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TREATMENT OF INFANTILE SYPHILIS.

it will be seen to be furnished almost entirely by the inner surface of the labia, by the nymphæ and the vulva generally, but to come scarcely at all from the canal of the vagina. The slight degree of swelling of the parts; the source of the discharge almost exclusively from the parts anterior to the hymen; and the absence of dysuria, or the very slight degree in which it has attended the onset of the affection, coupled with the integrity of the hymen, and the absence of all appearances of injury, are sufficient to distinguish this affection from gonorrhoea. Sometimes, indeed, when this discharge has come on during teething, it has been preceded by considerable dysuria; but older children rarely suffer more than a degree of itching and smarting of the parts, which is troublesome from its persistence rather than from its severity. When it occurs during dentition, the discharge is not in general abundant, and ceases so soon as the tooth has cut through the gum, though probably returning with a renewal of the irritation. Sometimes it occurs in children who are much troubled by ascarides, when it is kept up in many instances not merely by the irritation excited by their presence in the rectum, but in a measure also by their creeping about the vulva. In some instances it takes place as a sequela of the eruptive fevers, especially of scarlatina; and though I have never met with it under these circumstances, except as a chronic ailment, accompanied by great general debility, cases have been related,1 in which it came on with acute symptoms on the decline of the eruption. Generally, however, it neither succeeds to any previous fever, nor is dependant on any local cause, but occurs in strumous children in connection with general impairment of health, or following some considerable fatigue. Where no special cause can be assigned for its occurrence, its appearance is yet, in general, preceded for a day or two by some slight increase of indisposition; such as an attack of feverishness, or catarrh, or diarrhoea.

Be the cause what it may, our great difficulty in almost every instance is to effect a permanent cure, so that the suspension of our remedies may not be followed by a return of the discharge. When it is connected with teething, or with the presence of worms, the indications are plain enough, and cure is in general comparatively easy. Simple but abundant ablution with tepid water, repeated every hour or two on the first appearance of the discharge, will, in conjunction with appropriate general treatment, not infrequently suffice for its complete arrest. If the discharge, however, continue for more than one or two days, astringents must be had recourse to, such as the Liquor Plumbi Dilutus, or lotions of sulphate of zinc, or of alum, each of which may be employed for a few days, and then changed for another. At the same time frequent cold sponging of the nates and vulva should be employed; and it must be impressed on the child's attendants that no lotion whatever can supply the place of frequent ablution. Now and then, when at the onset of the discharge there has been more dysuria than common, I have given small doses of copaiba and liquor potassæ ; and have obtained from their administration just the same kind of relief as those remedies afford in acute vaginitis in the adult. Such

1 1 By Dr. Cormack, in the London Journal of Medicine, Sept. 1850.

cases, however, are quite exceptional; and usually, tonics, and expecially preparations of iron, are the only internal remedies which are required, while it is in general necessary to begin their administration early. These medicines, especially if associated with change to the sea-side, and sea-bathing, usually suffice, even in the most obstinate cases, to effect a cure. It is, however, in general a wise precaution to continue the employment of frequent ablution, and, in addition, to sponge the parts twice a day with alum lotion, even for weeks after the discharge has completely ceased; while once I found the employment of a lotion of a scruple of nitrate of silver to an ounce of water necessary to arrest a discharge which had bid defiance to all other remedies.

LECTURE XXXVII.

FEVERS-chiefly belong to the class of the Exanthemata. Mistakes with reference to simple fever in childhood-its identity with fever in the adult.

SIMPLE OR REMITTENT FEVER Occurs in two degrees-symptoms of its milder form-of its severer form-signs of convalescence-modes of death.-Diagnosis.-Treatment.

WE come now to the last part of this course of lectures; namely, to the study of the febrile diseases incidental to infancy and childhood. They belong, for the most part, to the class of the Exanthemata,— diseases characterized, as you know, by very well-marked symptoms, by a very definite course, and by usually occurring only once in a person's life. These peculiarities have always obtained from them the notice of practitioners of medicine, and few of the affections of early life have been watched so closely, or described with so much accuracy, as small pox, measles, and scarlatina. Hence it will be unnecessary to occupy so much of your time with their investigation as we have devoted to the study of other diseases which, though not so important, have yet been less carefully or less completely described.

While the well-marked and unvarying features of the eruptive fevers, however, have forced those diseases on the attention of all observers, the more fluctuating characters of simple continued fever have been so masked by the differences between youth and age, that the affection as it occurs in early life was long almost entirely overlooked, and its nature was, in many respects, still longer misapprehended. Many, indeed, even of the older writers on medicine, have spoken of fevers as occurring among children at all ages; but under this name they confounded together several diseases in which febrile disturbance was merely the effect of the constitution sympathizing with some local disorder. This mistake was committed with especial frequency in the case of various affections of the abdominal viscera; many of which are attended by a considerable degree of sympathetic fever, while their symptoms, in other respects, are often so obscure that the perfect diagnosis of former days failed to discover their exact nature. As medical knowledge increased, many of these disorders were referred to their proper place; but, never

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INFANTILE REMITTENT FEVER.

theless, the descriptions given of the so-called remittent fever, worm fever, and hectic fever of children, present little of a definite character, and are evidently the result of a blending together of the symptoms of various affections. The disease described under these different names was supposed to be a symptomatic fever, excited by gastric or intestinal disorder, and limited in the period of its occurrence to early life; while the absence of the well-marked shivering which usually attends the onset of fever in the adult, the rarity of any efflorescence on the surface of the body, and the comparatively low rate of mortality which it occasions, led persons altogether to overlook the close connection between it, and the continued fever of the adult.

If, however, we look attentively at the characters of this disease, and compare them, as has been done by MM. Rilliet and Barthez, with those presented by the simple continued fever of the adult, we shall, I think, see so close a correspondence between the two affections as to remove all doubt with reference to their identity. Both diseases occur independently of any cause which we are able to detect; and both, though generally affecting isolated individuals, yet have also their seasons of epidemic prevalence. Though varying in severity, so that in some cases confinement to bed for a few days is scarcely necessary, while in other cases the patient hardly escapes with his life, yet medicine has not been able to cut short the course even of their mildest forms. And, lastly, though the local affections associated with both. vary much in different cases, yet in every instance we meet with that assemblage of symptoms which make up our idea of fever. Or if, from the examination of the symptoms during life, we pass to the inquiry into the traces left by the disease on the bodies of those to whom it proves fatal, we shall find still further evidence of the close relation that subsists between the fever of the child and that of the adult. Enlargement, tumefaction, and ulceration of Peyer's glands, constitute one of the most frequent morbid appearances in both diseases, and in both, the changes that these glands are found to have undergone are more advanced and more extensive in proportion to their nearness to the ileo-cæcal valve. In both, too, the mesenteric glands are enlarged, swollen, of a more or less deep red colour, and manifestly increased in vascularity; while the softened state of the spleen, the gorged condition of the lungs, and the congestion of the membranes of the brain, are appearances common to both diseases. There is, however, no more relation between the severity of the intestinal lesion and the intensity of the symptoms in the fever of the child, than in that of the adult; and there is no ground for regarding the disease as the mere effect of the constitution sympathizing with a certain local mischief in the former case, which may not be equally alleged with reference to the latter. The symptoms in both "are the expression of the influence of the disease on the whole economy, of the disorder, which it occasions in the principal functions of the body, and are an essential part of the disease itself, rather than the secondary effects of certain lesions of the bowels.'

! Chomel, Leçons de Clinique Médicale: Fiévre Typhoide, p. 231, 8vo. Paris, 1834.

SYMPTOMS OF ITS MILDER FORMS.

445

There are still many questions that might be proposed with reference to the remittent fever of children, but on which I do not enter now, because I am at present unable to give you what would be, even to my own mind, a thoroughly satisfactory solution of them. We will, therefore, pass at once to a safer and more profitable field for inquiry, and will examine into the symptoms that characterize this affection.

The different degrees of severity which a disease may present in different cases do not in general form a good basis on which to found any classification of its varieties; but in the case of the remittent fever of children the differences are so great between its milder and its severer form, as to warrant our adopting them as a ground for a subdivision of the disease into two classes. In cases of the first or milder kind, the disease usually comes on very gradually, often so much so that the parents of a child who is attacked by it are unable to name any fixed time as that at which the illness began. The child loses its cheerfulness, the appearance of health leaves it, the appetite fails, and the thirst becomes troublesome; by day-time it is listless and fretful, and drowsy towards evening, but the nights are often restless, or the slumber broken and unrefreshing; while all these symptoms come on without any evident cause, and are not accompanied by any definite illness. When once the attention of the parents has been excited to the condition of the child, it is soon ascertained that the skin is often hotter, and almost always drier than natural, though now and then rather profuse sweats break out causelessly on the surface, and continuing for an hour or two, leave the patient in no respect relieved by their occurrence. The bowels are sometimes loose even at the onset of the disease, or if not, they are in general readily disturbed by medicine; a very mild aperient being not infrequently followed by three or four actions of the bowels daily for the next two or three days. In a few instances there is a condition of rather obstinate constipation at the onset of the disease, requiring active measures to overcome it; but this is not often the case, and when it does occur, it is, I think, more frequently in the severer than in the milder form of the disease. The appearance of the evacuations is almost always unhealthy, and they are usually relaxed and very offensive. The tongue is generally rather deficient in moisture, red at the tip and edges, thinly coated on the dorsum with white mucus, through which the papillæ appear of a deep red colour. The abdomen is soft, though there is some flatus in the intestines, and pressure is usually borne without pain. These characters often continue through the whole course of the affection, though sometimes, after the second week, pressure in either iliac region, especially the right, appears to cause suffering. The pulse is generally accelerated from the very commencement of the illness; sometimes it is very much so, but there is by no means a constant relation between the heat of the skin and the rapidity of the pulse. Occasionally there is slight cough, but this symptom is very frequently absent in the milder cases of the disease. As the symptoms which constitute this affection come on very gradually, so they often continue for several days with little, if any, change from day to day, though the patient is far from seeming equally ill at all times of the day; and this periodical exacerbation and remission of the

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SYMPTOMS OF THE MILDER FORM OF REMITTENT FEVER.

symptoms has obtained for the disorder the name of remittent fever. In some instances two distinct exacerbations and remissions may be observed in the course of every twenty-four hours, but in the majority of cases only one is well marked. The child, who during the day has been listless and poorly, but yet not incapable of being amused, and has had the appearance of a patient convalescent from illness, rather than of one still suffering from disease, becomes flushed and uneasy, and feverish, as evening approaches; and sometimes slight horripilation ushers in the evening exacerbation of fever. The child seems drowsy, and begs to be put to bed, where sometimes he sleeps, though seldom tranquilly, till morning. In the second week, the nights generally become worse than they were at an earlier stage of the disease; the child's skin is very dry and hot, he sleeps with his eyes half open, talks in his sleep, wakes often to ask for drink, and occasionally has slight delirium. Early in the morning he wakes pale and unrefreshed, but about 9 or 10 o'clock seems to have recovered something of his cheerfulness, and for the succeeding three or four hours appears tolerably well; but as evening approaches he seems weary and drowsy, again the febrile paroxysm occurs, and the succeeding night closely resembles the night before. Sometimes, in addition to the evening exacerbation, there is a second one, though less severe, at about 11 o'clock in the morning; from which the child has hardly recovered before the severe evening attack comes on. As the case advances towards recovery, the morning attack disappears long before the evening paroxysm ceases to recur; and it happens not infrequently that a slight threatening of the evening exacerbation continues to return for some time after the child has seemed in other respects well. It is during the second week of the disease that the typhoid eruption generally makes its appearance, if it appear at all. In the milder cases, it is, I believe, much oftener absent than present, and even in cases of a severe kind, it is, if I may judge from my own experience, much less common in this country than in France. Towards the end of the second, or the beginning of the third week, the symptoms begin to abate, the bowels act more regularly, the appearance of the evacuations becomes more natural, the tongue grows cleaner and uniformly moist, the thirst diminishes, and the evening exacerbations of fever become shorter and less severe; while the child's cheerfulness by day returns, and its face assumes the aspect of health. Still, after even a mild attack of this disease, the child is in general left extremely weak, and greatly emaciated; the loss of flesh and strength being quite out of proportion to the severity of the illness, and the progress to complete recovery being generally very slow.

It sometimes happens, that, having set in with comparatively mild symptoms, the infantile remittent fever assumes a serious character in the course of the second week. In the majority of instances, however, the severer form of the disease gives some earnest of its severity at a very early period. It commonly sets in with vomiting, accompanied, in many cases, by headache, or by a remarkable degree of drowsiness and heaviness of the head. Coupled with these symptoms, there are those indications of fever which attend the milder forms of the disease,