exert an alterative power over the secretions, without any of that depressing influence which attends the use of mercurials. In the same manner, there are many purgatives no less certain, and no less speedy in exciting the action of the bowels; so that, before prescribing calomel or grey powder, the practitioner ought to be satisfied that there is some special end, in producing an increased secretion of bile, in controlling an excited state of the circulation, or in rapidly modifying the condition of the intestinal mucous membrane, which no other remedy would attain, or at any rate would not attain so certainly or so quickly.

A second remedy of great value in early life is antimony, though one which also is not infrequently misapplied. It is not as a simple emetic that antimony ought to be employed, for, unlike ipecacuanha, its influence is not confined to inducing vomiting, but it also exerts a most powerful depressing action on the circulation, and is therefore specially indicated in acute inflammation of the lungs and air-tubes. When the object is merely to empty the stomach, to produce that revulsion which follows the operation of an emetic, and which leads us often to prescribe it at the onset of a febrile attack for the sake of the moist skin and tranquil pulse which seldom fail to succeed its operation; or when we seek simply to free the bronchi from the secretions poured into them in too great abundance, as in catarrh or in simple hooping-cough; every end is answered by the use of ipecacuanha. On the other hand, in the onset of croup, in the early stage of acute pneumonia or of capillary bronchitis, when disease is advancing every hour and when its advance directly threatens life, antimony is the only medicine sufficiently speedy and sufficiently powerful in its action to keep pace with the advances of the disease, and to hold it in check. Even in these cases, however, the administration of antimony needs care, and after tolerance of it has been established we cannot so safely as in the adult continue its use. I shall hereafter have to explain to you the liability to collapse of the lung in early life, when feeble inspiratory power is associated with the presence of secretion in the air-tubes. In this state the pulmonary tissue tends by its own elasticity to exclude the air from the air-vesicles; and if the muscular power be reduced below a certain point, the patient's efforts fail to dilate them, and by degrees more and more of the lung becomes dense, unaërated, and as useless for the time, for all purposes of respiration, as if it had been solidified by inflammation or compressed by fluid. This danger is always to be borne in mind in the pulmonary affections of early life, and the vigour of the

20

RULES FOR USE OF OPIUM

patient's powers must be the measure of our treatment, as much as the urgency of the disease.

As a mere diaphoretic, antimony, when administered in small doses, is as useful in the case of the child as in that of the adult. I am not fond of its use, however, as an antiphlogistic in ordinary febrile affections; for the nausea which it is apt to produce may obscure the approach of cerebral mischief, or lead to an erroneous interpretation of the symptoms.

A third great remedy in the diseases of early life is opium in its various preparations; and with it may be classed, though separated by a wide interval, other sedatives, such as hemlock, henbane, hop, and lettuce. Perhaps no remedies are so often needed in the diseases of early life as sedatives, for at no other age is the nervous system so easily disturbed. At the same time, the susceptibility to the action of narcotics and sedatives is so remarkable, and the evils which result from their unnecessary employment or from their adminstration in excessive doses are so serious, that some practitioners altogether abstain from their use. To do so, however, is to deprive ourselves of one of the most important classes of remedies, and of one for which no substitute can be devised.

The danger which especially attends the use of opium arises partly from the employment of uncertain preparations, such as the syrup of poppies; partly from the administration of over-doses, or from their too frequent repetition: of which two errors the latter is more frequently committed. In prescribing for children, preparations of definite strength should always be used, as the compound tincture of camphor, tincture of opium, or Dover's powder. The weaker preparation, the compound tincture of camphor, is often preferable to laudanum, since a slight error in dispensing is of so much less moment. Sometimes the comparative tastelessness of laudanum renders it the more suitable; but if so, even though only a single dose is needed, it is wiser in the case of infants to order a mixture containing two or three doses in order to lessen the risks of error. But mischief is more frequently done by the frequent repetition of opium, than by the improper prescription of over-doses; and I am always averse to the common practice of giving small quantities of opium at short intervals, for the purpose of checking diarrhoea or of soothing restlessness in young infants, and prefer, unless there be some strong reason to the contrary, to give a larger dose of the remedy once or twice in the twenty-four hours.

In addition to these general precautions with reference to the mode of administering opium, special care is needed in its employ

AND APPLICATION OF BLISTERS.

21

ment in some conditions. It must be given charily in all cases where the system has been exhausted by the previous disease, or by the previous treatment; and this caution must be particularly borne in mind during convalescence from fever, where yet the patient's restlessness not seldom requires its employment. In all cases of cerebral excitement the use of opium calls for great watchfulness; sometimes it must be given rather as an experiment whereby the real nature of the disease is tested, and when so employed its results must be scrutinised with the most anxious care. In severe diarrhoea, too, the transition from a state of excitability of the nervous system to a condition of coma is often very rapid in its occurrence; an over-dose of opium may hasten or induce this catastrophe, or, even though it should not have this result, yet without great care we shall be at a loss to determine how far the disease, and how far the medicine, has induced the symptoms.

In mere restlessness, unattended by severe pain, other sedatives are often preferable to opium: thus, for instance, the feverish disquietude of a child during teething is often soothed by henbane, while that which manifests itself by a disposition to carpopedal contraction and to spasm of the glottis is mitigated by small doses of hydrocyanic acid and chloric ether as effectually as by opiates, and with far greater safety.

The difficulties in the administration of internal remedies in early life have had no small share in leading practitioners to the employment of outward applications with much greater frequency than in the adult. Fomentations, poultices, and liniments of various kinds relieve pain, abate spasm, or serve as useful counter-irritants, in very many cases which I need not now occupy your time in specifying. But, besides these, blisters are also much used in different inflammatory affections, more particularly in those of the lungs and air-tubes, though I think their application is more restricted and is resorted to with greater caution now than formerly; and I see far fewer instances of unhealthy ulceration of blistered surfaces among the children of the poor now, than came under my notice fifteen or twenty years ago.

In applying blisters to infants and young children, it must be borne in mind, not only that they vesicate more speedily than in the adult, but that the vesicated surface is apt, especially in some diseases, to pass into a state of ulceration; and, further, that the amount of constitutional disturbance produced by blisters is considerable in proportion to the youth of the patient.

The ordinary rule, which prescribes four hours as the longest

22

APPLICATION OF BLISTERS.

time during which a blister should be allowed to remain on the skin in infancy, is on the whole a good one, but it must be remembered that some parts of the surface are far more sensitive than others. Thus, for instance, the skin on the front of the chest is peculiarly delicate, and a blister applied there for two hours would almost certainly vesicate, while it might not produce the same effect in double the time if applied beneath the scapula. On the other hand, the scalp is remarkably deficient in sensitiveness, and a blister may be allowed to remain on it for eight hours without any risk of mischief ensuing. There are, moreover, some diseases which increase the susceptibility of the skin to the action of irritants: thus, for instance, in all the ailments which accompany or succeed to measles, and especially in the pneumonia which often complicates it, a vesicated surface is apt to pass into a state of dangerous ulceration. Nor is this the only hazard which attends their use; but the constitutional disturbance which they produce, the pain while they are drawing, the soreness of the surface while they are being dressed, and the itching and irritation which accompany their healing, often keep up an amount of restlessness, and a state of feverish irritation, that are in every way prejudicial to the child's recovery.

On these accounts, therefore, I have almost entirely abandoned the use of blisters in infancy and early childhood, and am always most careful that no extensively abraded surface shall be left by their application. Partly with this object, and partly in order to avoid the inconvenience of the blister being dislodged by the movements of the child, I make use almost exclusively of the blistering fluid, which is painted once or oftener over the surface, according as it is wished to produce a more or less considerable degree of irritation. If vesication takes place, the serum is let out by pricking with a needle, and a layer of cotton wool being applied over the surface is allowed to remain there until, healing being completed, it drops off of its own accord. In addition to the avoidance of danger and the lessening of constitutional disturbance by these means, we have the great advantage of being able, if it should be desirable, to repeat the same proceeding in the course of three or four days, while, by the ordinary mode of employing blisters, ten days almost invariably elapse before the sore left by their application is healed. In other cases, such as those of chronic pleurisy, where we are anxious to promote the absorption of the effused fluid, or in cases of consolidation of the lung, associated with signs of tubercular mischief, the application

RULES FOR PRESCRIBING FOR YOUNG CHILDREN.

23

of tincture of iodine once a day over the surface takes the place most advantageously of the blisters which we should employ in the adult.

The whole range of remedies might thus be gone through; and with reference to each it might be pointed out how its employment requires to be more or less modified according to the age of the patient. But to do this would be more tedious than profitable, and the majority of details will find their fittest place when we notice the disease for the cure of which this or the other medicine is specially indicated.

A few general hints may, however, be given with reference to the art of prescribing for infants and children of tender age. But first of all I must remind you of the twofold difficulty which you encounter in the treatment of the diseases of children, owing partly to the waywardness of the little patients themselves, partly to the prejudices of their parents, while your success as practitioners will depend on the amount of tact with which you avoid coming into direct collision with either. To prescribe nauseous medicine when with a little care you could order it in a palatable form; to insist on a particular article of diet being given, or on a particular remedy being employed, which the parents fancy will not suit, unless you believe one or the other to be absolutely indispensable to your patient's cure-is needlessly to weaken that authority which in the graver maladies it is absolutely essential that you should be able to exert. As has been truly said by MM. Rilliet and Barthez, it is in the slighter much more than in the serious diseases of children that waywardness, fretfulness, and obstinate refusal of medicine are met with. In the majority of such cases nature alone suffices for the patient's cure, and, while you watch carefully the approach of any serious symptoms, you will lose nothing in the confidence of the parents, and gain much in the love of your patients, by sparing them the nauseous draught, and the agony of tears and fright and temper which they often undergo before they swallow it. The battle with a child to compel it to take medicine, to force it into a bath, or to give it an emetic, generally does far more harm than the remedy so administered can do good; and the many tears saved by it in the nursery are one of the strongest practical recommendations of homoeopathy to the public.

But even the most expectant plan of treatment does not leave you without the power of regulating to a great degree the diet of the child, the temperature of its room, the nature of its amusements, and of excluding bright light and loud sounds from its