes, Antemetics and Disinfectants, with brief references to the inhalation of atomized fluids, the nasal douche of Thudichum, suggestions upon the method of hypodermic injection, the administration of anassthetics, &c. &c. To accommodate these numerous additions, he has omitted much which the advance of science has rendered obsolete or of minor importance, notwithstanding which the volume has been increased by more than thirty pages. A new feature will be found in a copious Index of Diseases and their remedies, which cannot but increase the value of the work as a suggestive book of reference for the working practitioner. Every precaution has been taken to secure the typographical accuracy so necessary in a work of this nature, and it is hoped that the new edition will fully maintain the position which " Ellis' Formulary'' has long occupied. . PARSON {JOSEPH), M.D., v-/ Professor of Materia Medica and PJiarmacy in the University of Pennsylvania, Ae. SYNOPSIS OF THE COURSE OF LECTURES ON MATERIA MEDICA AND PHARMACY, delivered in the University of Pennsylvania. With three Lectures on the Modus Operandi of Medicines. Fourth and revised edition, extra cloth, $3 00. {Just Issued.) DUNGLISON'S NEW REMEDIES, WITH F0RMTTLJ5E FOR THEIR PREPAR.4.TI0.\ AND ADMINISTRA- TION. Seventh edition, with extensive additions. One vol. Svo , pp. 770; extra cloth. $100. ROYLE'S MATERIA MEDICA AND THERAPEU- TICS. Edited by Joseph Cakson, M. D. With ninety-eight illustrations. 1 vol. 8vo., pp. 700, ex- tra cloth. $:? 00. CHRISTISON'S DISPENSATORY. With copious ad- ditions, and 213 large wood-engravings. By R. E«LBSPEi,D Griffith, M, D. One vol. Svo., pp. 1000 ; eztr& cloth. $4 00. CARPENTER'S PRIZE ESSAY ON THE USE OF Alcoholic Liquors in Health awd Disease. New edition, with a Preface by D. F. Condie, M.D., and explanatlonsofscientiflc words. In one neat r2mo. volume, pp. 178, extra cloth. 60 cents. De JONGH ON THE THREE KINDS OF COD-LIVER Oil, with their Chemical and Therapeutic Pro- perties. 1 vol. 12ino., cloth. 75 cents. WAYNE'S DISPENSATORY AND THERAPEUTICAL Remembrancer. Uy R. E. Griffith, M. D. In one 12mo. volume, 300 pp., extra cloth. 7d cents. 14 Henry C. Lea's Publications — {Pathology). riROSS [SAMUEL D.), M. D., v^ Professor of Sv,rgery in the Jefferson Medical College of Philadelphia. ELEMENTS OF PATHOLOGICAL ANATOMY. Third edition, thoroughly revised and greatly improved. In one large and very handsome octavo rolame of nearly 800 pages, with about three hundred and fifty beautiful illustrations, of which a large number are from original drawings ; extra cloth. $4 00. The very beautiful execution of this valuable work, and the exceedingly low price at which i is offered, should command for it a place in the library of every practitioner. To the student of medicine we would say that we know of no work which we can more heartily com- mend than Gross's Pathological Anatomy.— /Sowt/ierw Med. and Surg. Journal. The volume commends itself to the medical student ; it will repay a careful perusal, and should be upon the book-shel f of every American physician.— OAar/e*- ton Med. Journal. • > It contains much new matter, and brings down onr knowledge of pathology to the latest period. — London Lancet. TONES [0. HANd)FIELD), F.R.S., and SIEV EKING [ED. K), M.D., *J Assistant Physicians and Lecturers in St. Mary's Hospital. A MANUAL OF PATHOLOGICAL ANATOMY. First American edition, revised. With three hundred and ninetyseven handsome wood engravings. In one large and beautifully printed octavo volume of nearly 760 pages, extra cloth, $3 50. Onr limited space alone restrains us from noticing more at length the various subjects treated of in this interesting work ; presenting, as it does, an excel- lent summary of the existing state of knowledge in relation to pathological anatomy, we cannot too strongly urge upon the student the necessity of a tho- rongh acquaintance with its contents. — Medical Ex- aminer. We have long had need of a hand-book of patholo- gical anatomy which should thoroughly reflect the present state of that science. In the tre.itise before ns this desideratum is supplied. Within the limits of a moderate octavo, we have the outlines of this great department of medical science accurately defined. and the most recent investigations presented in suffi- cient detail for the student of pathology. We cannot at this time undertake a formal analysis of this trea- tise, as it would involve a separate and lengthy consideration of nearly every subject discussed ; nor would such analysis be advantageous to the medical reader. The work is of such a character that every physician ouglit to obtain it, both for reference and study.-7iV. Y. Journal of Medicine. Its importance to the physician cannot be too highly estimated, and we %vould recommend our readers to add it to their library as soon as they conveniently can. — MoiUreal Med. Chronicle. GLUGE'S ATLAS OF PATHOLOGICAL HISTOLOGY. Translated, with Notes aud Additions, by .Toseph Leidy, M. D. In one volnme, very large imperial quarto, with 320 copper-plate figures, plain and colored, extra cloth. $4 00. SIMON'S GENERAL P.\THOLOGY, as conducive to the Establishment of Kational Principles for the Prevention and Cure of Disease. In one octayo volume of 212 pages, extra cloth. $1 2i5. ITTILLIAMS {CHARLES J. B.), M.D., ' ' Professor of Clinical Medicine in University College, London. PRINCIPLES OF MEDICINE. An Elementary Yiew of the Causes, Nature, Treatment, Diagnosis, and Prognosis of Disease; with brief remarks on Hygienics, or the preservation of health. A new American, from the third and revised London edition. In one octavo volume of about 500 pages, extra cloth. $3 50. No work has ever achieved or maintained a more deserved reputation. — Virginia Med. and Surg. Journal. There is no work in medical literature which can fill the place of this one. It is the Primer of the young practitioner, the Koran of the scientific one. — Stethoscope. • A text-book to which no other in our language is comparable. — Charleston Med. Journal. The absolute necessity of such a work must be evident to all who pretend to more than mere empiricism. We must conclude by again express- ing our high sense of the immense benefit which Dr. Williams has conferred on medicine by the pub- lication of this work. We are certain that in the present state of our Icnowledge his Principles of Medi- cine could not possibly be sui'passed. — London Jour, of Medicine. HARRISON'S ESSAY TOWARDS A CORRECT THEORY OF THE NERVOUS SYSTEM. In one octavo volume of 292 pp. *1 .50. SOLLY ON THE HUMAN BRAIN: its Structure, Phy- siology, and Diseases. From the Second and much enlarged London edition. In one octavo volume of .500 pages, with 120 wood-cuts: exti'8 cloth. $2 .')0. LA ROCHE ON YELLOW FEVER, considered in its Historical, Pathological, Etiological, and Therapeu- tical Relations. In two large and handsome octavo volumes, of nearly 1.500 pages, extra cloth, $7 00. LA ROCHE ON PNEUMONIA ; its Supposed Connec- tion, Pathological, and Etiological, with Autumnal Fevers, including an Inquiry into the Existence and Morbid Agency of Malaria. In one handsome oc- tavo volnme, extra cloth, of ."iOO paces Price f S Oft. BUCKLER ON FIBKO-BRONCHITIS AND RHEl^ MATIC PNEUMONIA, In one octavo vol,, extra clnth, pp 1.50. $1 2.'). FISKE FUND PRIZE ESSAYS.— LEE ON THE EF- FECTS OF CLIMATE ON TUBERCULOUS DIS- EASE. AND WARKEN ON THE INFLUENCE OF PREGNANCY ON THE DEVELOPMRNT OF TU- BERCLES. Together in one neat octavo Tolnme extra cloth, »1 00. B ARGLAY [A. W.), M. D. A MANUAL OF MEDICAL DIAGNOSIS; being an Analysis of the Sijcns and Symptoms of Disease. Third American from the second and revised London edition. In one neat octavo volume of 451 pages, extra cloth. $3 60. A work of immense practical utility. — London Mt^iX. Times and Oatette, The book should be in the hands of every practical I man. — DvMin Med. Press. Henry C. Lea's Publications — {Practice of Medicine). 15 'PLINT [A USTIN), M. D., ■*- Professor of the Principlts avd Practice of 3fedicine in Bellev^te Med. College, N. Y. A TREATISE ON THE PRINCIPLES AND PRACTICE OF MEDICINE ; designed for the use of Students and Practitioners of Medicine. Third edition, reviseu and enlarged. In one large and closely printed octavo volume of 1002 pages; handsome extra cloth, $6 00 j or strongly bound in leather, with raised bands, $7 00. {Just Issued.) From the Preface to the Third Edition. Since the publication, in December, 1866, of the second edition of this treatise, much time has been devoted to its revision. Recognizing in the favor with which it has been received a pro- portionate obligation to strive constantly to increase its worthiness, the author has introduced in the present edition additions, derived from his clinical studies, and from the latest contributions in medical literature, which, it is believed, will enhance considerably the practical utility of the work. A slight modification in the typographical arrangement has accommodated these additions without materially increasing the bulk of the volume. New York, October, 1868. At the very low price affixed, the profession will find this to be one of the cheapest volumes within their reach. This work, which stands pre-eminently as the ad- vance standard of medical science up to the present time in the practice of medicine, has for its author one who is well and widely known as one of the leading practitioners of this continent. In fact, it is seldom that any work Is ever issued from the press more deserving of universal recommendation. — Do- minion Med Journal, May, 1869. The third edition of this most excellent book scarce- ly needs any commendation from us. The volume, as it stands now, is really a marvel : first of all, it is excellently printed and bound — and we encounter that luxury of America, the ready-cut pages, which the Yankees are 'cute enough to insist upon — nor are these by any means trifles ; but the contents of the book are astonishing. Not only is it wonderful that any one man can have grasped in his mind the whole scope of medicine with that vigor which Dr. Flint shows, but the condensed yet clear way in which this is done is a perfect literary triumph. Dr. Flint is pre-eminently one of the stroug men, whose right to do this kind of thing is well admitted ; and we say no more than the truth when we affirm that he Is very nearly the only living man that could do it with such results as the volume before us. — The London Practitioner, March, 1869. This is in some respects the best text-book of medi- cine in. our language, and it is highly appreciated on the other side of the Atlantic, inasmuch as the first edition was exhausted in a few months. The second edition was little more than a reprint, but the present has, as the author says, been thoroughly revised. Much valuable matter has been added, and by mak- ing the type smaller, the bulk of the volume is not much increased. The weak point in many American works is pathology, but Dr. Flint has taken peculiar pains on this point, greatly to the value of the book. — London Med. Times and Gazette, Feb. 6, 1869. Published in 1866, this valuable book of Dr. Flint's has in two years exhausted two editions, and now we gladly announce a third. We say we gladly an- nounce it, because we are proud of it as a national representative work of not only American, but of cosmopolitan medicine. In it the practiceof medicine is young and philosophical, based on reason and com- mon sense, and as such, we hope it will be at the right hand of every practitiouerof this vast continent. — California Medical Gazette, March, 1S69. Considering the large number of valuable works in the practice of medicine, already before the profes- sion, the marked favor with which this has been re- ceived, necessitating a third edition in the short space of two years, indicates uuniistakahly that it is a work of more than ordinary excellence, and must be accept- ed as evidence that it has largely fulfilled the object for which the author intended it. A marked feature in the work, and one which particularly adapts it for the use of students as a text-book, and certainly ren- ders it none the less valuable to the busy practitioner as a work of reference, is brevity and simplicity. The present edition has been thoroughly revised, and much new matter incorporated, derived, as the author informs us, both from his own clinical studies, aud from the latest contributions to medical literature, thus bringing it fully up with the most recent ad- vances of the science, and greatly enhancing its prac- tical utility ; while, by a slight modification of its typographical arrangement, the additions have been accommodated without materially increasing its hulk. — St. Louis Mtd. Archives, Feb. 1869. If there be among our readers any who are not fa- miliar with the treatise before us, we shHll do them a service in persuading them to repair their omission forthwith. Combining to a rare degree the highest scientific attainments with the most practical com- mon sense, and the closest habits of observation, the author has given us a vcilume which not only sets forth the results of the latest investigations of other laborers, but contains more original views than any other single work upon this well-woru theme within our knowledge,— iV^. Y. Med. Gazette, Feb. 27, 1869. Practical medicine was at sea when this book ap- peared above the horizon as a safe and capacious har- bor. It came opportunely and was greeted with pleasurable emotions thronghout the land. — Nash' ville Med. and Surg. Journal, May, 1869. jyUNGLISON, FORBES, TWEED IE, AND CONOLLY. THE CYCLOPEDIA OF PRACTICAL MEDICINE: comprising Treatises on the Nature and Treatment of Diseases, Materia MeJioa and Therapeutics, Diseases of Women and Children, Medical Jurisprudence, Ac. &c. In four large super-royal octavo volumes, o 13254 double-columned pages, strongly and handsomely bound in leather, $15; extra cloth, $11. *jif* This work contaiusno less than four hundred and eighteen distinct treatises, contributed by sixty-eight distinguished physicians. The most complete work on practical medicine extant, or at least in our language. — Buffalo Medical and Surgical Jotirnal. For reference, it is above all price to every practi- 'tiouer. — We.stern Lancet. One of the most valuable medical publications of the day. As a work of reference it is invaluable.— Western Journal of Medicine and Surgery. It has been to us, both as learner and teacher, a work for ready and frequent reference, one in which modern English medicine is exhibited in the mostad- vantageous i\g)xt.— Medical Examiner. BARLOW'S MANUAL OF THE PRACTICE OF I HOLLAND'S MEDICAL NOTES AND EEFLEC- MEDICINE. With Additions by D, F, Condib, tioxs. From the third and enlarged English edi- 11. D. 1 vol. 8vo., pp. 600, cloth. $2 50. I tion. In one handsome octavo volume of about I 500 pages, extra cloth. $3 50. 16 Henry C. Lea's Publications — {Practice of Medicine). fTARTSHORNE [HENR Y), M. D., J- J- Professor of Hygiene in the University of Pennsylvania. ESSENTIALS OF THE PRINCIPLES AND PRACTICE OF MEDI- CINE. A handy-book for Students and Practitioners. Second edition, revised and im- proved. In one handsome royal ]2mo. volume of 450 pages, clearly printed on small type, cloth, $2 38; half bound, $2 63. {Just Issued.) The very cordi»l reception with which this work has met shows that the author has fully suc- ceeded in his attempt to condense within a convenient compass the essential points of scientific and practical medicine, so as to meet the wants not only of the student, but also of the praxiti- tioner who desires to acquaint himself with the results of recent advances in medical science. safe and accomplished companion. We speak thus As a strikingly terse, fnll, and comprehensive em- bodiment in a condensed form of the essentials in medical science and art, we hazard nothing in saying that it is incomparably in advance of any work of the kind of the past, and will stand long in the future without a rival. A mere glance will, we think, im- press others with the correctness of our estimate. Nor do we believe there will be found many who, after the most cursory examination, will fail to possess it. How one could be able to crowd so much that is valu- able, especially to the student and young practitioner, within the limits of so small a book, and yet embrace and present all that is important in a well-arranged, clear form, convenient, satisfactory for reference, with so full a table of contents, and extended general index, with nearly three hundred formulas aod recipes, is a marvel. — Western Journal of Medicine, Aug. lSb7. The little book before us has this quality, and we can therefore say that all students will find it an in- valuable guide in their pursuit of clinical medicine. Dr. Hartshorne speaksof itas "an unambitious effort to make useful the experience of twenty years of pri- vate and hospital medical practice, with its attendant study and reflection." That the effort will prove suc- cessful we have no doubt, and in his study, and at the bedside, the student will find Dr. Hartshorne a highly of the volume, because it approaches more nearly than aoy similar manual lately before us the standard at which all such books should aim — of teaching much, and suggesting more. To the student we can heartily recommend the work of our transat- lantic colleague, and the btisy praciitioner, we are sure, will find in it the means of solving many a doubt, and will rise from the perusal of its pages, having gained clearer views to guide him in his daily struggle with disease. — Dub. Med. Press, Oct. 2, 1867. This work of Dr. Hartshorne must not be confound- ed with the medical manuals so generally to be found in the hands of students, serving them at best but as blind guides, better adapted to lead them astray than to any useful and reliable knowledge. The work be- fore us presents a careful synopsis of the essential elements of the theory of diseased action, its causes, phenomena and results, and of the art of healing, as recognized by the most authoritative of our profes- sional writers and teachers. A very careful and can- did examination of the volume has convinced us that it will be generally recognized as one of the best man- uals for the use of the student that has yet appeared. — American Journal Med. Sciences, Oct. 1867. TU:a TSON [THOMAS), M. D., ^c. LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Delivered at King's College, London. A new American, from the last revised and enlarged English edition, with Additions, by D. Francis Condie, M. D., author of " A Practical Treatise on the Diseases of Children," &o. With one hundred and eighty- five illustrations on wood. In one very large and handsome volume, imperial octavo, of over 1200 closely printed pages in small type ; extra cloth, $6 60 ; strongly bound in leather, with raised bands, $7 60. Believing this to be a work which should lie on the table of every physician, and be in the hands of every student, every effort has been made to condense the vast amount of matter which it con- tains within a convenient compass, and at a very reasonable price, to place it within reach of all. In its present enlarged form, the work contains the matter of at least three ordinary octavos, rendering it one of the cheapest works now offered to the American profession, while its mechani- cal execution makes it an exceedingly attractive volume. DICKSON'S ELEMENTS OF MEDICINE; a Compen- dious View of Pathology and Therapeutics, or the History and Treatment of Diseases. Second edi- tion, revised. 1 vol. 8vo. of 750 pages, extra cloth. $4 00. WHAT TO OBSERVE ATTHE BEDSIDE AND AFTER Death in Medical Cases. Published under the authority of the London Society for Medical Obser- vation. From the second London edition. 1 vol. royal 12mo., extra cloth. $1 00. LAYCOCK'S LECTURES ON THE PRINCIPLES AND Methods of Medical Observation and Rb- 8EABCH. For the use of advanced students and junior practitioners. In one very neat royal 12iao. volume, extra cloth. $1 00. TpULLER [HENRY WILLIAM), M. D., -*• Physician to St. George's Hospital, London. ON DISEASES OF THE LUNGS AND AIR-PASSAGES. Their Pathology, Physical Diagnosis, Symptoms, and Treatment. From the second and revised English edition. In one handsome octavo volume of about 500 pages, extra cloth, $3 50. {Just Issued.) accordingly we have what might be with perfect jus- tice styled an entirely new work from his pen, the portion of the work treating of the heart and great vessels being excluded. Nevertheless, this volume is of almost equal size with the first. — London MediccU Times and Gazette, July 20, 1867. Dr. Fuller's work on diseases of the chest was so favorably received, that to many who did not know the extent of his engagements, it was a matter of won- der that it should be allowed to remain three years out of print. Determined, however, to improve it. Dr. Fuller would not consent to a mere reprint, and jDRINTON [WILLIAM), M.D., F.R.S. -^LECTURES ON THE DISEASES OF THE STOMACH; with an Introduction on its Anatomy and Physiology. From the second and enlarged London edi- tion. With illustrations on wood. In one handsome octavo volume of about 300 pages, extra cloth. $3 2b. {Just issued.) Nowhere can be found a more full, accurate, plain, I The most complete work In our lasguage upon the and instructive history of these diseases, or more ra- | diagnosis and treatment of these puz/liug and impor- ti'.Qal views respecting their pathology and therapeu- I tant diseases. — Boston Med. and Surg. Joli.rna^,'S^ Ready.) Henry C. Lea's Publications — (Diseases of Children). 21 (^MITH {J. LE WIS), M. D., ^^ Pro/esxnr of Morbid Anatomy in the Bellevue HoxpUal Med. CnUege, iV T. A COMPLETE PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. In one handsome joctaTO volume of 620 pages, extra cloth, $4 75 ; leather, $5 76. (Just Issiud.) We have no work upon the Diseases of Infancy and | of the diseases of childhood, eminently fli him for the Childhood which can compare with it. — Buffalo Med and Surg. Journal, March, 1S69. The description of the pathology, symptoms, and treatment of the different diseases is excellent. — Am. Med. Journal, April, 1869. So full, satisfactory, and complete is the information to be derived from this work, that at no time have we examined the pages of any book with more pleasure. The diseases incident to childhood are treated with a clearness, precision, and understanding that is not often met with, and which must call forth the ap- proval of all who consult its pages. — Cincinnati Med. Rejjertory, May, 1869. The author of this volume is well known as a valued contributor to the literature of his specialty. The faithful manner in which he has worked in the public institutions with which he has been connected, the conscientioas regard for truth which has for years characterized all his researches, the great amount of experience which he has been enabled to acquire in task which he has taken upon himself The remark- able faculty of bringing out salient points and stating concisely other less imporiant fact.s, euables him to crowd within a small compass a vast amount of pracv tical information. The attention given to the treat- ment of the varioac maladies, as well as the presenta- tion of all the recently accepted pathological views, make it one of the most valuable treatises, within it?i present compass, that can be placed in the hands of any seeker after truth. The volume as a whole will still further establish for the writer a permanent and enviable reputation as a careful observer, an impar- tial interpreter, a safe and trustworthy adviser, and a modest and untiring student. — N. T. Med. Record, March 1.5, 1869. We have perused Dr. Smith's book with not a little satisfaction; it is indeed an excellent work ; well and correctly written ; thoroughly up to the modern ideas ; concise, yet complete in its material. We cannot help welcoming a work which will be worthy of reliance 1 as a text-book for medical students and younger phy- the treatment of infantile diseases, and the care which ' (;icians in their investigation of disease i'n thildcen. he has accustomed himself to take in the stndy.of the ■ Boston Med. and Surg. Journal, March i, lad9. significant facts relating to the pathological anatomy | ffONDIE [D. FRANCIS), M.D. A PRACTICAL TREATISE ON THE DISEASES OF CHILDREN. Sixth edition, revised and augmented. In one large octavo volume of nearly 800 closely- printed pages, extra cloth, $5 25 ; leather, $6 25. (Lately Issued.) before his countrymen as one peculiarly pre-eminent in this department of medicine His work lias been so long a standard for practitioners and medical stu- dents that we do no more now than refer to the fact that it has reached its sixth edition. We are glad once more to refresh the impressions of our earlier days by wandering through its pages, and at the same time to be able to recommend it to the youngest mem- bers of the profession, as well as to those who have the older editions on their shelves. — St. Louis Mtd. Reporter, Feb. 15. 186S. We pronounced the first edition to be the best work on the diseases of children in the English language, and, notwithstanding all that has been published, we still regaid it in that light.— Jtredicai ExamiTier. Dr. Condie has been one of those who have per- formed such a service satisfactorily, and, as a result, his popular, comprehensive, and practical work has received that high compliment of approval on the part of his brethren, which several editions incontes- tably set forth. The present edition, which is the sixth, is fully up to the times in the discussion of all those points in the pathology and treatment of infan- tile diseases which have been brought forward by the German and French teachers. As a whole, however, the work is the best American one that we have, and in its special adaptation to American practitioners it certainly has no equal. — iV«w York Med. Record, Jiai-ch 2, 1868. No other treatise on this subject is better adapted to the American physician. Dr. Condie has long stood JJ/'EST [CHARLES), M.D., ' ' Physician to the Hospital for Sick Children, Ac. LECTURES ON THE DISEASES OP INFANCY AND CHILD- HOOD. Fourth American from the fifth revised and enlarged English edition. In one large and handsome octavo volume of 656 closely-printed pages. Extra cloth, $'1 50 ; leather, $5 60. (Lately issued.) Dr. West's volume is, in onr opinion, incomparably the best authority upon the maladies of children that the practitioner can con.salt. — Cincinnati Jour, of Medicine, March, 1866. We have long regarded it as the most scientific and practical book on diseases of children which ha.s yei appeared in this coantry. — Buffalo Medical Journal. Of all the English writers on the diseases of chil- dren, there is no one so entirely satisfactorj' to us as Dr. West. For years we have held his opinion as judicial, and have regarded him as one of the highest living authorities in the difficult department of medi- cal science in which he is most widely known. — Boston Med. and Surg. Journal, April 26, 1866. ^MITH [E USTA CE), M. D., Physician to the l^orthwest London Free Dispensary for Sick Children. A PRACTICAL TREATISE ON THE WASTING DISEASES OF INFANCY AND CHILDHOOD. 1 vol. 8vo. Second and revised edition. (Prtpariug.) a purpose of clinical usefulness, he has succeeded In producing a treatise on the causes of chronic wasting so complete that but little could be added, and yet so concise that it would be almost impossible to give a In this brief treatise, the author has made one of the most valuable contributions to medical literature that has been given to our profession for many years. To supply the want of information on this subject is the task which Dr. Smith has set himself, and admi- rably has he performed it. Keeping steadily in view synopsis of his views in fewer words than the book itself contains.— X T. Med. OazMe, April 2, 1870. D EWEES {WILLIAM P.), M.D. A TREATISE ON THE PHYSICAL AND MEDICAL TREAT- MENT OF CHILDREN. Eleventh edition, with the author's last improvements and cor- rections. In one octavo volume of 548 pages. $2 80. 22 Henry C. Lea's Publications — {Diseases of Women). ffHOMAS {ZGAILLARD),M.D., -L PriifkSKor of Obstetrics, &c in the Cdlege of Phyfticianft and Surgeons, N. T., Ac. A PRACTICAL TREATISE ON THE DISEASES OF WOMEN. Se- cond edition, revised and improved In one large and handsome octavo volume of 650 pages, with 225 illustrations, extra cloth, $5; le.other, $6. {Just Issued.} From tJie Preface to the Second Edition. In a science so rapidly progressive as that of medicine, the profession has a right to expect that, when its approbation of a work is manifested by a call for a new edition, the author should re- spond by giving to his book whatever of additional value may be derivable from more extended experience, matiirer thought, and the opportunity for correction. Fully sensible of this, the a«thor of the present volume has sought by a careful revision of the whole, and by the additipn of a chapter on Chlorosis, to render his work more worthy of the favor with which it has been received. — New York, March, 1869. If the excellence of a work is to be judged by its rapid sale, this one ranst tiike precedence «f all otbers npoa the ?ame, or kindred subjects, as evidencpd in the shiirt time from its first appearance, in which a new edition is called for, resulting, as we are informed, from the exhaustion of the previous large edilion. We deem it scarcely necessery to recommend this work to phy.sicians as it is now widely known, and most of them already possess it, or will certainly do so. To students we unhesitatingly recommend it as the best text-book on diseases of females extant.— jSt.Xowi* Med. Reporter, June, 1869. Of all the army of books that have appeared of late years, on the diseases of the uterus and its appendages, we know of none that is so clear, comprehensive, and practical as this of Dr. Thomas', or one that we should more emphatically recommend to the young practi- tioner, as his guide. — California Med. Gazette, June, 1869. If not the best work extant on the subject of which it treats, it is certainly second to none other. So short a time has elapsed since the medical press teemed with commendatory notices of the first edition, that it would be superfluous to give an extended re- view of what is now firmly established as icieuce. And wliat, in our opin- ion, enhances the value of the work is that, while the practising surgeon will find all that he requires in it, it i^ at the same time one of the most valuable trea- tises which can be put into the hands of the student seeking to know the principles aud practice of this branch of the profession which he designs subse- of modern turgery, where the student and practi- quently to follow. — Tfie Brit. Am. Journ., Montreal. or THE SAME AUTHOR. A PRACTICAL TREATISE ON FOREIGN BODIES IN THE AIR-PASSAGES. In one handsome octavo volume, extra cloth, with illustrationp. pp. 468. $2 75. MALGAIGNE'S OPERATITE SUROERT. With nu- merous illn^tratil..ns on wo^id In one handsome octavo volume, extra cloth, of nearly 600 pp. fi2 50. SKET'S OPERATIVE SURGEP.T. In one v«.ry hand- some octavo volume, extra cloth, of over bii'J jagee with about 100 wood-cats. $S 26. Henry C. Lea's Publications — (Surgery). 27 PRICHSEN [JOHN), -*-• Senior Surgeon to Univergity Cnlhge Hnsjiitnl. THE SCIENCE AND ART OF SURGERY; being a Treatise on Siir- gical Injuries, Diseases, and Operations. From the Fifth enlarged and carefully revised London Edition. With Additions by John Asiihukst, Jr., M. D., Surgeon to the Episcopal Hospital, Ac. Illustrated by over six hundred Engravings on wood. In one very large and beautifully printed imperial octavo volume, containing over twelve hundred closely printed pages : cloth, $7 50 ; leather, raised bands, $8 50. (Just Issued.) This volume having enjoyed repeated revisions at the hands of the author has been greatly enlarged, and the pre.sent edition will thus be found to contain at least one-half mo.re matter than the last Am'erican impression. On the latest London edition, just issued, especial care has been bestowed. Besides the most minute attention on the part of the author to bring every portion of it thoroughly on a level with the existing condition of science, he called to his aid gentlemen of distinction in special departments. Thus a chapter on the Surgery of the Eye and its Appendages has been contributed by Mr. Streatfeild ; the section devoted to Syphilis has been rearranged under the supervision of Mr. Berkeley Hill ; the subjects of General Surgical Diseases, including Pyaemia, Scrofula, and Tumors, have been revised by Mr. Alexander Bruce ; and other professional men of eminence have assisted in other brunches. The work may thus bo regarded as eniljodying a complete and comprehensive view of the most advanced condition of British surgery ; while such omissions of practical details in American surgery as were found have been supplied by the editor, Dr. Ashhurst. Thus complete in every respect, thoroughly illustrated, and containing in one beautifully printed Tolume the matter of two or three ordinary octavos, it is presented at a price which renders it .one of the cheapest works now accessible to the profession. A continuance of the very remarkable favor which it has thus far enjoyed is therefore confidently expected. those eulightened surgeons of the present day, who regard an acquaintance with the manual part •)f sur- gery as only a portion of that kno^viedge wliich The high position which Mr. Erichsen's Science and Art of Surgery has for some time attained, not only in this couutry, but on the Continent and in America, almost limits the task of the reviewer, on the appear- ance of a new edition, to the mere announcement. Elaborate analysis and criticism would be out of place ; and nothing remains to be done except to state in general terms that the author has bestowed on it that labor which such a work required in order to be surgeon should possess. — British Medical Journal, Jan. 2, 1S69. Thus the work bears in every feature a stamp of novelty and freshness whicli will commcud it to those who are making its acquaintance for thL> first time. made a representative of the existing state of surgical whilst those who have fnund it a sale guide and science and practice. Of the merits of the book as a friend in former years will be able to refer to the new guide to the "Science and Art of Surgery'' it i.-3 not edition for the latest information upon any point of necessary for ns to say much. Mr. Erichseh is one of ' surgical controversy. — London Lancet, Jan. 23, 1S69. or THE SAME AUTHOR. [Just Issued.) ON RAILWAY, AND OTHER INJURIES OF THE NERVOUS SYSTEM. In small octavo volume. Extra cloth, $1 00, llflLLER [JJiMES), •*-'-*- £,„(,; Profe.v.^-or of Surgery in the University of Edinburgh, &e. PRINCIPLES OF SURGERY. Fourth American, from the third and revised Edinburgh edition. In one large and very beautiful volume of 700 pages, with two hundred and forty illustrations on wood, extra cloth. $3 75. -DY THE SAME AUTHOR. THE PRACTICE OF SURGERY. Fourth American, from the last Edinburgh edition. Revised by the American editor. Illustrated by three hundred and sixty-four engravings on wood. In one large octavo volume of nearly 700 pages, extra cloth. $3 75. It is seldom that two volumes have ever made so I acquired. The anther is an eminently sensible, prac- profcund an impression in so short a time as the | tical, and well-informed man, who knows exactly "Principles" and the "Practice" of Surgery by Mr. what he is talking about and exactly how to talk it.— Miller, or so richly merited the reputation they have | Kr.ntucky Mtdical Recorder. PIRRIE ( WILLIAM), F. R. S. E., Professor of Surgery in the University of Aherdeen. THE PRINCIPLES AND PRACTICE OF SURGERY. Edited by John Neill, M. D., Professor of Surgery in the Penna. Medical College, Surgeon to the Pennsylvania Hospital, IGELO W [HENRY J.), M. D., -'-' Professor of Surgery in the Massachusetts Med. College. ON THE MECHANISM OF DISLOCATION AND FRACTURE OF THE HIP. With the Reduction of the Dislocation by the Flexion Method. With numerous original illustrations. In one very handsome octavo volume. Cloth. $2 50. {Jtist Issued.) We cannot too highly praise this book as the work graph is largely illustrated with exquisitely executed of an accomplished and scientiflc surgeon. We do woodcuts, after photogr«phs, which help to elucidalo ' not hesitate to siiy that he has done much to clear up the admirable subject-matter of the text. We cor- the obscurities connected with the mechanism of dis- dially commend the " Hip," by Dr. Bigelow, to the location of the hip-joint, and he has laid down most attention of surgeons. — Dtvblin Quarter ly Journal ()f valuable practical rules for the easy and most sue- Medical Science, Feb. 1870. cessful management of these injurie'si- The mono- mnoMPsoN [SIR henr y), J- Surgeon and Professor of Clinical Surgery to University College Hospital. LECTURES ON DISEASES OF THE URINARY ORGANS. With illustrations on wood. In one neat octavo volume, extra cloth. $2 25. (Just Issued.) These lectures stand the severe test. They are in- structive without being tedious, and simple without being diffuse; and they iuclude many of those prac- tical hints so useful for the student, and even more valuable to the young practitioner. — Edinburgh Med. Journal, April, 1869. Very few words of ours are necessary to recommend these lectures to the profession. There is no subject on which Sir Henry Thompson speaks with more au- thority than that in which he has specially gathered his laurels; in addition to this, the conversational style of instruction, wliich is retained in these printed lectures, gives them an attractiveness which a sys- tematic treatise can never possess. — Loiidoi^ Medieal Times and Gazette, April 24, 1S6». , ■DT THE SAME AUTHOR. ON THE PATHOLOGY AND TREATMENT OF STRICTURE OP THE URETHRA AND URINARY FISTULA. Wjth plates and wood-cuts. From the third and. revised English edition. In one very handaome octavo volume, extra cloth, $3 60. {Just Issued.) Thi.s classical work has so long been recognized as a standard authority on its perplexing sub- jects that it should be rendered accessible to the American profession. Having enjoyed the advantage of a revision at the hands of the author within a few months, it will be found to present his latest views and to be on a level with the most recent advances of surgical science- With a work accepted as the authority upon the I ably known by the profession as this before us, must tubjects of whidi it treats, an extended notice Would | create a demand for it from those who would keep be a work of supererogatiou. The simjile auuouuce- I themselves well up in this department of surgery.— ment of another edition of a work so well and favor- | St. Louis Med. Archives, Feb. 1870. Henry C. Lea's Publications — {Medical Juriiiprudenre, i%c.). 31 fTAYLOR {ALFRED S.), M.D., ■*- Lecturer on Mt-d. Jurisp. find ChmtUntry in Guy's ffnspitnl. MEDICAL JURISPRUDENCE. Sixth American, from the eighth and revised London edition. With Notes and References to American Decisions, bj-'cLE- ME.VT B. Penrose, of the Philadelphia Bar. In one large octavo volume of 776 pages, extra cloth, $4 50 ; leather, $5 50. (J?t.'!t Issued.) Considerable additions have been made by the editor to this edition, comprising some important sections from the author's larger work, " The Principles and Practice of Medical Jurisprudence," a;s well as references to American law and practice. The notes of the former editor. Dr. Harts- home, have likewise been retained, and the whole is presented as fully worthy to maintain the di.'tinguished position which the work has acquired as a leading text-book and authority on the subject. A Lew edition of a work acknowledged as a stand- I nected with forensic medicine, and every successive ard authority everywhere within the range of the 1 edition of his valuable work gives fresh assurance to English language. Considering the new matter intro- j his many admirers thut he will continue to maintain duced, on tricliiniasis and other subjects, and the | his well-earned position. No one should, in fact, be plates representing the crystalsof poisons, etc., it may i without a text-book on the subject, as he does not fairly be regarded as the most compact, comprehen- ' know but that his next case may create for him an give, and practical work on medical jurisprudence ' emergency for its use. To those who are not the for- which has issued from the press, and the one best ! Innate possessors of a reliable, readable, interesting, fitted for students.— Poci/Jc Med. and Surg. Journal, I and thoroughly practical work upon the subject, we would earnestly recommend this, as forming the best groundwork for all their future studies of. the more elaborate treatises. — yeio York Medical Record, Feb. 1.5, lSt)7. The present edition of this valuable manual is Feb. 1867. The sixth edition of this popular work comes to us in charge of a new editor, Mr. Penrose, of the Phila- delphia bar, who has done much to render it useful, not only to the medical practitioners of this country, but to those of his own profession. Wisely retaining great improvement on those which have preceded it. the references of the former American editor, Dr. i It makes thus by far the best guide-book in this de- Hartshorne, he has added many valuable notes of his i partment of medicine for students and the gen'?ral own. The reputation of Dr. Taylor's work is so well ' practitioner in our language. — Boston Med. and Surg . established, that il needs no recommendation. He is i Journal, Dec. 27, IStiS. now the higliest living authority on all matters con- I • ' ^yiNSLOW [FORBES], M.D., D.C.L., ^c. ON OBSCURE DISEASES OF THE BRAIN AND DISORDERS Of the MIND; their incipient Symptoms, Pathology, Diagnosis, Treatment, and Pro- phylaxis. Second American, from the third and revised English edition. In one handsome octavo, volume of nearly 600 pages, extra cloth. $4 25. (Just Issued.) Of the merits of Dr. Winslow's treatise the profes- thereby undertaken responsibilities in which the Bion has sufficiently judged. It has taken its place in welfare and happiness of individuals and families the front rank of the works upon the special depart- ; are largely involved. We shall therefore close this ment of practical medicine tp which it pertains. — i brief and necessarily very imperfect notice of Dr. Cincinnati Journal of Medicine, Ma,Tch,\S(i6. | Winslow's great and classical work by expressing It is an interesting volume that will amply repay ' °^^ convictiofl that it is long since so important and for a careful perusal by all intelligent readers.— 1 ^eaalifnlly written a volnrae has issued from the Chicago Med Examiner Feb. 1866. British medical press.— InMm Medical Prtxs. A work which, like the present, will largely aid ' It is the most interesting as well as valuable book the practitioner in recognizing and arresting the first 1 ^^^^ ^e have seen for a long time. It is truly fasci- insidlous advances of cerebral and mental disease, is | uating.— ^wi. Jour. Med. {sciences. one of immense practical value, and demands earnest j Dr. Winslow's work will undoubtedly occupy an attention and diligent study on the part of all who ' unique position in the medico-p.sychological litera- have embraced the medical profession, and have j ture of this country. — London Med. Review. T EA {HENRY C). SUPERSTITION AND FORCE: ESSAYS ON Tfe[E WAGER OF LAW, THE WAGER OF BATTLE, THE ORDEAL, AND TORTURE. Second Edition, Enlarged. la fine handsome volume royal 12mo. of nearly 500 pages; extra cloth, §2 75. {Just Issued.) The copious collection of facts by which Mr. Lea has j a humor so fine and good, that he makes us regret it Illustrated hissubject shows in the fullest manner the j was not within his intent, as it was certainly within constant conflict and varying success, the advances his power, to render the whole of his thorough woik and defeats, by which the progress of humane legisla- tiou has been and is still marked. This work fills up with the fullest exemplification and detail the wise remarks which we have <4uoted above. As a book of ready reference on the subject it is of the highest value. — Wt.itrninister Review, Oct. 1867. When — half in spite of himself, as it appears — he sketches a scene or character in the history of legalized error and cruelty, he betrays so artistic a feeling, and more popular in manner. — Atlantic Monthly, Feb. '67. This is a book of extraordinary research. Mr. Lea has entered into his subject con amore ; and a more striking record of the cruel superstitious of our un- happy Middle Ages could not possibly have been com- piled. ... As a work of curious inquiry on certain outlying points of obsolete law, "Superstition and Force' is one of the most remarkable books we have met with. — London Atluai(eu,m, Kov. 3, 1866. B Y THE SAME AUTHOR. (JuH Issued.) STUDIES IN CHURCH HISTORY— THE RISE OF THE TEM- PORAL POWER— BENEFIT OF CLERGY— EXCOMMUNICATION. In one large royal 12mo. volume of 516 pp. extra cloth. $2 75. is shown in weaving in anecdote and picturesque stories, without impairing the flow of the relation or the proper dignity of the composition. — Hartford Oiurant, Jan. 22, '1870. We recommend the book as a highly instructive discussion of matters which are always of interest to scholars, and which are just aowclothed with a spe- cial importance.— A". Y. Nation, Feb. 3, 1870. Altogether, the book is a useful addition to the po- pular literature of a most important and too little known department of mediieval history. — London Saturday Review, Feb. 26, 1870. They are careful studies by a thorough scholar in the most interesting of all historical fields, made without passion or prejudice, and recorded with hon- esty. The whole volunie is of the deepest interest ; the style is masculine and animated, and great skill 32 Henry C. Lea's Publications. INDEX TO CATALOGUE. Allen's Dissector and Practical Anatomist Amei'ican Journal of the Medical Sciences Abstract, Half-Yearly, of the Med Sciences Anatomical Atlas, by Smith and Horner Ashton on Ihe Rectum and Anus . Attfield's Chemistry Ashwell on Diseases of Females . Basham on Renal Diseases . Brlnton on the Stomach Bigelow on the Hip Barclay s Medical Diagnosis . Barlow's Practice of Medicine Bowman's (John E.) Practical Chemistry Bowman's (John E.) Medical Chemistry Brande & Taylor's Chemistry Brodie's Clinical Lectures on Surgery . Brown on the Surgical Diseases of Women Buckler on Bronchitis .... Bucknill and Tuke on Insanity Bumstead on Venereal .... Bumstead and CuUerier's Atlas of Venereal Carpenter's Human Physiology . Carpenter's Comparative Physiology . Carpenter on the Use and Abuse of Alcohol Carson's Synopsis of Materia Medica . Chambers on tne Indigestions Christison and Griffith's Dispensatory Churchill's System of Midwifery . Churchill on Diseases of Females Churchill on Puerperal Fever Clymer on Fevers Coudie on Diseases of Children . Cooper's (B. B ) Lectures on Surgery . CuUerier's Atlas of Venereal Diseases Cyclopedia of Practical Medicine . Dalton's Human Physiology . . . De Jongh on Cod-Liver Oil . Dewees's System of Midwifery Dewees on Diseases of Females . Dewees on Diseases of Children . . Dickson's Practice of Medicine . . Druitt's Modern Surgery . , . Dunglison's Medical Dictionary . Dunglison's Human Physiology . Dunglison on New Remedies Ellis's Medical Formulary, by Smith . Erichsen's System of Surgery Erichsen on Nervous Injuries Flint on Respiratory Organs . Flint on the Heart Flint's Practice of Medicine . Fownes's Elementary Chemistry . Fuller on the Lungs, &c. . . . Gibson's Surgery Gluge's Pathological Histology, by Leidjr Graham's Elements of Chemistry . . Gray's Anatomy Griffith's (R. E.) Universal Formulary Gross on Foreign Bodies in Air-Passages Gross's Principles and Practice of Surgery Gross's Pathological Anatomy Hartshorne's Essentials of Medicine . Hartshorne's Conspectus of the Jledical Sciences Hartshorne's Anatomy and Physiology Habershon on Alimentary Canal . Hamilton on Dislocations and Fractares Harrison on the Nervous Syst<^m . Heath's Practical Anatomy . Hoblyn's Medical Dictionary Hodge on Women Hodge's Obstetrics Hodge's Practical Dissections Holland's Medical Notes and Reflections Horner's Aaatotny and Histology Hudson on Fevers, .... Hill on Venereal Diseases Hillier's Handbook of Skin Diseases Jones and Sieveking's Pathological Anatomy Jones (C. Handfiold) on Nervous Disorders Kirkes' Physiology Knapp's Cliemioal Technology . Lea's Superstition and Force dged Lea's Studies in Church History . Lallemand and Wilson on Spermatorrhoea La Roche on Yellow Fever . La Roche on Pneumonia, &c. Laurence and Moon's Ophthalmic Surgery Lawson on the Eye .... Laycock on Medical Observation . Lehmann's Physiological Chemistry, 2 vols, Lehmann's Chemical Physiology . Ludlow's Manual of Examinations Lyons on Fever Maclise's Surgical Anatomy . Malgaigne's Operative Surgery, by Brittan Marshall's Physiology . Mayiie's Dispensatory and Formulary Mackenzie on Diseases of the Eye Medical News and Library . Meigs's Obstetrics, the-Science and the Art Meigs's Lectures on Diseases of Women Meigs on Puerperal Fever Miller's System of Obstetrics . Miller's Practice of Surgery . . Miller's Principles of Surgery . Montgomery on Pregnancy . Morland on Urinary Organs . Morland on Ureemia .... Neil I and Smith's Compendium of Med. Science Neligan's Atlas of Diseases of the Skin Neligan on Diseases of the Skin . Odling's Practical Chemistry Pavy on Digestion .... Prize Essays on Consumption Parrish's Practical Pharmacy Pirrie's System of Surgery . . ". Pereira's Mat. Medica and Therapeutics, abr Quain and Sharpey's Anatomy, by Leidy Rauking's Abstract .... Roberts on Urinary Diseases . Ramsbotham on Parturition . . Rigby on Female Diseases . . ' . Rigby's Midwifery ..... Rokiiansky's Pathological Anatomy . Royle's Materia Medica and Therapeutics Salter on Asthma Swayne's Obstetric Aphorisms Sargent's Minor Surgery Sharpey and Quain's Anatomy, by Leidy Simon's General Pathology . . Simpson on Females .... Skey's Operative Surgery Slade on Diphtheria .... Smith (J. L.) on Children Smith (H. H.) and Horner's Anatomical Atlas Smith (Edward) on Consumption . Smith on Wasting Diseases of Children Solly on Anatomy and Diseases of the Brain Still6's Therapeutics . Tanner's Manual of Clinical Medicine Tanner on Pregnancy Taylor's Medical Jurisprudence . Thomas on Diseases of Females . Thompson on Urinary Organs Thompson on Stricture . Todd and Bowman's Physiological Anatomy Todd on Acute Diseases .... Toynbee on the Ear .... Wales on Surgical Operations Walslie on the Heart . . . . Watson's Practice of Physic . Wells on the Eye West on Diseases of Females West on Diseases of Children West on Ulceration of Os Uteri What to Observe in Medical Cases Williams's Principles of Medicine Wilson's Human Anatomy . Wilson's Dissector Wilson on Diseases of the Skin . Wilson's Plates on Diseases of the Skin Wilson's Handbook of Cutaneous Medicine Wilson on Sperniatorrbcea Wiuslow on Brain and Miud PAOB 31 UNIVERSITY OF CALIFORNIA LIBRARY Los Angeles This book is DUE on the last date stamped below. 076 ^PR 5R£C'D Form L9-Series 4939 r.C'