Transactions of the Provincial Medical and Surgical Association/Volume 1/5
SOME OBSERVATIONS
ON THE PECULIARITIES OF
DISEASES IN INFANTS AND CHILDREN.
BY J. K. WALKER, M. D. HUDDERSFIELD.
IN a recent paper on the late population returns, I
took occasion to submit some account of the relative
decrease of mortality in different parts of the empire,
and, at the same time, I endeavoured to trace the
operation of those causes, which appeared to me
most influential in producing this happy change.
In prosecuting this enquiry, I was induced to compare
the last returns with those of the ten years
preceding, and it was a gratifying result of such
comparison to find that, in by far a majority of
towns, a very considerable decrement had taken
place in the rate of infant mortality. But, though
this was strikingly the case in many, yet, in other
parts, this declension is less obvious. In some of
the manufacturing districts, the number of children
who have been buried, under one year old, was one fourth
of the whole number of burials in the last ten
years. In one report, I observe the number of
children who have been buried, under the age of
six, is more than half of the whole number. But,
as the highest rate of infant mortality has usually
been in large towns, so has the diminution of deaths been the greatest there. It is the object of the following
paper to take a cursory view of those causes
which tend to cut short the career of human beings
in the very threshold of existence. Nor can I conceive
any subject of higher importance than the study
of medical statistics, and especially of that branch of
it, which leads to a more correct estimate of the
sources of infant mortality.
At a period when pathological research is lending its aid in investigating the appearances of disease in every part of the body, and many nice distinctions in diagnosis are aimed at, which are better calculated for nosological than practical purposes, it seems to me not a little extraordinary, that so few have cultivated that most important branch of medicine, the study of the diseases of children. It is true there are some splendid exceptions to this, and, from the increasing attention of the profession to this department of our art, some valuable addition has been made to our knowledge of the morbid phenomena peculiar to that tender age; yet it is to be lamented that so little advantage is taken of the opportunities possessed by most practitioners, to investigate the pathology of infantile maladies, and thus still further to augment the resources of our art in ministering to the relief of this interesting class of sufferers, at a period of life the most helpless, and when the average mortality is the greatest. It is gratifying, however, to observe, that the practitioners of our day are more alive to the various ailments incidental to infancy, and a corresponding improvement has taken place in their treatment. Formerly it was too much the fashion to consign this most difficult task to anile empiricism, and the baneful fruits of that system were seen in the bills of mortality. Since that time the subject has attracted the attention of the faculty, and the most eminent men have not thought it beneath them to dedicate their talents to the elucidation of its difficulties. The beneficial consequences of this change have evinced themselves in the more successful management of children, both in health and disease, and a gradual decrement in the rate of infant mortality. Every friend of humanity, too, will hail with satisfaction the influence which the practice of vaccination has had in curtailing the mortality of the first years of life. If the Jennerian discovery has not always prevented the small-pox, it has, at any rate, diminished its frequency and fatality. By its means, many thousands of lives are annually saved in this country alone, nor is it manifest that any other disease is superinduced by it. The frequent cutaneous deformities, swellings, blindness, lameness, &c. incidental to variola, have never been known to follow the cow-pox. Nor is it very evident that the substitution of a milder for a more malignant disease, has materially altered the character of other diseases, though it has by some been thought that the cow-pox is capable of hybridising with other cutaneous diseases, so as to give rise to new eruptions; by others, that it has diminished the number and modified the appearance of the old ones. Certain it is, that when vaccination is performed on a child labouring under any cutaneous malady, however slight, such as chaps and sores behind the ears, or on any other part, it not infrequently fails in producing its full and salutary effects. It seems as if the system were reluctant to admit the operation of a second morbid action, while a former one exists. Where, however, vaccination is successful, its influence in retarding the appearance of other cutaneous affections appears very transient, for we find them appearing just as usual, within a few weeks after the cow-pox. And with respect to many of these cutaneous eruptions, it did not escape the medical sages of yore (and every day's experience confirms the fact), that it is often fraught with the greatest hazard to attempt their hasty suppression. Hippocrates himself was not ignorant of the efficacy of counter-irritation, for he asserts in his observations on epilepsy, that in infants, if ulcers appear on the head, round the ears, and on the face, or even in other parts of the body, the epileptic symptoms are removed. It is true, indeed, at every period of life, that the most alarming diseases are kept in a state of abeyance by perpetuating the influence of counter irritation, for medical men are willing to take a lesson from nature herself in this respect, and learn to imitate the superficial irritation she is wont to set up; and it is equally true, that where such irritation (be it natural or artificial) has long existed, it can seldom be interfered with, but at the risk of superinducing, sooner or later, some more dangerous morbid process. Every practitioner has met with cases of this kind, where the periodical recurrence of certain cutaneous eruptions, has been the means of preserving to the individual an uninterrupted enjoyment of health. For the same reason, ulcerations that have existed for a series of years, cannot always be treated with impunity. Nay, the drying up of an issue or seton, that has been long established, has been followed, in many instances, by the most disastrous consequences. I had an instance of this but a short time ago, in a patient who, at the age of 60, permitted an issue, which had run for more than 15 years, to heal, and though no inconvenience was felt for some weeks, yet anasarcous swellings, and, subsequently, difficulty of breathing, with many other symptoms indicative of effusion in the chest, supervened, though his surgeon had re-established the issue. The case eventually proved fatal, nor would it be difficult to adduce other analogous instances to shew how dangerous it is, even in adults, to suffer undue interference with every morbid process that developes itself, provided the viscera are not implicated in the disease. Now, if this is true in the case of adults, how much greater must the danger be in the premature suppression of infantile eruptions. There are, indeed, certain eruptions peculiar to infancy, as no less than five or six different affections of the skin occur during the process of dentition. Some of these never take place until the teeth begin to appear, the strophulus confertus for instance. But, are not all these eruptions, when spontaneous, the surest means of easy and safe dentition? Experience shews us that these cuticular developments are designed by nature, in most instances, to subserve some beneficial purpose, to ward off some worse danger; perhaps to relieve some local congestion, or furnish an outlet to some noxious principle. This, indeed, seems more especially to be the case in that class of infantile eruptions which are unaccompanied with pyrexial symptoms, and in those five species of the eruption called the gum, as described by Dr. Willan. It is common, at least in most instances, to find that, during their existence, so far is the general health of the child from suffering any manifest detriment, that no disturbance in the usual functions supervenes, whereas in those instances where, from whatever cause, a sudden repulsion has taken place, the shock is often felt in every part of the system. The brain, the liver, and the intestines, seem among the first to feel the effect of this change, and cerebral excitement is not slow to shew itself, especially if other circumstances combine to favour such determination. Where repulsion takes place, before all the deciduous teeth have made their appearance, the danger is greater, as the nervous as well as vascular system, seems endowed with singular susceptibility during dentition. Not infrequently violent spasmodic affections have speedily followed the disappearance of the eruption, and sometimes unequivocal indications of cerebral excitement. Instances not a few have occurred to me in proof of this fact. Very lately I saw a child, Mary Calverly, æt. two years, who lay in a comatose state, the pupils dilated and insensible to light; the respiration interrupted by sighs; pulse weak and irregular; bowels costive. On enquiry, I found that the child for several months had been troubled with an eruption which the mother called the itch, which had occupied not only the arms and thighs, but other parts of the body. The eruption not giving way to the internal exhibition of alternatives, the external application of an ointment, consisting of the unguentum sulphuris, with a little of the ung. hydrar. nitrat. added to it, was successful in producing the desired result about three weeks ago. Since that time the child's health has been on the decline, and she has complained of great pains in the bowels and loss of appetite, succeeded by frequent evening exacerbations of fever, and grinding of the teeth during sleep, &c. About ten days ago, she first felt pain in her head, which has since been followed by stupor and convulsions. At the period my attention was drawn to the case, she had been relieved by the repeated application of leeches to the head, and the continued use of calomel, to which I added the friction of the tartar emetic ointment upon the arms and thighs, wishing to re-produce an eruption on those parts. The relief (if relief it might be called) continued but for a day or two, for the stupor increased, the pulse became weaker, and general convulsions followed, terminating in death. In other instances I have observed a less degree of cerebral irritation to follow the disappearance of the cutaneous symptoms; other viscera, the lungs, liver, and alimentary canal, become the seat of disordered action, even in children, who appeared, previously, free from disease in this respect. Take, for instance, one of the earliest of the infantile eruptions, the strophulus intertinctus, which is not always accompanied or preceded by any disorder of the constitution, but appears, occasionally, in the strongest and most healthy children. Even this cannot always be suppressed with impunity. We cannot explain the mysterious play of sympathy existing between the skin and the abdominal viscera, yet every one has noticed the various consecutive derangements of the functions of the bowels, which result from such repelled eruptions. In one, it will create febrile disturbance, and alter the colour of the stools in a few hours; in another, occasion diarrhœa and vomiting; in a third, serious spasmodic affections. But, should the eruption re-appear, all these symptoms very frequently vanish, and the child is reinstated in its usual health. This reciprocation is familiar to every experienced observer. It seems as if the right performance of the functions of the viscera depended on the determination of a certain quantity of blood to the papillæ of the skin. There may exist some peculiarity in the structure of an infant's skin, that may especially adapt it for the reception of the superfluous parts of the blood, as often as it is disproportionate to the wants of the system. Such contrivance would be in perfect unison with the many merciful provisions made by unerring wisdom, to meet the special wants of helpless infancy; for every part of the human frame, at man's entrance into the world, is full of prospective contrivances. Take the teeth as an illustration, which are formed within the gums, and there stop, as their further development would incommode the process of sucking, by which the infant is for some time to be nourished. The milk itself too. It is secreted just at the moment it is wanted, and, above all, is found to contain those ingredients that are best adapted for infantile aliment. No substitute is equal to a healthy mother's milk. Its properties seem to undergo some alteration with the age of the child; any irregularity of diet, or ill health of the mother, affects its salubrity. Every thing indicates a special provision for a special contingency. We all know how readily cow's milk coagulates on the addition of acids, but healthy human milk will not do so. No coagulation is effected either by acids, alcohol, rennet, or by infusion of the stomach of the foetus, at least for some days. Neither has it the same tendency to run into acescency that cows' milk exhibits. In speaking of this phenomenon, I am aware that it applies only to the milk of such mothers as are supported by a generous diet; where this is not the case, the milk will not have the same properties, and this will account for the variety of results obtained by different chemists. It is, indeed, a practical fact, of no small utility to know, that the constituent properties of the lacteal fluid vary with the quantity and quality of the food. Experiments have been made, that place this matter in a striking light in animals of the Mammalia class. It has been ascertained, for instance,[1] that if a suckling bitch be made to live, for eight days, on vegetable aliment alone, its milk will readily undergo spontaneous separation, and be coagulable by the ordinary means. But, if the same bitch be fed solely with raw flesh, the quantity of her milk will sustain a considerable decrease, but it will resist spontaneous coagulation, and instead of the acidulous, will present alkalescent properties. Here we have experimental proof of the tendency of the mammary secretion in animals to vary with the nature of the aliment, nor can it be doubted that the same tendency obtains in the milk of the human female. Neither should it be forgotten that other causes as well as diet, exercise a material agency in modifying the human milk. We know that intemperance of any kind will influence its nature, so will grief, anger, fear or joy. Nor do I think it possible, as some have done, to form a correct estimate of the relative virtues of milk, by chemical analysis. There is often some occult quality, utterly inappreciable by tests, but such as is capable, nevertheless, of exercising an important influence on the constitutional properties of the milk. The idiosyncrasy of the mother may affect the mammary secretion; and diseases, we know, exercise a direct influence, in proportion to their intensity, on the fluid secreted, and the effects are not slow to show themselves on the health of the child. Even a slight derangement of the digestive organs of the mother is apt to become transmissible by the milk, and the stools of the infant, from being of a natural appearance, suddenly assume a green or darkish tinge. Nor can they often be made to resume their pristine state, until the restoration of the maternal health shall have effected a corresponding change in the mammary secretion, and the fluid elaborated acquired its usual salubrity. In some instances, violent convulsive affections of the infant will follow any sudden deviation in the health of the mother. And even where there is no sudden or marked declension of her health, yet any cause, (whether in high or low life) tending to enervate the body, is sufficient to deteriorate the quality of the milk. Every one can understand how a participation in the pleasures of fashionable life must, in various ways, affect the infantile beverage; and among the poor it is not uncommon to see cases of convulsions or intestinal derangements in children, arising from the impoverished aliment of the mother. For the last nineteen years, during which it has been my lot to see, annually, very many children of the poor admitted as patients of our local charitable Institutions, I have frequently had my attention drawn to this source of infantile malady. When the state of the poor is such as to enable the mother, who is suckling an infant, to partake of a more liberal diet than she had previously been accustomed to, what a change will often take place in the health of the babe. The habit too frequent among the poor, of deferring the time of weaning beyond the proper period, is often followed by the most mischievous consequences to the health of the child. Is it surprising that the lacteal secretion of a mother, who has given suck for nearly two years, should be deficient in the requisite nutritious qualities, especially when the system has not had the benefit of proper support? and if there should chance, at the same time, to be a predisposition to disease in the mother, perhaps a strumous diathesis, what more likely than that the milk secreted from her blood should convey the seeds of disease to her progeny? To this cause may be attributed not a few of those distressing disorders which affect our infant population in large and populous cities, where defective nutriment, and want of pure air, elicit a variety of morbid appearances, of rare occurrence among the offspring of our peasantry. Compare the ruddy complexions of the latter with the pasty visages of the former. You find fatal diseases in both; indeed, the proportion of acute cases will be greater, probably, in the country district; but, if you would witness the insidious developments of disease, its slow and silent ravages, its endless modifications, functional, perhaps, only in the first place, but terminating, eventually, in incurable organic derangement; it is in the cellars and dirty alleys of a crowded city, that such examples are to be found, and it is in these that infant mortality attains its maximum. Of a large proportion of these little sufferers, it may be said that they die without medical aid; and of many more, that the disease has made incurable inroads, before it becomes the subject of medical treatment. The child is already in a state of marasmus. At first there is some functional derangement of the alimentary canal; the intestinal discharges are too frequent, perhaps, and in process of time, assume a chyliferous appearance. Nor is the disease confined to the bowels, but the mesentery and peritoneum, lining the parietes of the abdomen, share in the affection, and the belly is tumefied and tense. The surface of the abdomen is often tender to the touch, and there is frequent deep-seated lancinating pain within its cavity. Should these symptoms not subside under proper treatment, a rapid increase of the emaciation ensues, and the evening accession of fever is more severe, and in some instances, towards the conclusion, the little patient becomes comatose. This is a form of disease that has doubtless occurred to every practitioner. But in some instances, along with many of the above symptoms, there is cough, with chronic diarrhoea, followed by a febrile and marcescent state; and some structural derangement of the lungs is superadded to the abdominal mischief. From the appearances on dissection, of some such cases, one might suppose that the germs of tubercles are sometimes born with us, for in one such dissection of a child, I find it recorded, that both lungs were completely studded with tubercles. There was a cavern in the right lung filled with tuberculous matter, that drained into it from broken down tubercles. Tubercles were also found in the liver, spleen, and mesentery.
This disease, it is well known, more commonly arises in children of a scrofulous habit, from the age of a few months to that of ten or twelve years. It is only in the earlier stages that its progress seems capable of being arrested; but, even in these cases, such is the treacherous nature of the disease, that its reappearance is often ushered in under a different form. Where the predisposition to scrofula is inherited by children from their parents, we find many anomalous symptoms arising out of slight attacks of indisposition, and diseases usually curable in a short time by ordinary means, acquire additional complexity and danger. Wherever it mingles with any accidental or local complaint, it makes all the symptoms worse, and there is no structure nor organ of the body which is not obnoxious to its ravages. It is not merely in the tumid abdomen and the enlarged joint, but in the lungs, heart, liver, kidneys and intestines, in the eyes and brain, that its destructive effects unfold themselves. We are told by Dr. Davis, (Annals of the Universal Dispensary) that the principal source of mortality among the children of the lower classes in the Metropolis, is the prevalence of pulmonary affections, in many of whom were discovered, on dissection, unequivocal indications of incipient scrofula. The same is stated also to be the case at Paris. It appears that at the Hotel des Enfans Malades, where upwards of five hundred children die annually, and whose bodies are almost uniformly opened, nearly one-half of them presented scrofulous tubercles in some part or other. It is undoubtedly true that, in many of the fatal cases of hydrocephalus inspected after death, marks of scrofulous inflammation have been detected. It is no infrequent occurrence to find the ventricles of the brain distended with serum, at the same time that the peritoneum exhibits marks of inflammation, and depositions of various sizes, which have passed into the form of the tuberculated accretions on the peritoneum, described by Dr. Baron. What is the postmortem appearance in fatal cases of rubeola? In some we find the interior surface of the peritoneum studded with tubercles, but, especially in the bronchial tube, and in the intestinal canal, their number is often great. At other times the mesenteric glands are in a tubercular condition. The bones, too, do not escape the ravages of scrofula, which affects the softer and more spongy structure at the heads of cylindrical bones, the bones of the carpi, tarsi, and vertebræ. In its early development, so insidious and imperceptible is the change, that it is most frequently overlooked. Perhaps a sense of slight weakness is all that attracts attention, until the disease is more advanced, and a dull pain is felt in the hip, knee, or ankle joint, which is aggravated by pressure or long exercise. As the inflammatory stage advances, the constitution sympathizes with the local affection, and an abscess is formed. The cartilages ulcerate or are absorbed, and, perhaps, the whole joint is implicated in the disease. This, at least, has been the case in those morbid preparations of this disease which I have inspected, as well as in the scrofulous joints of such patients as have undergone amputation in our infirmary.
Sometimes, along with an enlarged joint, we find associated (in scrofulous children) a simultaneous participation of other structures in the disease, such as glandular enlargement; and the lymphatic glands of the neck occasionally undergo scrofulous disorganization. At other times, the abdominal viscera are the seat of scrofulous disease, along with the osseous structure. I may mention, as an example of such combination, the case of a child who is now an in-patient of the infirmary, in whom there was a tumefaction of the ankle joint, which first made its appearance above a year ago, and which, for some months back, has discharged matter. Since the commencement of the discharge, the functions of the alimentary canal have been frequently disordered, and the stools of an unhealthy appearance; but a few weeks ago she began to experience deep-seated pain in the cavity of the abdomen, which is now tumefied and tense, with a sense of fluctuation. In other parts of her body some emaciation has taken place. The countenance is altered; the eyes seem glassy; the nose sharpened, and the cheeks of a marble whiteness, unless when they are flushed with fever. There are other symptoms, also, which make it extremely probable that the mesenteric glands are in a state of active disease, and there is every reason to fear an unfavourable termination of the case. Lloyd, in his treatise on scrofula, gives an instance of a child, who, during dentition, became diseased, emaciated, comatose, and died; on its neck, there had long been a cluster of gangliform tumours, of different sizes, some of which were red, others somewhat softened; the right hypochondrium was tumid, and the liver greatly enlarged; the inferior extremities became œdematous, the rest of the body bloated, the skin squamous and dry. Serum, in considerable quantity, had been effused into the cerebral ventricles, between the cranium and dura mater, and into the vertebral canal; the en cephalic textures were unchanged; the lungs and heart healthy, but the liver was exceedingly voluminous, indurated, and covered with tubercles, some of which contained a dense substance, resembling coagulated white of egg; they were soft and greyish; the mesenteric glands were distended, and full of similar tubercles; and there was an infinite number of concrete bodies, of the size of a small pea, interspersed between the coats of the stomach and intestinal canal. In this case we have, in a very young child, an assemblage of morbid changes, appearing in the encephalic textures, in the hepatic enlargement, in the fluid effused into the vertebral canal, and in the mesenteric disease; any one of which would be sufficient to account for the fatal result of the case. Nor can it be doubted that scrofulous disorganization, in each of these parts, is a more frequent occurrence than is usually imagined. In how many cases of hydrocephalus, do we find extensive tubercular derangement in different viscera? Nay, even in the brain itself such morbid appearances are detected. In one instance, the particulars of which are now before me, where death occurred, such a combination was remarkably illustrated. It was the case of a child, æt. 18 months, that was first attacked with cerebral symptoms, after the decline of the morbillous eruption; the cough was troublesome, and the fever considerable. He had occasional screaming and vomiting, and was afterwards comatose, with dilated pupils, &c. Here the disease of the brain, and effusion into the ventricles, which appeared on dissection, were the immediate cause of death, and there were incipient tubercles on the pia mater, and the lungs were found studded with tubercles in their nascent state.
Neither can it be denied, that though hydrocephalus does not spare the most healthy children, yet it is more frequent in those of a scrofulous diathesis. Percival states that, out of twenty-two cases, eleven were decidedly, and four apparently, scrofulous; and Cheyne records two instances, where five out of one family, and ten from another, fell victims to this disease. In a family residing in this neighbourhood, where, out of fourteen children, eight have died; it appears that, of these eight deaths, three were cases of hydrocephalus, two of disease of the mesenteric glands, and two of phthisis pulmonalis. In other families we find the osseous fabric the seat of strumous disorganization, and one child will have a rickety affection, or a deformity of the chest, such as in after life may evoke some phthisical tendency, another a caries of the bones, and a third spinal distortion.
In a young girl whom I lately saw, along with Mr. Sargent, of this town, and who had, from her birth, exhibited unequivocal indications of a strumous diathesis, and who, for many months past, was suffering from scrofulous ulceration of the ankle joint, there appeared (after some exposure to cold) a gradual inability to rotate or to perform the nodding motions of the head upon the atlas. It was considered, in the first instance, to be nothing more than a stiff neck, and was treated, accordingly, with liniments, warm fomentations, &c. The symptoms, however, gradually assumed a more aggravated form, and on pressing the spinous processes of the third and fourth cervical vertebræ, pain was felt, and on the right side of the neck a considerable prominence was visible The neck inclined to the right side, and the chin, at one time, almost touched the centre of the right clavicle. The treatment consisted in the application of leeches to the back of the neck, followed by emollient cataplasms, and subsequently a succession of blisters. By long perseverance in this plan, some diminution of the pain and swelling of the integuments occurred, and the rotatory and nodding motions of the head were performed with greater facility. In this case there was no pain in any other portion of the spinal column, but the morbid process seemed confined to the cervical vertebræ Whether there is any disease in the osseous structure of the vertebræ, or only in the intervertebral cartilages, it is difficult to decide, but the tout ensemble of the symptoms, and other concomitant circumstances, induced us to refer the development of the disease in so uncommon a form, to the predominance of a strumous diathesis. The insertion of a seton, aided by the external, as well as internal, use of the hydriodate of potass, has latterly been of considerable service; but the most fortunate termination that can be hoped for, is the gradual recovery, in part, if not entirely, of the freedom of rotation, as well as flexion and extension of the head; and this, I trust, we shall be able to accomplish, as there exists no present indication of pressure on the medulla spinalis, and nothing to denote the slightest cerebral affection. I have endeavoured to describe this case more fully, because, though not more fatal, perhaps, than some other forms of scrofula, yet it is confessedly much rarer; and it cannot be denied that affections of the cervical vertebræ, perhaps from their infrequency, are less understood than those of the dorsal or lumbar vertebrae; and it is rather surprising that, among so many volumes of interesting information on structural derangement of the spinal marrow, and its osseous investment, the attention of so few pathologists has been directed to the cervical section, and I urge this the more strongly, from a conviction that a better knowledge of this part, and especially of the share which the nerves it supplies have in producing or influencing certain spasmodic affections, incidental to infants and children, as well as adults, will prove of the highest importance in improving our treatment of so distressing a class of diseases. There is no part upon which the practitioner is in the more frequent habit of ordering a blister to be applied, and none, perhaps, where more marked benefit has followed its application.
Though it has been usually considered that phthisis pulmonalis is the effect of tubercular development in the pulmonary structure, and that hæmoptysis is among its premonitory symptoms, yet hæmorrhage from the lungs rarely occurs in very young children. To this, however, I had, but a few days ago, an exception in a little girl, Rachel Thewlis, æt. 4, who is an out-patient of the infirmary, and I am induced to mention this case as no inapt illustration of the protean nature of scrofula, and the power of the system to survive repeated attacks of disease. During the period of dentition, this child had been troubled with frequent looseness, and irregular febrile symptoms. Before the expiration of the second year, the belly was tumid and pain frequent, with some disposition to coma. These symptoms were, however, relieved for a short time, but the abdomen still appeared fuller than natural, and the stools often of a chylous appearance. At the period I first saw her, about a year and a half ago, she laboured under many of the symptoms of oppressed brain. The comatose state had lasted for two or three days, and, in fact, it was regarded on all hands as a case of hydrocephalus. From a general survey of all the symptoms and circumstances of the case, from the temperament and previous diseases of the child, I considered that a strumous habit had created a predisposition to cephalic effusion. There were in this case abdominal enlargement, and some indications of mesenteric affection, which induced me to employ a combination of ung. hydrarg. with hydriodate of potass, as a liniment to the belly, which was continued for several days. Except the repeated application of blisters near the head, and the internal use of the carbonate of soda and calomel, no other remedies were employed; but we were agreeably surprised to find that the size of the abdomen was somewhat diminished, but, above all, that the marks of cerebral oppression had disappeared. Some months elapsed before I again saw this child, with Mr. Ledgard, the house surgeon of the infirmary, when symptoms of dyspnœa were present, and an œdematous state of the lower extremities, which were likewise relieved in less than two months, leaving, however, a tickling cough and great emaciation. Nor was this cough relieved until the appearance of a small tumour, of a scrofulous kind, on the lower part of the sternum, which afterwards proceeded to suppuration, and though the discharge was considerable, yet the child gradually gained strength, under the use of chalybeate drops and the daily allowance of a small quantity of port wine. On visiting her a few days ago, the tumour on the breast appeared nearly healed, but for several days the cough had returned with great severity, accompanied with a spitting of blood. The other children of this family, I should observe, had strong indications of strumous diathesis, and three of them, like their mother, had been the subjects of scrofulous ophthalmic.
I have dwelt more largely on the multiform aspects of scrofula, because its appearance is often insidious, and its coincidence with other diseases such, as not infrequently to occasion great obscurity in the symptoms. It is important, too, always to watch those circumstances, or local peculiarities, which favour its development in different situations, as it is by observations of this kind, that some useful practical suggestion may be derived, and its ravages curtailed. We know that scrofula is of more frequent occurrence among the inhabitants of great towns, than in the agricultural population of a country; and though no locality is exempt from its invasion, yet a more clear and purer atmosphere, and the salubrious exhalations from growing vegetables, are most influential in averting some of its worst modifications. To the statistical enquirer this subject is of the last importance, as the influence of scrofula in warm, as well as cold climates is great, and especially during early life. But there are other causes which play an important part in the production of infantile diseases, some of which I have already alluded to; such as dentition, worms, eruptions, &c. Yet pathologists have hardly, I think, attached sufficient importance to the peculiarities of infant organization, and the influence which they exercise on the character of the morbid phenomena which occur at that period. Take, for instance, the state of natural hypertrophy of the livers of very young children, as compared with what we observe in adult age. We know that as the infant advances in age, the liver diminishes in size, and instead of extending into the abdomen, retires behind the ribs, below which it does not extend, except when in a state of disease. In some cases, it is true, the child retains this natural hypertrophy, and in some children it is greater than in others. In those in whom this disproportion is the greatest, it is consistent with analogy to suppose, that its influence must more or less be felt in the digestive functions, on the lungs, and on the brain; just as is the case in a greater degree, in the enlarged liver occurring in after-life.
Another peculiarity may be found in the size of the brain, which is usually so much larger, in proportion in infants than in adults; and we are told by M. Jadelot, that in many children who had died with symptoms of hydrocephalus, dissection presented no other pathological condition than morbid hypertrophy of the brain. It is a fact of some importance to know, that cerebral hypertrophy may present symptoms indicative of effusion, and may even terminate fatally, yet without any other morbid appearance than extraordinary development of the brainular mass, and with only very little fluid in the ventricles. Instead of effusion, the convolutions of the brain appear flattened from previous pressure, exhibiting increased density of structure.
But, even where there is no præternatural size of the encephalic contents, yet cerebral congestion, from whatever cause, may exhibit symptoms bearing a strong resemblance to hydrocephalus, and death may supervene without effusion; and it is probable, also, that many of those cases (which are recorded as cures of hydrocephalus) may depend more on pressure of blood, arising from a congested state of the cerebral vessels, than on effusion of water. Under active treatment, such cases may admit of relief, and the symptoms of oppressed brain may disappear. It is worthy of remark that the two organs I have above alluded to, as the seat of hypertrophy in infants, not infrequently exhibit simultaneous disease. What morbid link exists between the two, how far they stand in the relation of cause and effect, and which most frequently assumes the initiative in the circle of changes, physiologists are not yet prepared to decide. It is certain, however, that if either viscus is structurally. or even only functionally, affected for a length of time, the other is not slow to exhibit some morbid change, and there is no fact better established than the tendency of hepatic enlargement, to induce congestion or excitement of the brain. How often, in the detail of morbid appearances of hydrocephalus, do we find it recorded, that the liver is either inflamed, enlarged, or studded with tubercles? How often, among the symptoms of that disease, do we see it ourselves, and find it confirmed by others, that the bile is unnatural, either in quantity or quality? Green bile is often found in the gall bladder and ducts, and the action of a brisk purgative, especially of calomel, will often dislodge morbid secretions from the liver, and from the bowels, and the consequence of such free evacuations, is seen in the restoration of the healthy functions of the liver, and along with it a frequent disappearance of that formidable array of symptoms which so closely simulate hydrocephalus. Every practitioner who has had much experience in the treatment of children, must have remarked the closest sympathy betwixt the chylopoietic viscera and the brain, insomuch that a morbid condition of one will influence the functions of the other; and there is need of some caution to distinguish between cause and effect, lest, in attending to the one, we may overlook the other. It fortunately happens that mercurial preparations, which are so useful in counteracting hydropic effusion, are equally calculated to improve the action of the liver, and, though prudence will generally point out the expediency of combining other remedies with them, where the strength of the child will admit of it, yet, it cannot be denied, that cases not infrequently occur, presenting all the phenomena characteristic of hydrocephalus, which have been effectually relieved by the use of calomel, without the aid of either leeches or blisters. Nor is there any case that calls for nicer discrimination, than the treatment of infantile comatose symptoms, which are too generally received as unequivocal indications of oppressed brain, and consequently calling for the most active treatment. How often does it happen, that simple debility, unassociated with increased vascular action, exists in children supposed to labour under hydrocephalus? If, for instance, the system has been reduced by long disease, or if the child has been suckled too long, or where (from the ill health of the mother,) the quality of the milk is bad, and a gradual wasting of the body of the infant takes place; is a tendency to coma in such a child, to be treated as an indication of oppressed brain? We know that, when debility exists, the irritability of the system is often increased by it, and convulsions take place as the consequence of extreme exhaustion. In delicate and feeble children, and particularly among the poor, when the milk of the mother is impoverished by scanty nutriment, and a tabid state of the infant is the consequence, do we not find that a careful exhibition of tonic remedies will often succeed in removing that tendency to drowsiness, better than a system of depletion? One of the most recent instances of the efficacy of such treatment, which I have seen, occurred a few months ago, in a child, Mary Shaw, æt. two years, an out-patient of the infirmary, who lay for many weeks in a state of coma, from which it was difficult to rouse her. There was, at the same time, excessive emaciation of the entire body, produced partly by a protracted diarrhœa, and previous inadequate nutrition, so that it was considered by all who saw it, as a hopeless case; and yet this child gradually recovered by the occasional use of carbonate of soda and calomel, in powders, with the aid of chalybeate drops; and under this treatment we were able to extricate the little patient from the state of stupor which wore so menacing an aspect. The diarrhœa gradually gave way, and along with an improved state of the digestive functions, the appetite and strength increased, and nothing has since occurred to retard a complete return to health. From the chyliferous appearance of the stools, in the early stage of this case, I was induced, at first, to refer its origin to disease of the mesenteric glands, but, from a review of all the symptoms, I had reason to consider it rather as one of those cases of chylous diarrhœa, arising from functional disease of the liver, and a deficient secretion of bile; as the existence of a certain proportion of bile is necessary to make the lacteals act. It is not surprising that, in cases of hepatic hypertrophy, the chyle, which ought to be absorbed by the lacteals, should be expelled by the rectum. Still less is it to be wondered at, that a state of atrophy should succeed, since the nourishment, which ought to supply the hourly waste of the body, escapes with the dejections; and that this occurs oftener than is generally supposed, seems probable from the frequent relief of such instances being more rapid than would be the case, were the disease seated in the mesenteric glands. Though many of the symptoms, indicative of the latter disease, present themselves; such as prominence of the belly, and wasting of the muscular flesh, with a chylous aspect of the stools, yet, if we find all of them yielding, in a reasonable time, to ordinary treatment, we must surely conclude that no very serious disease exists in the mesenteric glands. It is true that hypertrophy of the liver, in children of a scrofulous habit, may give rise to mesenteric affections; for post mortem examinations frequently shew disease existing in both these organs, yet what I wish to be borne in mind is, that hepatic hypertrophy may exist, uncombined, and in that simple form, produce symptoms liable to be mistaken for enlarged mesenteric glands.
But there is one viscus that, in the pathological detail of infantile maladies, appears hardly to have attracted that attention its importance demands, I allude to the kidney, which, in dissection, seems to exhibit more frequent marks of disease than is usually supposed. The urine of children is but seldom attended to, either by mother, nurse, or medical practitioner. Neither has the art of chemistry lent us any aid in deciding what are the component parts of healthy urine in children. The few experiments that have been made, are unsatisfactory and inconclusive; one chemist tells us one thing, another maintains the contrary. Where the diet of children is unwholesome, and the consequent disorders of their digestive organs neglected, it is common to find a deposition of red sand in the urine. This, however, will often disappear after the exhibition of alkalies, and, in some instances, the urine of a child undergoes a singular change after a continuance of alkaline remedies. It will no longer turn litmus paper red; in other cases, litmus paper (previously reddened by immersion in healthy urine) is turned blue by that under examination. But I have observed, also, in a great number of cases, where both soda and magnesia have been given for weeks together, no effect produced on the urine. Nor is it always the case in emaciated children, that the urine has an alkaline tendency. Neither is the appearance of the urine in children very uniform, for we sometimes find it quite limpid, in others milky; occasionally it is of a pale straw colour, and now and then greenish. In the cases of infantile diabetes recorded by Dr. Venables, he informs us that the urine sometimes seems milky and dense, and that its specific gravity is much increased. It frequently coagulates by heat, or by the addition of the different re-agents. Emaciation seems, in such cases, to advance with the increase of the coagulable matter.
Though this cause of emaciation among children is rarely mentioned by pathological writers, yet there is reason to believe that many children fall victims to this inordinate secretion of urine, who have been treated for mesenteric disease or hydrocephalus; for it should seem that a tumid prominent abdomen, as well as a comatose state, are the frequent accompaniments of the more fatal form of this disease. Cases occur, where the brain, lungs, heart, liver, and other digestive organs, are implicated in the affection; yet this (according to Dr. Venables) is rather an adventitious occurrence, than essential to the disease, the substance of the kidneys being the primary seat of the disorder. Though I have, for some years back, paid especial attention to the urinary secretion in children, during disease, I have only lately succeeded in detecting this form of disease in early life. The last case was that of a boy, æt. 3½ years, who, but a few months before, had slowly recovered from the measles, and was beginning to regain his strength. Without any apparent cause, his appetite failed, his stools were irregular, and the symptoms assumed the form of remit tent fever. No worms were seen in his stools, and the urine was, for some time, little more than common. Nor did it appear of a chyliferous character, and the quantity not, perhaps, so excessive as is recorded by Dr. Venables. About five pints were said to have been voided in one day. Many weeks elapsed before the appetite returned, and the stools became natural. He was relieved by the use of the nitric acid, and subsequently by the sulphate of quinine. The local treatment consisted in the frequent application of spir. terebinth, to the lumbar region, and, occasionally, small blisters to the same part.
Nor should I, in stating the peculiarities of infantile diseases, overlook the singular susceptibility to morbid action in the organs of respiration, at that tender age. Not, indeed, that the diseases of those parts are more numerous or more complicated than in after-life, but the delicate texture of these organs, and their yet imperfect development, tend to impart certain peculiarities to disease. To this should be added that nervous excitability, and extreme irritability, of fibre, so peculiar to this stage of life. Nor, among the least important of these organs, should be reckoned the larynx, which, for the delicate simplicity of its structure, no less than for the number, importance, and complexity of its functions, is not exceeded by any other organ of the human frame. Placed like a sentinel, as it were, at the very threshold of the pulmonary system, the air, which is to supply the purposes of respiration, first comes into contact with this susceptible mechanism, and we all know, by experience, when certain noxious vapours are presented to it, with what admirable fidelity it executes its functions by excluding them.
The frequency of idiopathic diseases of the larynx, in adults as well as children, which it has been my lot to witness, and the melancholy fatality so common in these insidious and relentless maladies, make it a matter of surprise to me, that it should have been reserved for the medical writers of our day, to draw the special attention of the profession to its pathology. But, in the case of children, it seems endowed with a peculiar tendency to disease, and that of a specific kind, sometimes alone, at others in conjunction with the trachea.
Nor is it always an easy matter to distinguish between structural and functional disease of these parts, for a case may terminate fatally, where, on dissection, no lesion of structure may appear, and, in such instances, we can only account for its sudden fatality, by supposing the existence of some irregular action, as spasm. That the aperture of the glottis is often in a state of spasmodic constriction, is shewn by the crowing noise which some infants make in the act of respiration, even when they are adjudged to be in good health. This tendency to spasmodic constriction of the larynx, if neglected, is capable of superinducing other affections, such as convulsions; and, in these cases, when they terminate fatally, the brain is often found highly vascular. Nay, in some instances, it seems that these paroxysms of spasm, and croupy respiration, may recur for several weeks, and terminate fatally, and yet, on dissection, no other mark of disease is discovered than effusion into the ventricles, or between the membranes of the brain. This pathological fact establishes, in my opinion, the propriety of the term spasmodic croup, as calculated to distinguish it from that of the disease which developes membranous inflammation, and which produces the adventitious membrane; and when we consider how many cases of croup are relieved by the use of calomel, may we not attribute one source of the disease, in such instances, to a sympathy with the liver, which, as I have before observed in infancy, is in a state of hypertrophy? at any rate, it is no uncommon thing to find the period of relief synchronous with a full evacuation of dark-coloured dejections. I have witnessed more than one instance, where relief followed the repeated exhibition of pavements, charged with turpentine, though leeches had previously been applied to the throat without success; and it is probable that the occasional use of enemata in children in whom this stridulous breathing occurs, or wherever the respiration is not free, would, frequently, by removing intestinal irritation, remove the fomes of the disorder, and where that was not the case, tend to mitigate the severity of the threatened attack. It seems as if the disposition to laryngeal disease was so common at some seasons, as to put on the form of an epidemic. During the various years in which measles have prevailed among the children of this neighbourhood, I have had frequent occasions to remark, that the fatality was very trifling during the early stage, where the eruption was freely developed; but where that was not the case, or where there was a premature retrocession of the eruption, the respiration often assumed a croupy sound, accompanied with a dry cough. And this was sometimes the case, even when the little patient had passed favourably through an attack of the measles. The plan of treatment was varied according to circumstances; in some leeches were found necessary, in others external applications, such as the spir. terebinth, to the neck; and where there was reason to believe the development of the rash was deficient, to the calves of the legs.
In some of the cases of that singular form of laryngeal spasm, described by Dr. Marshall Hall, little organic change was discernible on examining the fatal cases after death. The abdominal and thoracic viscera presented no morbid appearance; the mucous membrane of the larynx, trachea, and bronchi, indicated no structural disease. In some there was a turgid state of the cerebral vessels, and of the lungs, but this was not an essential part of the disease, but arising wholly from the violence of the spasm and the struggle for breath; just as is the case in hooping cough, where, after death, both the brain and the lungs exhibit organic changes, from the same cause. It has been my lot to witness several marked instances of this singular species of convulsion, which appears to consist, primarily, in spasm, occurring suddenly, often without any perceptible cause, and affecting the muscles of the glottis.
One of the last examples of this spasmodic affection, which has fallen under my observation, occurred in an infant, whose health, in other respects, did not materially suffer. The attacks of crowing inspiration returned at intervals, sometimes during the night; occasionally they were accompanied by a rigidity of the thumbs and toes, often with convulsions. At all other times the child was playful and lively. From the kind and able care of Mr. Smith, surgeon, of this town, she received considerable relief. The gums were promptly lanced, and the bowels maintained in an open state with the aid of calomel, and the occasional use of glysters medicated with assafœtid. or spir. terebinth. On the supposition that, from the violence of these attacks, some cerebral affection might supervene, leeches were applied to the neck. From a steady perseverance in these remedies, no advantage was reaped beyond a temporary respite from these spasmodic shocks. They again returned, and the gums were again divided, and counter-irritation applied to the nape of the neck. At the time I was first consulted in the case, the child was slightly relieved by a tonic plan of treatment, and by the sulphas quininæ repeated in small doses. But, on reading those cases of Dr. Marshall Hall, where such striking benefits resulted from a change of air, under similar circumstances, I had no hesitation in recommending a trial of the same plan in this case, and though neither the weather, nor the season of the year, was very auspicious, yet, after a removal to Matlock, the child experienced fewer of these convulsive movements, and, in a few weeks, they ceased entirely, and a rapid amendment in health and strength ensued. I have often seen the same gratifying effects in the children of the poor, after removal from a damp and unwholesome abode, to a dry and airy situation. Nor can it be doubted that, for want of this, the tendency to convulsive diseases of all kinds, in children, is increased, and many lives annually lost, which, under other circumstances, might have been spared. We need look no further for an illustration of this fact, than by comparing the health of those nursed in great towns, with that of those reared in the country. Before the act of Parliament was passed, which obliged the parish officers of London and Westminster to send their infant poor to be nursed in the country, not above one in twenty-four of the poor children received into the work-houses, lived to be a year old; so that, out of two thousand eight hundred, (the average annual number admitted) 2690 died; whereas, since this measure was adopted, only 450, out of the whole number, died, and the greater part of those deaths occurred during the three weeks that the children were kept in the work-houses.[2] And it is gratifying to find, every where, that the increased attention of the profession to the effects of management, and of medicine, on the manifold circumstances of children, in health and disease, has already reaped a rich harvest of reward, in the decreased mortality at that tender age. I have already extended these desultory observations to a greater length than I had originally designed, and I shall therefore defer, to a future occasion, the insertion of some interesting cases of infantile disease, intended to confirm the opinions broached in this paper. I cannot conclude, however, without calling the attention of the profession to the treatment of infantile diseases, by the introduction of remedial agents, through the medium of the cutaneous absorbents, rather than by the mouth. In the diseases of adults, we see how powerfully certain very useful remedies act when absorbed by the skin; and many substances, which are quite inert, when applied to the skin of an adult, are not only partially absorbed, in the case of infants, but exhibit very marked effects. Liniments, ointments, fomentations and poultices, may be made the vehicle of medicines, which cannot always be introduced by the mouth. It is quite manifest, as has been observed by an able writer on the diseases of infants, from the innumerable ramifications of the capillary vessels which penetrate the cutaneous texture, and the multitude of nervous filaments which give them sensibility, that poultices, in their simple or medicated forms, can be made remarkably efficient in counteracting the impressions of disease in many of the living structures. They may, occasionally, be employed as the vehicle of opiates, aperients, diuretics, stimulants, and other active remedies. If the mother's milk is not efficacious enough to counteract a tendency to sluggishness in the bowels of her infant, and the aid of medicine is required, some aperient powder, sprinkled, or, in some instances, a little castor oil, rubbed, on the abdomen, and the subsequent application of a warm poultice, will often suffice. In former days, great reliance was placed on strong decoctions of herbs, applied externally, in the diseases of children; and I have, myself, witnessed very singular effects, from the continued use of such medicated fomentations to the abdomen, where some enlargement existed, and when there was ground to suspect mesenteric disease. Where the infant cannot be made to swallow, it is of vital importance to have it in our power to apply external agents. An anodyne liniment to the spine has sometimes appeared to arrest the most violent spasms. A Very slight application of the nitro-muriatic acid lotion to the extremities, will, in some instances, shew its effects on the stools in a few hours; the same may be said of many other powerful medicines. But it is unnecessary to multiply examples of this kind. Every one's own experience will point out to him the substances most likely to be absorbed, and to answer a specific purpose. It only remains for me to observe, that it is the duty of every practitioner to acquaint himself with the causes which cut off so many of the human race, at so early a period of their existence, and, as far as possible, also, with the best means of remedying the evil. It is a subject not unbecoming the highest attainments, to increase the stock of medical knowledge in that branch of our art. So important, indeed, to society, is the successful treatment of infantile diseases, that happy shall I be, if any effort of mine shall awaken attention to this hitherto neglected department of medicine. There is no brighter reward, that is in the power of this world to bestow, than to be made the instrument of relief to these helpless little ones, and of saving the lives of these engaging beings, to be a blessing to their parents, and, perhaps, the future ornaments of society.