Book XIV.]

DISEASES OF THE GENITO-URINARY ORGANS.

555

children, or in those born of parents themselves of feeble constitution. +/cally Pruritus of the vulva is sometimes accompanied by leucorrhoea, and ble appears to be occasioned by an alteration and a vitiated secretion of hd, Children, the mucous membrane of the vulva. The children incessantly scratch themselves, and this may originate the habit of onanism. If my

The children should be bathed every day in infusions of bran, or induce

of the leaves of the walnut tree. They should be washed several times a day, either with aromatic wine or aromatic vinegar diluted with Chaus, water, or with a solution of eight grains of corrosive sublimate in one pint of water, or a solution of sixty to one hundred and twenty grains of borate of soda in one pint of liquid.

10. ON CONGESTION OF THE BREASTS.

There is sometimes observed in the newly-born, whether boys or

girls, a painful swelling of the breasts, which lasts from four to five

y

days, and which, on pressure of the breast, allows the escape of a drop of colourless and viscid liquid. This swelling disappears naturally, and du the small gland appears to be entirely atrophied. It becomes manifested cíznulunk in a very evident manner in cases of hæmorrhage from the vulva. It is & Lotions a true congestion of the breast. Dr. Camerer, Ollivier of Angers, and Barrier have described this phenomenon in a very precise manner; one of these cases has been related when treating of vulvar hæmorrhage. car

MALFORMATIONS AND IMPERFECTIONS OF THE BLADDER.

[Malformations and imperfections of the bladder may be included under the follow

ing heads-I, absence of the bladder; II, bilobation or multiplication of the organ; III, congenital extroversion. Complete absence of the bladder is very rare; that h there is no foundation for the statement that such a condition must be accompanied with imperfect development of the kidneys, absence of the urethra, and defective development of other organs, is proved by the examination of the body of Abraham Clef, the account of which is quoted by Gross (A Practical Treatise on Diseases.“ and Injuries of the Bladder, &c. Philadelphia; 1851) from Benninger. In that instance the bladder was totally wanting, the urine flowing from the kidneys directly through the ureters into the urethra; and although it is not stated whether the urine was discharged involuntarily and constantly, it is evident that the inconvenience was not extreme, as the patient had managed to conceal the infirmity both from his physician and his friends.

Congenital subdivision of the bladder into two or three compartments are on record. Gross cites a case in which a child, who died when eight weeks old, was found to have a sort of supernumerary bladder, in the form of a pouch, filled with urine, arising from the lower and back part of the bladder, at the place usually occupied by the right seminal vescicle, and attached by a narrow pedicle. Occasionally the bladder is very small, whilst the other portions of the urinary apparatus are of normal size; its parietes are then imperfect; it is in fact represented by a delicate mucous bag, a mere dilatation of the ureters.

The various fissures of the bladder which have been observed are other forms of arrest of development. The cases of fissure or division of the bladder by

means of a perfect or an imperfect partition in the median line, the so-called double bladder, is very rare.

Extroversion of the bladder is the most interesting in a practical point of view, and at the same time the most frequent of the malformations of this viscus-it forms a disgusting deformity, and various operative procedures have been devised for its alleviation. In a case at St. Bartholomew's, an attempt was made to divert the flow of urine into the rectum-the patient died of peritonitis; and more lately, at St. Thomas's, Mr. Simon very ingeniously endeavoured to make the ureters permanently open into the rectum-the operation partly succeeded; but after a time the openings of the ureters became contracted, and the patient died.-P.H.B.]

BOOK XV.

ON THE ERUPTIVE FEVERS.

The eruptive fevers are less often observed amongst the newly-born and children at the breast than in the second stage of childhood; on the other hand, they are usually more severe at this first period of existence, for in their invasion and progress they then present numerous irregularities which are not observed at a more advanced age.

These constitute specific diseases, which have for their necessary and absolute cause a specific, fixed, or volatile agent, termed the virus. They all result from the impression exercised in the organism by this agent, which runs with the blood, and escapes on the surface of the skin in the liquids which emanate from the blood.

The eruptive fevers of the first period of childhood are small pox, and the eruptions of modified small pox, varioloid, chicken pox, measles, and scarlatina. Their three generating causes are the variolic, morbillous, and scarlatinous virus.

Variola and scarlatina are very rare in the first years of existence, and if their anatomical characters are the same as in the adult, their symptoms, although very nearly similar, present some differences with which it is well to be acquainted. They will now be described; we shall then treat of the eruptions of modified small pox, also known under the name of trivial small pox, and which often occasions mistakes amongst children which we should know how to avoid. Measles will then be described, the most important of the eruptive fevers amongst children, as much on account of the symptoms which accompany it as of those which follow it.

Measles

Book XV, Chap. I.]

ON VACCINATION.

557 host th

However, before commencing the description of these, we should bestow a short time on the subject of vaccination, an operation which all practitioners should well understand-firstly, in order to practise it at the proper opportunity; and secondly, in order to be acquainted with the symptoms which it may originate.

CHAPTER I.

ON VACCINATION.

The term vaccination is applied to the inoculation in man of the matter contained in the pustules developed on the udder of cows, and described under the name of cow pox. This inoculation produces an eruption of similar pustules, the development of which almost constantly resembles those of small pox, and always diminishes the action of its contagion when it does not completely screen the individual.

We will now describe, 1st, the method of practising the operation of vaccination; 2nd, the results of this operation; and 3rd and lastly, the symptoms which it may originate, and to which the name of secondary vaccinal eruptions has been applied.

1st. The inoculation of cow pox or of vaccine matter, that is to say, the operation of vaccination, is practised by means of blisters, incisions, or punctures.

The proceeding by puncture is that usually aodpted; it is quite as efficacious in its results and less painful in its application.

A lancet specially devoted to this use is taken, the point being charged with a drop of vaccine matter, and after having with one hand made tense the skin of the arm over the situation of the insertion of the deltoid muscle, with the other three or four inoculations are made. The lancet should be introduced horizontally and gently so as only to wound the superficial layers of the skin, and it is to be pushed forwards until a drop of blood exudes. The operator then applies the thumb of the hand which fixes the arm on the puncture so as to retain the instrument in its interior.

The operation should be practised on both arms, and the punctures should be about one-third of an inch apart. Care should be taken not to vaccinate on the shoulder in girls, so as not to leave disagreeable scars on a spot which the fashion of dress allows women to leave uncovered on evening visits.

Vaccination should be practised as much as possible from arm to arm, that is to say, by taking the vaccine matter from another healthy child, of good constitution, which presents well developed vaccinal

558

no cure Mirus this proceeding is not absolutely necessary. Should

SPECIAL PATHOLOGY OF INFANCY.

[Part III.

pustules at the fifth or seventh day of the inoculation. However, We may make use of vaccine matter preserved from air and light between two plates of glass or in cylindrical capillary tubes of glass, about one inch in length, invented by M. Bretonneau.

When the vaccine matter is collected, it should be taken from the pustules on the fifth or seventh day. It is placed between the applied surfaces of two plates of glass, which should be covered with lead paper. It becomes dry and keeps good for several months. When about to be used it should be moistened with a very small drop of cold water until it has acquired an oleaginous consistence, and the above described operation practised.

This fluid

If the glass tubes are made use of to collect the matter, it is done in the following manner: the capillary tube should be open at its two extremities. It is applied on the pustule, superficially lacerated by the lancet and surmounted by a drop of vaccine matter. naturally rises in the tube by capillary attraction; the tube is then closed when it is full. It is then preserved from the action of heat, , so that the vaccine matter can undergo no alteration. When required for use, the two extremities of the tube are broken off, and by blowing at one end the fluid contained in its interior is received on a spoon or on a plane and polished surface. It is then made use of for the operation required.

It is no inconvenience to the children to collect their vaccine matter; it may be taken with impunity, without fear of detriment to the preservative qualities of the vaccination. The opening of vaccinal pustules is not at all dangerous, and in no way increases the inflammation of the arm which follows vaccination.

This fluid should be taken from children in good health, and in whom the pustules have arrived at the fifth or seventh day of their development.

It has been thought that it was necessary to submit those about to be vaccinated to a preparatory treatment; this is not indispensable, and if 4 it may be done in the cases of adults, it is useless in young children. This treatment consists in diet, and in the use of slight purgatives repeated for several days consecutively.

2nd. Development of the vaccination. Three or four days after the inoculation of the vaccine matter, little red projections of the skin appear at the situation of the punctures, and which increase rather rapidly. On the fifth day each of these elevations becomes circular with a depression in the centre; on the sixth day it is more flattened and whitish, it has the form of a small disc about a quarter of an inch across, depressed in the centre, and surrounded by a small red areola. At the seventh day, the pustules increase in size, become flattened, and

assume a silvery aspect; a small areola surrounds them. On the eighth day, the colour changes a little; the pustules, always flattened, are a little more swollen and assume a deeper colour; they are surrounded by an inflammatory areola of some extent, which still further increases during the three following days. On the tenth day, the pustules are very large, being about half an inch across; they are very much swollen, depressed in the centre, and contrast by their pale colour with the inflammatory redness of the integuments; their surface appears granulated and slightly roughened, and by means of a lens a large quantity of small vesicles filled with a transparent liquid may be observed. The vaccine matter is enclosed in the pustule in a cellular pseudo-membrane, nearly in the same manner that the vitreous humour of the globe of the eye is enclosed in the cellular membrane which supports it.

At the twelfth day the period of dessiccation commences; the central depression assumes the appearance of a crust; the matter contained in the disc above alluded to becomes thick and opaline; the inflammatory areola becomes pale and the vaccinal pustule begins to collapse. This process is continued on the following days.

*

The pustule up to this period is cellular, and forms but a single cavity; it then becomes dry, forms a hard crust, of a yellowish black colour, which remains until the fifteenth or twentieth day. During this time the inflammatory redness of the skin diminishes and disappears, and when the crust is detached, a deep, puckered, ineffaceable cicatrix remains.

When the vaccinal pustules are in full vigour, and when the inflammation which surrounds them is rather considerable, the children are observed to be uneasy, restless, and to be more or less feverish, which is nothing to be alarmed at. The arm is the seat of an acute pain; the glands in the axilla becomes enlarged; but these symptoms soon disappear with the cause which produced them.

The progress of the vaccination is not always such as has been just described. There are children in whom the pustules shrivel almost immediately after their appearance without their becoming completely developed. There are others in whom the inoculation does not occasion any pustule, and appears to have been unsuccessful; in this case we must revaccinate until pustules of a satisfactory nature are obtained. However, children are met with who are refractory to this inoculation, and there are others who, having been vaccinated, are, at the end of some days, seized with a slight fever of short duration, without the development of the vaccination; this has been termed vaccina sine vaccinis. Examples of it are very rare.

Vaccination is not a disease, it does not in general cause other symp

*Rayer, Traite des maladies de la peau. Paris, 1835: t. i, p. 607.