LECTURES

ON THE

DISEASES OF INFANCY AND CHILDHOOD.

INTRODUCTORY LECTURE.

Causes of peculiarities presented by diseases in childhood-These peculiarities are reasons for their special study-Difficulties of their study, and how to overcome them-Rules for the examination of sick children, and for taking notes of Cases.— General plan and objects of the Course.

GENTLEMEN,

It is not without hesitation that I have determined on adding another to the already numerous courses of lectures that you are called on to attend while engaged in the study of medicine. My reasons and I trust my justification-for so doing are furnished partly by the frequency of the diseases of infancy and childhood, partly by their fatality, but still more by their many peculiarities.

Children will form at least a third of all your patients, and so serious are their diseases, that one child in five dies within a year after birth, and one in three before the completion of the fifth year. These facts, indeed, afford conclusive arguments for enforcing on you the importance of closely watching every attack of illness that may invade the body while it is so frail; but they alone would scarcely be adequate reasons for my bringing these diseases under your notice as objects for special study.

The body, however, is not only more frail in infancy than it becomes in after life, but the sympathies between its different parts are more extensive and more delicate. One organ seldom suffers alone, but the effects even of local diseases extend to the whole system, and so disorder its workings that it is often no easy matter to determine the seat of the original mischief. Nor is this all; but many important consequences result from the period of childhood being one of unceasing development. In the adult the structure of the body is complete, and its functions are the same to-day as they were yesterday, but the child learns successively to breathe, to feel, to think: and its body is daily undergoing modifications to fit it for new duties, as well as daily growing in size and strength. Disease,

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PECULIARITIES OF THE DISEASES OF CHILDREN.

therefore, not merely disturbs the present, but its influence reaches to the future; it not only interrupts the present function of the organ that is affected, but it puts a stop for a time to the completion of the general machinery of the body, or disarranges the due proportion of one part of that machinery to another. Moreover, there are periods, namely, those of the first and second dentition, when very great changes take place in the organism of the child, and when all these dangers are especially to be feared. Disease is then frequent and serious beyond what it is at other times, and every ailment then warrants a double measure of anxiety; while, on the other hand, if these epochs are safely passed, there succeeds a season of comparative immunity from many affections that before were both common and perilous.

But, if this be so, you will at once perceive that something more is essential to the successful treatment of children's diseases than to watch their advances carefully, and to adapt the strength and doses of your remedies to the tender years of your patients. It is not mere hyperbole to say that you have to study a new semeiology, to learn a new pathology, and new therapeutics. Matters of such importance. cannot be properly examined at the end of a course of lectures on midwifery. I have therefore preferred making them the subjects of separate consideration during the summer, when the comparative leisure of the season will, I hope, enable you to devote some of your time to the practical as well as the theoretical study of the diseases of children.

I must warn you, however, of one difficulty which you will encounter at the very onset, a difficulty that disheartens many, and makes them abandon in despair the study of children's diseases. Your old means of investigating disease will here to a great degree fail you, and you will feel almost as if you had to learn your alphabet again, or as if, entering a country whose inhabitants you expected to find speaking the same language, and having the same manners as the people in the land you had lately left, you were to hear around you everywhere the sounds of a foreign tongue, and to observe manners and customs such as you had never seen before. You cannot question your patient; or if old enough to speak, still, through fear, or from comprehending you but imperfectly, he will probably give you an incorrect reply. You try to gather information from the expression of his countenance, but the child is fretful, and will not bear to be looked at; you endeavour to feel his pulse, he struggles in alarm: you try to auscultate his chest, and he breaks out into a violent fit of crying.

Some practitioners never surmount these difficulties, and the diseases. of children are consequently a sealed book to them. After a time they grow satisfied with their ignorance, and will then with the greatest gravity assure you that the attempt to understand these affections is useless. They have fallen into this unfortunate error from not taking the pains to start aright: they have never learned how to interrogate their little patients, and hence they have never received satisfactory replies. I speak of interrogating them; for though the infant cannot talk, it has yet a language of its own, and this language it must be your

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19

first object to learn, if you mean ever to acquire the character of successful practitioners in the diseases of children. But, if you have not cultivated your faculties of observation, you cannot learn it, for it is a language of signs, and these signs are such as will escape the notice of the careless: if you are not fond of little children you cannot learn it, for they soon make up their minds as to who loves them, and when ill they will express their real feelings, whether by words or signs, to no one else.

There is, moreover, a certain tact necessary for successfully investigating the diseases of children. If, when summoned to a sick child, you enter the room abruptly, and, going at once to your patient, you begin to look closely at it, while at the same time you question the mother or nurse about its ailments in your ordinary pitch of voice, the child, to whom you are a perfect stranger, will be frightened, and will begin to cry; its pulse and respiration will be hurried, its face will grow flushed, and you will thus have lost the opportunity of acquainting yourself with its real condition in many respects. Besides this, the child's alarm, once excited, will not subside so long as you are present: if you want to see its tongue, or auscultate its chest, its terrors will be renewed, and it will scream violently; you will leave the room little wiser than you entered it, and, very likely, fully convinced that it is impossible to make out children's diseases.

Very different would be the result if you conducted this examination properly; and though I believe, where there is real love for children, the tact necessary for examining into their ailments will not be long in being acquired, still a few hints on this subject may not be out of place in an introductory lecture.

The quiet manner and the gentle voice which all who have been ill know how to value in their attendants, are especially needed when the patient is a child. Your first object must be, not to alarm it; if you succeed in avoiding this danger it will not be long before you acquire its confidence. Do not, therefore, on entering the room, go at once close up to the child, but, sitting down sufficiently near to watch it, and yet so far off as not to attract its attention, put a few questions to its attendant. While doing this, you may, without seeming to notice it, acquire great deal of important information; you may observe the expression of the face, the character of the respiration, whether slow or frequent, regular or unequal, and if the child utter any sound you may attend to the character of its cry. All your observations must be made without staring the child in the face; little children, especially if ill, seem always disturbed by this, and will be almost sure to cry. If the child be asleep at the time of your visit, your observations may be more minute: the kind of sleep should be noticed, whether quiet or disturbed, whether the eyes are perfectly closed during it, or partly open as they are in many cases where the nervous system is disordered: you may, too, if the sleep seem sound, venture to count the frequency of the respiration, and the beat of the pulse, but in doing this you should be careful not to arouse the child. It should be awakened gently by the nurse or mother, and a strange face should not be the first to meet its eye on awaking. If it were awake when you entered the room, it will

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EXAMINATION OF SICK CHILDREN.

probably in a few minutes have grown accustomed to your presence, and will allow you to touch its hand, and feel its pulse. This must always be done at as early a period in your visit as possible, in order that you may count it while the child is undisturbed, since the pulsations of the heart vary, in young children, as much as twenty in a minute under comparatively slight disturbing causes, and any inferences that you might draw from the pulse of the child, when frightened or excited, would almost certainly be erroneous. Besides the pulse, the frequency of the respiration should, if possible, be noticed, since the results obtained by a comparison of the two are always more valuable than those of either taken alone. But if this be your first visit to the child, do not, for the sake of ascertaining either of these points exactly, persevere in attempts which irritate or frighten it: probably you would, after all, be unsuccessful, and even though you were to succeed, the knowledge would not repay you for the loss of the child's confidence, which it must be your grand object to acquire and keep.

With management and gentleness, however, you will comparatively seldom fail, and while you are feeling the pulse, or with the hand on the abdomen are counting the frequency of the inspirations, you will also learn the temperature of the body and the condition of the skin. Supposing your examination has thus far been pretty well borne, you may now, probably, venture to talk to the child, or to show it something to amuse it as your watch or stethoscope, and while thus testing the state of its mental powers, you may pass your hand over the head, and note the state of the fontanelle, and the presence or absence of heat of the scalp.

The examination of the state of the abdomen, though too important to allow of its ever being omitted, will often lead to no satisfactory result unless carefully managed. If you allow the nurse to change the child's posture and to lay it back in her lap, in order that you may pass your hand over its stomach, the child will often be alarmed, and begin to cry, its abdomen then becomes perfectly tense, and you cannot tell whether pressure on it causes pain, or whether the cries are not altogether the consequences of fear. It is therefore the best plan to pass your hand beneath the child's clothes, and to examine the abdomen without altering its posture, while, at the same time, the nurse talks to it to distract its attention, or holds it opposite the window or a bright light, which seldom fails to amuse an infant. If there be no tenderness of the abdomen the child will not cry on pressure, or if, during your examination, the presence of flatus in the intestines should occasion pain, gentle friction, instead of increasing suffering, will give relief.

You must next examine the chest: and for this purpose immediate auscultation is always to be preferred, since the pressure of the stethoscope generally annoys the child. If the child be not in its bed-gown, it will usually be your best course to have the back of its dress undone, and then, while it is seated on its mother's or nurse's lap, to kneel down behind it, and apply your ear to its chest. In all acute diseases of the lungs in infancy the condition of their posterior part is a sure index to the extent of the mischief from which they are suffering; for, owing to the infant passing so much of its time in the horizontal position, the

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21

blood naturally gravitates towards the back of the lungs, and the secretions are much more likely to accumulate in the bronchi in that situation than elsewhere: hence, if air be heard permeating the lungs throughout the whole posterior part of the chest, and unaccompanied with any considerable amount of crepitation, it may fairly be inferred that their front parts are free from serious disease, even though we should be unable to ascertain the fact by actual observation.

When you have listened thoroughly to the back of the chest, you may next percuss it. Your must not percuss first and listen afterwards, as you often do in the adult; for even when practised with the greatest gentleness, percussion sometimes frets the child, and makes it cry, whereby any subsequent attempt to listen to the breathing will often be rendered unsuccessful. But you must not neglect percussion: it is of peculiar value in childhood, since auscultation is then unavoidably incomplete in many instances, sometimes quite impracticable. In practising it, however, there are some rules without attention to which you will very likely fail of acquiring any information whatever. You must never, in the child, attempt to percuss the walls of the chest immediately, but should strike on your finger, and even then very gently. The chest of the child is so resonant, that, if you percuss smartly, you will fail to perceive the finer variations in sonoriety which would be readily appreciable on gentle percussion. Always observe to compare the results obtained by percussing opposite sides of the chest, since otherwise you may overlook a very considerable degree of dulness. It often happens, too, that the lower lobes of both lungs are involved nearly equally; you must therefore notice the resonance of the lower as compared with that of the upper part of the chest. Sometimes you are compelled, by the fretfulness of the child, or by the tenderness of the walls of its chest, to percuss so gently as scarcely to elicit any sound. It is of importance, therefore, to attend to the sensation of solidity communicated to the finger, as well as to the sound of dulness that falls upon the ear, since, if your sense of touch be delicate, it will correct or confirm the evidence of hearing.

Having thus examined the back of the chest, you may, if the child be likely to tolerate it, try to listen at its sides, and then in front. You can, however, scarcely auscultate the front of the chest in infancy without a stethoscope, and this you will very seldom be able to use; for, if the child be not frightened, it will probably be so exceedingly amused at what it regards as specially intended for its own diversion, that it will join in the game, and disconcert you by playing with the instrument. You will encounter this difficulty in cases of phthisis in early childhood, and will often find it no easy matter to ascertain the character of the respiration in the front of the chest. In such cases you will learn all the value of percussion, which may be practised over the front of the chest as well as the back, while the state of the breathing in the upper and back part of the chest will generally be a correct index to its condition in front.

Your examination of the chest will not be complete until you have noticed the general character of the breathing, whether the whole of the chest is expanded by it, or whether the respiration is merely abdominal

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