LECTURE II.

INTRODUCTORY.

ON THE TREATMENT OF CHILDREN'S DISEASES.-Influence of remedies modified by the age of the patient. -Rules for the practice of depletion, for the use of mercury, antimony, and opium, and for the employment of blisters. Suggestions as to the mode of prescribing for infants and children.

IN the introductory lecture, I tried to point out the main peculiarities which distinguish the diseases of early life, and to furnish you with some general rules for their investigation. It may not be time misspent if, before we begin the examination of any special class of ailments, I endeavour to give you a few general directions for their treatment, though in so doing I must of necessity anticipate some things which will require notice hereafter, and must occasionally presuppose the possession of that knowledge which it is the main object of these lectures to impart.

The importance of great exactness in prescribing for infants and children, and the necessity for regulating the doses of our remedies according to the tender years of our patients, are self-evident. Posological tables, as they are termed, are, however, of very little value for our guidance, since the susceptibility of the young to the action of different remedies varies greatly according to their nature, so that the rule which safely defines the dose of an opiate would be altogether inapplicable as determining the strength of a purgative or of an emetic.

The abstraction of blood, the use of emetics and purgatives, the employment of antiphlogistics, and the administration of sedatives are the great weapons with which we endeavour to combat the advances of acute disease. The safe use of each of these in early life implies the observance of certain precautions which I will now attempt to explain, and will then try to furnish you with a few general directions that may be of service in prescribing for infants and children.

RULES FOR DEPLETION IN CHILDREN.

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The early age of our patients imposes of necessity some restriction on the mode in which depletion can be practised; for venesection in the arm is hardly ever possible before the age of three years, often not till later, in consequence both of the small size of the veins, and of the quantity of fat in which they are imbedded. In cases of extreme urgency the jugular vein may be opened, and I have never found any difficulty in the operation, though I believe the necessity for the proceeding very seldom arises, and the only instances in which I have had recourse to it were either instances of violent convulsions succeeded by profound coma, or else of very acute inflammatory croup.

For almost all purposes of depletion in early life we are dependent on the use of leeches, and by this means, if rightly managed, we may attain nearly all the ends of general bleeding. The great objection to the employment of leeches rests on the difficulty of estimating and of controlling the quantity of blood abstracted by them. This objection, however, applies almost entirely to the common practice of putting on a comparatively small number of leeches, and trusting to the application of a poultice, or the employment of fomentations, for obtaining a sufficient quantity of blood. Instead of adopting this plan, than which nothing can be more uncertain, it is far better to apply a larger number of leeches and to allow of no subsequent bleeding. It may then be calculated that each leech takes about two drachms of blood, and we are thus enabled to estimate the quantity removed with a certainty little less than we are possessed of, if we employ venesection, while, further, the blood is removed in the course of fifteen or twenty minutes, instead of draining away, as in the other case, for six or eight hours, weakening the patient, and yet exercising comparatively small influence on the disease.

To ensure certainty and safety, however, in the employment of leeches, there are several precautions which must not be neglected. Of these, the most important is, that their application should not be left to a nurse, but that, wherever it is at all practicable, the medical attendant should himself superintend it. This is of special moment in all acute diseases in which it is desired to obtain by local bleeding the constitutional effects of general depletion, since, according to the result produced, it may, on the one hand, be desirable to put on a larger number, or, on the other, to remove some before they have completely filled themselves. The effects produced by the loss of blood often influence the character of the subsequent treatment. On this account, therefore, as well as with

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RULES FOR DEPLETION

the view of lessening the risk of hæmorrhage going on from the leech-bites unperceived, it is desirable to apply leeches by day, not towards evening, or at bed-time, as is commonly the practice. Attention should further always be paid to apply leeches in situations where they will not alarm the child by being within his sight, and where, also, there is a firm surface beneath against which pressure can be made, so as readily to control the bleeding. Behind the ears, therefore, or on the vertex, are the best situations for applying leeches to the head, and under the scapula when it is necessary to deplete from the chest; while, in many abdominal affections, all the advantages of local bleeding may be most safely obtained by the application of leeches to the anus.

The above rules apply to the mode of practising depletion in early life; but, independently of the mere manner of drawing blood, there are some still more important cautions which have reference to the general principles which should govern us in resorting to depletion at all.

1st. It should be remembered that large losses of blood are worse borne by the child than by the adult; that if syncope is produced, its effects do not pass away so speedily, but leave a much more abiding depression.

2nd. That the shock consequent on large losses of blood, shows itself, not merely by causing syncope, but also, not very seldom, by producing convulsions; and such convulsions are specially apt to be excited in cases where the previous disorder of the nervous system was considerable, even though that disorder depended on congestion of the brain which called for depletion to relieve it. It seems as if in these cases, just as in some of comparatively slight disease of the heart, if the equilibrium of the circulation is suddenly disturbed, it altogether fails to recover itself. A child of ten months old was brought to me many years ago with symptoms of cerebral congestion-a hot head, a raised fontanelle, a burning skin, and twitchings of the tendons of the arms and legs. I ordered leeches to the head, which drew freely; but the convulsions, which it was hoped they would ward off, occurred while the bleeding was still going on, and the child sank at once into a state of coma, from which it never rallied completely, and died in the course of forty-eight hours. Now, in this case, the abstraction of blood was indicated, and the appearances discovered after death showed that the depletion had not been excessive. It had, however, been too sudden; and probably, had I been present when the leeches were applied, I should have noticed some change in

AND EMPLOYMENT OF MERCURY.

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the child's condition which would have warned me to put a stop to further bleeding, and might thus have led to an entirely different result. In proportion, therefore, to the youth of our patient, must be our caution in ordering free depletion, and our care in watching its effects; and these must both be greater when marked disorder of the nervous system forms the indication for our treatment.

3rd. Not only are very large losses of blood hazardous, and great shock by its too sudden abstraction also attended with danger in early infancy, but repeated bleedings are also inexpedient. The system rallies from them with proportionately far greater difficulty than in the adult, and that peculiar class of symptoms, by which exhaustion is apt to simulate congestion of the brain, is specially likely to be induced. It may be added that, to a considerable degree, the same caution holds good with reference to all other antiphlogistic remedies; that free purgation, spare diet, and depressing measures of all kinds, though often requisite, yet require most heedful watching, and generally need to be soon discontinued.

Among antiphlogistic remedies, the two which in the child, as in the adult, are of the greatest value and of the most general application in the treatment of acute inflammatory diseases, are antimony and preparations of mercury. Both, however, are not infrequently used in cases where they are either not needed, or are positively injurious.

The peculiar influence of mercury is exerted too slowly to control the first rapid advance of some acute diseases, such as croup and pneumonia, though in both after previous depletion, and the administration of antimony, mercury often proves most serviceable. In those forms of pulmonary inflammation, also, which sometimes occur in comparatively weakly subjects, or in which the disease has already advanced unchecked so far as to produce consolidation of the lungs, it is on mercury that our chief reliance must be placed. Mercury, too, is our great stay in all cases of acute inflammation of the serous membranes of the chest and abdomen; and in severe inflammation of the mucous membrane of the large intestine, or dysentery, the disease often admits of control by no other means than by the conjoint employment of calomel and opium.

In cachectic diseases its utility is far more limited. The earlier symptoms of congenital syphilis yield rapidly to the employment of small doses of mercury; but the tertiary results of the disease

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RULES FOR EMPLOYMENT OF MERCURY

are often aggravated, very seldom indeed benefited, by that medicine. In the majority of disorders connected with the tubercular diathesis, mercurials are not beneficial; and in tubercular hydrocephalus in particular, in which they are so often given, I never saw even momentary improvement from them, apart from their occasional action as purgatives. It must, however, be confessed that, in their powerlessness to control this disease, they do but stand on the same footing with all other medicines. There is one class of ailments, too, connected with tuberculosis in which the action of mercury is almost uniformly beneficial; and that is tubercular peritonitis, and those vague disorders of the functions of nutrition so commonly referred to disease of the mesenteric glands.

In administering mercury to infants and young children, it must be borne in mind that evidence of the system being affected by it is seldom afforded, as in the adult, by the occurrence of salivation. So rare, indeed, is mercurial stomatitis in early life, that I have seen but one instance in which it proved fatal, and have very seldom met with it in such a degree as to be troublesome. I should therefore regard the production of gangrene of the mouth by the administration of mercury, as an evidence of some rare idiosyncrasy on the part of the patient, rather than of want of due care on that of the doctor. In early life, mercury, instead of affecting the mouth, usually acts very speedily as an irritant on the intestinal canal; and the green stools, which are often looked on with satisfaction as a proof of the system being brought under the influence of the medicine, are far from always having that meaning. They prove its action as a local irritant-a result which may be most undesirable, and which often compels us to diminish its dose, sometimes even completely to suspend its administration. Sometimes, too, calomel acts as an irritant on the mucous membrane of the stomach, producing nausea and vomiting, and giving rise to so great a degree of depression as to necessitate its discontinuance.

Besides its use in those more formidable diseases to which reference has hitherto been made, mercury is also often employed as a purgative and alterative. There is no doubt but that used with either of these objects it is a remedy of great value, and the objection to its employment is, not that it fails to accomplish these ends, but that it answers them at a greater expense of constitutional power than was necessary. Rhubarb, soda, the mineral acids, aloetic preparations, taraxacum, and other remedies,