INTERNAL REMEDIES.

83

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 purgatives given by the mouth. The latter method is inapplicable as long as the 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 every 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 sedative to the stomach:

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.

The same remedy should not be continued too long at a time, if no improvement is seen to follow its employment. Our greatest trust should be placed in warmth, stimulation of the surface, and 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.

*See Underwood's Treatise on Diseases of Children, p. 227.

When the prostration is great the stimulant may be repeated 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 only increase the prostration. Vomiting 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 sometimes 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 continues after the tongue has become clean, stimulants should at once be given, and the following are very useful :—

Aquæ carui, ad 3ij. M. 3j quartâ quâque horâ.

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 important agent in the treatment of this as of all the other chronic diseases of children.

The symptoms which have been described as "spurious hydrocephalus" 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-Softening-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-Arrest 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.

Pathology.-Rickets a general disease-Anatomical characters of bony changes-Köllicker'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 assimilation, 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 interference with the assimilative functions, which must take place to a certain degree before the disease can be established. This preliminary stage is not,

however, always present. Rickets is the result of malnutrition any disease, therefore, which seriously interferes with the assimilative power, and causes sufficient impairment of the general strength, may be followed directly by the disorder under consideration, without any intervening stage. Reduce 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, therefore, which will reduce the strength to this point lays the foundation 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. When 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 bathed 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.

GENERAL TENDERNESS.

87

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 the bones. It is, however, frequently absent in mild cases. This symptom is general tenderness. The child at first shows signs of uneasiness when danced up and down in the arms of his mother. As the tenderness increases, he becomes peevish at being touched, and prefers sitting quietly in his little chair, or lying down in his cot, for all voluntary movements increase the pain. Eventually, as the disease 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 phenomena 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 constipation. More often, however, there are three or four evacuations in the course of the twentyfour 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 exaltation 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,