fresh layer of epidermis is formed, which takes place very readily, the old epidermis and cotton come off together, leaving a smooth whole surface below."

As a general rule we ought never to apply a blister to a child under five years of age, and even then it should only be allowed to remain sufficiently long to redden the skin, after which a linseed or bread poultice should be applied. Dr. Graves observes, "In treating the bronchitis of children, and in the bronchial affections of fever, I have frequently directed the blister to be left unopened, and I can state from experience that this plan answers very well. The effused serum forms one of the best dressings for the excoriated surface of the skin, and the formation of troublesome sores is avoided. I have frequently had recourse to this mode of treating blistered surfaces in children, and in persons of irritable habit, in whom the cutis is extremely tender and vascular." The dressing under these circumstances consists merely of a piece of lint and spermaceti ointment applied twice a day over the blister.

Where it is only wished to produce a mild effect, a sinapism made of equal parts of mustard and flour or linseed applied for ten or twenty minutes, will be found to answer every purpose. It must not be forgotten, however, that when the skin is very delicate, even a sinapism will give rise to great general excitement, as well as to severe local irritation.

Blood-letting.

The abstraction of blood from the system acts in six principal ways:-1. It diminishes the quantity of blood in the system. 2. It impoverishes the blood by increasing its watery constituent, and diminishing its fibrin and globulin. 3. It weakens the heart's action. 4. It causes general debility, with malnutrition of the various viscera and tissues. 5. It drains blood from parts other than those whence it is taken. And 6. It promotes absorption.

The tolerance of blood-letting is admitted by all to be diminished in the very young, the old, and the feeble. We have only to consider its effects upon the very young; and, with regard to them, we may at once assert, as the results of our own experience and what we have witnessed in the practice of others, that not only do they bear bleeding badly, but that the abstraction of blood is very seldom necessary in the treatment of their diseases. Indeed we believe that the only infantile diseases in which it is ever necessary to take away blood, are those where an obstruction to the due circulation of that fluid exists as in certain cardiac affections: and, in those in

stances, where much pain is caused by mischief resulting from mechanical injury. When, however, we find full directions given by some authorities for opening one of the brachial veins, or one of the veins on the dorsum of the foot or back of the hand, or these failing-instructions are given for getting blood from the jugular vein; when further, it is stated, that cupping may be advantageously practiced on infants less than a month old, and that leeches may be applied, and their bites allowed to bleed until exhaustion-indicated by great pallor, stupor, or convulsions-ensues; we cannot help being struck by the wide divergence of opinion which exists on a matter of such vital importance in therapeutics.

It may be well therefore to make a few brief remarks on this subject, though in subsequently speaking of each disease, we shall show clearly the plan of treatment which we are in the habit of adopting, and shall also often allude to that which we find recommended by other authorities.

First, then, we would say, that no child should, under any circumstances, be bled without the most anxious reflection; nor without a strong conviction that no other plan of treatment will be efficacious; nor without remembering that, though the circulation in childhood may be active, yet at this period of life slight causes produce great results; and that children, when greatly lowered, rally with difficulty.

Secondly, should it be determined that blood must be taken, we are convinced that leeches will effect all that can be required. They should be applied over some part where pressure can be resorted to, and in the presence of the practitioner, who should not leave the house until the bleeding from the bites has ceased. Where there is any difficulty in stopping the hæmorrhage, the application of pressure, or of dry powdered starch, or of a small piece of glazed card, or of matico-leaf, or of the nitrate of silver, will generally suffice to do so; but these means failing, a fine needle should be passed under the bite, and a thin ligature twisted round it, much in the fashion adopted for the obliteration of varicose veins.

Thirdly, in deciding upon the quantity of blood to be removed, the practitioner must not be led away by the idea that children suffering from acute disease bear the loss of blood well: he should remember that all the strength which they may have at the commencement of an attack will be certainly required to carry them through it.

Fourthly, during the first six weeks of life, the loss of about one ounce of blood is said to be sufficient to relieve most inflammations; from six to twelve weeks, an ounce and a half

or two ounces; from four to twelve months, three or four ounces; and subsequently, an additional ounce for each year of the child's age.

Fifthly, it may be estimated that each leech draws from four to six drachms of blood, including subsequent bleeding.

Lastly we may add, that all authors agree that repetitions of bleeding are not borne well by children.

If all these points are borne in mind, we shall at least avoid doing much harm: whether or no by resorting to it we shall do good is a more doubtful matter. But it is probable, that, in the reaction which has set in against all depletion in our day, we may be guilty of an opposite error, and be depriving ourselves of a remedy which, though unquestionably powerful for evil, is also capable of doing good. Dr. Markham has, in his Gulstonian Lectures, very forcibly pointed out some of the good results of this practice, and we are able to agree in much that he has advanced, especially in the following:-"Venesection is not a remedy for inflammation, but a remedy for the accidents which accompany or rather arise out of certain inflammations and non-inflammatory diseases-viz., those inflammations and diseases which are accompanied with obstructions of the cardiac and pulmonary functions. It is therefore of service only in those inflammations which are attended with such obstructions." Again, "in local inflammations the direct abstraction of blood (by leeches, &c.), acts immediately upon the seat of inflammation; its benefits are sure and immediate also, and, as usually practiced, its influence over the system generally is scarcely perceptible. Venesection, on the other hand, has no such influence over the local inflammation, but a very powerful one over the system at large. It acts only through the influence which it exercises indirectly over the inflammation. The good effects of direct abstraction of blood are positive and manifest, and admitted by all, and they are obtained at a small cost to the system at large." Lastly, "in all those cases of internal inflammation in which there is a direct capillary connection between the skin and internal inflamed part (this applies to pleuritis, peritonitis, &c.), the local abstraction of blood (by leeches, &c.) is of manifest service, just as we see it to be in external inflammations; but in all those inflammations in which there is no such capillary communication, the benefits of the local abstraction of blood are neither so clear nor positively ascertained."

While, however, we admit in the main the general truth of the latter statement, we cannot doubt that good not unfrequently results from local depletion over the site of deep-seated

inflammation. It is probable that both in this and in the case of counter-irritation the benefits are really due to some reflex action in the capillaries of the latter through the vaso-motor nerves; and this we believe is especially the case in children, in whom reflex action is so remarkably acute and sensitive.

Medicines.

In considering some of the more important medicines in use for the treatment of children's diseases, it might be thought that we should arrange these in some definite therapeutical order; it is, however, a subject for regret, that in the present confused state of therapeutics there is no system of classification which can lay claim to more than a very partial acceptance, and under these circumstances we do not feel that at present we can do more than make a few general observations on certain classes of drugs which may, it is hoped, serve as a guide for the practitioner in this special branch of medical practice.

Alteratives.

Alteratives and Resolvents or Deobstruents are medicines which promote secretion and exhalation generally, soften and loosen textures, check phlegmonous inflammation, lessen inflammatory effusions, and promote their re-absorption. They are opposed to the exudation of plastic or coagulable lymphhence they check adhesive inflammation-and the formation of false membranes. During their use, visceral and glandular enlargements and indurations, thickening of membranes, and nonmalignant morbid growths of various kinds, are sometimes observed to get smaller and softer, and ultimately to disapper. The chief agents of this class are mercurials, iodine and its combinations, antimonials, and alkalies.

The different preparations of mercury are extensively used in the diseases of children, and, when judiciously employed, with the best results. Even during infancy comparatively large doses of these agents are usually well-borne; and it is remarkable that at this period of life, and up the third or fourth year, salivation is never, or very rarely, produced. This circumstance, however, must only make us more cautious in prescribing any preparation of mercury: since, in consequence we are deprived of a valuable criterion by which to judge of the effect of the remedy on the constitution; for it must not be thought that because mercury does not salivate an infant, therefore it does not affect the system.

The principal ill effects which sometimes result from the use

of mercury are, violent purging and griping, profuse sweating, a disordered state of the digestive organs, with loss of appetite and wasting, a tendency to early decay of the teeth, a tremulous condition of the muscular system, eruptions on the skineczema mercuriale—and, after the fourth or fifth year, salivation. With regard to salivation, however, it must be remembered that this condition may be produced by a few other medicinal agents, as iodine, arsenic, antimony, nitric acid, and even opium, and also that it sometimes arises spontaneously. Gangrene of the mouth-cancrum oris-is a disease which is often mistaken for the effects of mercury; but although, in this distressing affection, there is a copious secretion of saliva, with ulceration or gangrene of the inside of the cheek, yet the morbid action is more circumscribed, and the gums, salivary glands, and tongue are not all swollen and inflamed as they are from the first in mercurial ptyalism.

The chief value of mercurials is usually said to be obtained in inflammations of the serous membranes, as in meningitis, pericarditis, pleurisy, and peritonitis; in inflammations of the mucous membrane of the air passages, especially croup; in iritis; synovitis; congestive states of the liver, and mucous follicles of the intestines; and in syphilis, congenital or acquired. It must be confessed, however, that we are still ignorant of the exact value of this class of medicines in many of the foregoing disorders; and it is by no means improbable that, as our knowledge increases, we may find the employment of the various preparations of mercury greatly diminish. Mecurials are also administered in small doses as alteratives in certain chronic skin diseases, in some forms of dyspepsia, and in many cases to improve the secretions of the liver, pancreas, &c.; and in large doses as purgatives, though the practice of employing calomel and other mercurials as ordinary purges is bad. Their employment is generally contra-indicated in strumous children, and in cases where there is great irritability of the stomach or bowels.

Hydrargyrum cum Cretâ is a mild laxative and alterative. It is valuable in tubercular meningitis, in infantile syphilis, and in diseases due to or accompanied by-faulty secretions. Dr. Pereira states that in the strumous affections of children (especially enlarged mesenteric glands) and other chronic maladies, it is administered with great advantage as an alterative; we cannot, however, speak from any favourable experience on this point, and we are inclined to believe that, having regard to its decidedly liquefacient properties, and to the fact that the strumous constitution is one characterized