No. 3401.

NOVEMBER 3, 1888.

Introductory Lecture ON THE

DIFFERENCES BETWEEN CHILDREN ANDADULTS IN REGARD TO MORBID ACTION

AND THE EFFECTS OF TREATMENT.Delivered at the Hospital for Sick Children, Oct. 15th, 1888,

BY W. H. DICKINSON, M.D., F.R.C.P.,HONORARY FELLOW OF CAIUS COLLEGE, CAMBRIDGE ; SENIOR PHYSICIAN

TO ST. GEORGE’S HOSPITAL ; CONSULTING PHYSICIAN TO THEHOSPITAL FOR SICK CHILDREN.

GENTLEMEN,-The advantages or disadvantages of sepa-rate hospitals or wards for children have been discussed witha general bias of late years in their favour. It has beensaid with truth that to give a special care to sickly childrenis to enfeeble the race. We know that among the Spartansfeeble or deformed children were disposed of by exposure;’while I am told that, among the New Zealanders, infantswhose physique was not considered satisfactory, on con-’sultation between the family and the priest, were forthwithknocked on the head and utilised as food. But such directmeans of promoting the survival of the strongest are

Tepugnant to the sentiments of modern civilisation, the

tendency of which is to take care of the individual, and letthe race take care of itself. The only question before us nowis how to keep with us the weak and ailing, not how to getrid of them. It was formerly maintained that to congregatesick children together was not the best way of doing this.Such communities, it was urged, must necessarily be espe-cially liable to the spread of infectious diseases ; while tomix children with grown persons, particularly with women,must lighten the labour of nursing, as many of the olderpatients would find occupation and pleasure in ministeringto the wants of the younger. As to the first objection, it istrue that it is not safe to associate a patient with diphtheriawith others who have not got it, or one with scarlatina,measles, or whooping-cough with children who have notot, or have not had, the disease in question. But in thishospital we have separate wards for diphtheria, scarlatina,and measles, and trust soon to have, as a most necessaryaddition, one for whooping-cough. As to the second con-sideration, it must be said with regret that convalescentfemales are seldom eager, and sometimes positively refuse,to act as nurses. Nursing, to be willingly and well done,must be by those whose special duty it is ; and the nursingof sick children is undoubtedly better done in a children’s shospital, where the nurses acquire familiarity with the waysand needs of childhood, than in a general hospital, wheretheir opportunities of doing so are but small. Another ad-vantage which pertains to the aggregation of sick childrenis the special knowledge which the medical officers acquireto the undoubted advantage of their patients. For thereare many and important points of difference between’children and grown persons in the course of disease and theaction of remedies, which cannot be learned by any arith-metical consideration of age or weight, or otherwise thanby clinical observation. I therefore think that, whether welook at the sound teaching of doctors or the successful treat-ing of patients, the two inseparable as cause and effect, thecollection of children in separate hospitals, or in specialwards in general hospitals, is beneficial ; and I would urge,every student about to become a practitioner to spend sometime in some such place as I have indicated. In a generalward he sees few children, and has few opportunities ofbecoming acquainted with their peculiarities. That heshould do so in his own interest as well as in theirs will beevident to anyone who will consider how large a proportionof an ordinary mixed practice children form, and how deeplytheir ailments engross the attention of their seniors.

I propose to take as the chief subject of my discourseto-day the differences between children and adults in regardto morbid action and the effects of treatment. Children diein greater proportion than adults, though all due allowance’B* t).1

0

may have been made for the fact that there are more ofthem. The less the age, as a rule, the greater the number.The trap-doors and pit-falls which beset the bridge of lifeare more thickly placed at its entrance than later on, andthough they become more numerous again towards its end,there are fewer travellers left to encounter the dangers.One-third of those who are born die before the completionof their fifth year.

It is often said in a case of illness, and sometimes withtruth, "The youth of the patient is in his favour"; but itmay sometimes be said with equal truth, "It is to theadvantage of this patient that he is not young." We maybe old, battered, gouty, and atheromatous, every part aboutus blasted with antiquity; our arteries are apt to break, andthat suddenly ; but we get slow, and some of our disorderspartake of our disposition. Youth is the period of activenutrition, while degeneration is the slow accompaniment ofage. The active nutrition of youth is by no means anunmixed advantage, for it imparts its character to alldiseases which depend on production and growth. Besidesthis, the activity of nutrition calls for a proportionatesupply, and entails liabilities when that supply is insuf-ficient or unsuited which keep pace with the demand madeby the tissues. " Old persons," says Hippocrates, "endurefasting most easily; next adults ; young persons not nearlyso well; and most especially infants, and of them such asare of a particularly lively spirit." Chossat found by experi-ment that young animals bore fasting worse than older ones.At the siege of Paris we are told that those who sufferedmost from want of food were the very young, nursingmothers, the sick, and the wounded, among all whichclasses the mortality from this cause was great. And itneeds no multiplication of testimony to prove what isalmost self-evident-that as infants require food more oftenthan older children, and children more often than adults, sothe effects of its absence or insufficiency must present them-selves in some similar ratio.The quick exhaustion of childhood might be exemplified

in other ways. The apparently disproportionate effects ofloss of blood are well known to surgeons; let us hope thatthey are chiefly made known to physicians by the writingsof a bygone age, in which we may without difficulty findcases which would seem likely to have ended otherwisethan they did had leeching or some other mode of depletionbeen less liberally employed. I may add a word in the samedirection about diarrhoea. This is very common amonginfants; I cannot here discuss its causes or management.Our out-patient physicians treat cases by scores, and mostlywith success. But one of the medical experiences whichone is least desirous of repeating is the rapid and unexpectedsinking which sometimes occurs in this disease and time oflife. This may take place with a rapidity and absence ofwarning which has no parallel among older persons, atleast in this country. No disorder so lightly looked uponcalls for more watchful care. When death occurs, it is withevery organ ostensibly sound; death has been caused bythe drain of fluids, and that long before any such resultwould have occurred at a greater age. I need not point torickets as a disease almost peculiar to early childhood, andwhich is continually due to defects in quantity or quality ofthe milk provided as food. It is not perhaps so generallyknown that a similar deficiency is apt to make infantsscorbutic. There is land scurvy as well as sea scurvy, andfrom this young children suffer far more often than grownpeople. Sore gums, purpura, and haemorrhages, especiallyby way of the kidneys, are often met with in infants, andalways, so far as I have seen, from one of two causes, theabsence of fresh milk or the use of fresh milk of an inferiorquality. Fresh milk, if good, whether from the woman orthe cow, is antiscorbutic ; but, curiously enough, that pro-perty is not possessed, or not to the same extent, by condensedmilk. I do not profess to explain this, but have seen manyproofs of it in the appearance of scurvy under some artificialprepawtion of milk, and its disappearance under milk freshfrom the cow. Perhaps if we could fully explain this itmight teach us something about scurvy.Another result of the active nutrition of childhood is to be

seen in the rapid exaggeration of fibrous tissue, which is theessential change in certain diseases to which children as wellas grown people are liable, and in the quick growth oftumours. As to tumours, look at the astonishing rapiditywith which sarcomata, say of the kidney, increase in size.Such a tumour of the kidney is seldom suspected until it has

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reached a tangible bulk, and it will often fill the greaterpart of the abdominal cavity and cause great abdominalswelling within a few months of its first detection. Howdifferent in these respects is the tumour of the same classwhich presents itself in middle or declining life. Here wemay be long puzzled by obscure symptoms before a growth

. can be recognised, and then years may elapse before anygreat size is attained, which indeed may never come to pass.In later life I have seen a tumour of this nature as hard asa scirrhous cancer, and as slow in its progress as this usuallyis. I have never seen this in childhood, when the tumoursare generally soft, and may even tluctuate.A similar rate of progress is to be discerned in diseases

which consist, not of new growth, but of exaggeration of theold, such as cirrhosis of the liver and interstitial nephritis.Cirrhosis of the liver is not very common in childhood ; butit is by no means unknown, and so rapid may it be that itmay reach its fatal ending before the second year of life hasconcluded. It is always cliaracterised, so far as I have seen,by a profuse overgrowth of fibrous tissue, the hypertrophicprocess so far outstripping die contractile that the organ isgreatly increased in bulk, and the increase of its fibrous 9tissue is conspicuous to the naked eye. I could adduce inexemplification of what I may call cirrhotic precocity quitea long series of cases ranging at death between the ages ofone year and eight months and twelve years. The causesare not always the same ; syphilis has its place, and so liasalcohol, which is sometimes intruded as a cause of diseaseat a time of life which should be a sure protection from it.And alcohol when thus administered to tne young does itswork as an organic irritant with a rapidity and luxurianceof result of which later life affords few examples. Like thecirrhotic liver, the granular kidney sometimes presents itselfin childhood, and then displays to the morbid anatomist aprofusion of fibrosis, while clinically symptoms and secondarychanges, cardiac and arterial, are hurried forward at a ratewhich has no parallel afterwards.Among the diseases which childhood accelerates is one

which is happily rare at this time of life-diabetes mellitus.Rapid progress to inevitable death is the leading charac-teristic of the disease as it now presents itself; and it maybe added that the rapidity is, roughly speaking, in inverseproportion to the age at which it occurs; the less the age thegreater the rate. It is not too much to say of diabetesmellitus, for no such statement applies to diabetes insipidus,that the former disease may cause death in a child in as fewmonths as it sometimes takes years to run its course in anolder person. I cannot speculate as to why this is. We ehave as yet discovered no new growth to point an analogywith the sarcomata and fibroses nor can we invariably asso-ciate the rapidity with the advance of exhaustion; forthough diabetes in these circumstances may kill by thismeans, yet it often does so by toxic agency.Let us glance now at inflammatory disorders, and see

how these vary with age in their incidence and effects.When inflammation is mixed with tubercle the disease maybe said to occupy an intermediate position between growthsand inflammations, or rather to display an admixture of thetwo. Among the inflammatory diseases to which childrenare especially liable, the most fatal are those of the brain.It is not necessary within these walls that I should dwellupon the frequency of tubercular meningitis in childhood;but the q uestion may be put, Is the leading character of thedisease tubercular or cerebral. Miliary tuberculosis is notextremely common in childhood excepting in this shape, andtuberculoses of other kinds are considerably less frequent inchildhood than afterwards. But the brain in childhood isthe seat of activity, the like of which exists nowhere else.It doubles its weight in the first two years, and is beingeducated, not by the School Board, but by the almightyuniverse, at a rate which, if it could be kept up, would makethe angels envious. That an organ in which there is somuch going on should sometimes go wrong is not to bewondered at, or that it should go wrong in the direction ofinflammation. It may be added that infants and youngchildren are affected more numerously than used to bethought by meningitis, which is inflammatory but nottubercular.

Let us look at inflammation of the lungs, and at thedifferences which it presents at different periods of life.When I speak of inllammation of the lungs, I mean an

inflammatory disease which leads to consolidation. This is,of course, sometimes mixed with bronchitis, and so far

inseparable from it ; but I exclude bronchitis pCI’ se, and

also cases which have been recognised as broncho-pneumoniaor lobular pneumonia. It is well known that pneumonia isa large cause of mortality in childhood, particularly in earlychildhood. More deaths occur from this cause in the firstfive years of life than in any subsequent twenty, and morebetween five and ten than in any subsequent period of the samelength. This is because children are more often attacked, not,because when attacked they more often die. Having had theprivilege of experience at two hospitals, I have had undermy care a considerable number of cases of pneumonia atall ages. I have sorted the notes, so as to include onlylobar pneumonia or pneumonia, such as during life cannot bedistinguished from it. I have included attacks described aspneumonia, or lobar pneumonia; I have excluded all de-scribed as capillary bronchitis, broncho-pneumonia, or lobu-lar pneumonia. It can scarcely be that lobular pneumoniahas not been often, though unintentionally, admitted amongthe cases at the earlier ages, but in every one at least therewas evidence of inflammatory consolidation of the lung. Ifind, as shown in the accompanying table, that of ninety-onecases up to the age of twelve, collected from this hospitaland St. George’s, ten ended fatally, or about one in nine.Between the ages of twelve and twenty the mortality wasone in ten. From the age of twenty-one upwards, of eighty-nine cases twenty ended fatally, a mortality of rather more.than one in five. Thus it appears that individuals undertwenty-one years of age have on an average twice the chanceof recovering from pneumonia which pertains to persons overthat age. There is no abrupt difference on the completionof the twenty-first year, but the statement fairly comparesearly witli advanced life. It is the more significant becausedifferences of treatment do not intervene, all the cases havingbeen under the care of the same physician-myself.

.zllo2-t(tlity of Lobar Pne1l1nonia in. relation to Age.

It might have been expected that children, with theirmobile tissues and active nutrition, would give a higherrange of temperature--in other words, would be more com- Ibustible-tlian older persons ; but this does not appear tobe the case to any marked extent, nor does the diseaseappear to run a decidedly quicker course in early life thanlater. Among children we have the problem complicatedby mixture with lobular pneumonia; but, nevertheless, wehave among them many cases which are apparently lobar,and often end as it does, ahruptly. With those that do sothe temperature appears to fall on about the same day, theseventh or eighth, whether the patient be old or young-asif the date were determined by the disease with little modi-fication from the circumstances in which it works.While upon the subject of the chest I may say a word

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about empyema. Children are more liable than grownpersons to suppurative pleurisy, but they are more easilytreated for it. A larger proportion of the young than theold are to be cured by simple aspiration without theestablishment of a continuous drain.Among the inflammatory disorders to which children have

a special liability are endocarditis and pericarditis in con-nexion with rheumatism. Acute rheumatism is less frequentin childhood than afterwards, but it involves the heartproportionately more often. This fact was long ago pointedout, I think, by Peter Mere Latham. In childhood andage the cardiac and articular affections appear to varyinversely. In youth the heart is early and frequentlyaffected. A child may have pericarditis, and we may smellthe rheumatism to which it belongs, but there may be noarticular affection, or only enough, to speak vulgarly, toswear by. In elderly people their joints are often red andpainful for weeks, while their hearts escape from first tolast. It is better to be old and racked in the joints thanto be young with an insidious clutch upon your heart-strings. Wrat practice teaches, or, at least, has taughtme, with regard to all acute rheumatisms, but most em-phatically when children are the subjects, is the early andfree use of alkalies, which have an effect in saving theheart not possessed by salicylic acid or anything else.There are other diseases which, like pneumonia, cause

the greatest number of deaths in early life, but are thesource of the greatest danger in advanced life. Of thedeaths from measles, over 90 per cent. occur in childrenunder five years old ; but the attacks are numerous ratherthan dangerous. The contrary holds later on, when thedanger of the disease increases together with its rarity.You will remember that Major Pendennis excused himselffrom visiting his sick nephew on the ground that his illnessmight be measles : " He had never himself had the measlesthey were dangerouswhen contracted at his age." Diphtheria,like measles, is most frequent in early life ; but, unlikemeasles, it is now not less dangerous than afterwards, butis probably more so ; for with children it is especially aptto take the form and name of membranous croup, which is one of the most fatal diseases to which children are liable. With regard to the continued fevers the case somewhatdiffers. These disorders are more dangerous in advanced 1life than earlier; in childhood, at least in early child- <hood, they are less frequent as well as less dangerousthan later. Typhus seldom presents itself in childhood, and <

then carries little risk. According to Dr. Murchison, typhus ’’

is most frequent between thirty and forty; it kills most after ififty. Under ten the mortality of typhus is but 3-27 per Icent. of those attacked; after fifty the mortality is 57’03A distinguished physician became aware that lie had caught <

this disease; his friends sought to lessen his apprehensions, t

but he said, "I know what typhus means after sixty,"and his anticipation was verified. Typhoid, according to 1Murchison, is most common between twenty and thirty, and (

lills most within this decade. The danger of typhoid, 1

however, presents less variation with age than does that of t

typhus; it varies in the same manner, but not to the same c

degree. Under ten it kills 11’36 per cent. of those attached;over fifty, 34’94 per cent. Typhoid is so rare in infancy ithat under two it need scarcely embarrass our diagnosis. r

Murchison once ascertained by post-mortem that this dis- Iease had existed at the age of six months; and I once was iassured of its presence by a most unequivocal eruption in a c

child of between two and three years old, whose symptoms, "chiefly cerebral, delirium, and screaming pain in the head, ’]had presented an apparently hopeless prognosis in the way nof meningitis. But, as a rule, typhoid, though a disease of fchildhood, is not one of infancy. a

I might tuin from diseases to drugs, and show in how o

many particulars their action differs in early and later life. gThe intolerance of opium in infancy is well known. Not so awell known, perhaps, is the extraordinary tolerance of bella- s

donna which children share with rabbits. My late colleague, a

Dr. Fuller, once gave daily to a girl ten years old siwenty t:

grains of the Pharmacopoeial extract, a grain and a half of o

which acted upon myself most unpleasantly; and lie showed -

that this insusceptibility was common to the time of life.Mercury is said seldom to salivate in childhood, and the Iway children thrive upon it in congenital syphilis is remark- bable. But in other diseases I have witnessed not a few o

instances of salivation from its use, and two in which the d.cheek was perforated. One, which ended fatally, was that wof a boy with nephritis, to whom a single dose of five grains p

of grey powder was given as an aperient ; the subject ofthe other was a girl with obstinate eczema, which yieldedat last to minute repeated doses of calomel, but with thepenalty described. I have already referred to alcohol.Children are extraordinarily susceptible, the youngerthe more so, both to its beneficial and its injuriousinfluences. I have never seen delirium tremens in a child,or recognised alcoholic paralysis; but I have seen, as Ihave said, early and rapid cirrhosis from this cause.

Alcohol naturally leads to feeding, and that to nursing, alarge part of which, at least in the medical diseases ofchildren, is comprised in the judicious selection of foodand its liberal and regular administration. In most severediseases alcohol forms an essential part of it. The feedingof sick children calls for conscientious watchfulness andjudgment by night and day, which makes all the differencein the result. It follows from what I have drawn yourattention to as regards the nutrition of children, and it isno less a matter of experience, that children need betternursing, or, in other words, better feeding, than grownpeople. With many of their diseases, whether of ex-

haustion, of inflammation, or of fever, we have more in ourhands, the more depends on what we do, or rather on whatthe nurses do for us, the younger the patient. The phy-sician may be inattentive, and it may happen that thepatient may be none the worse, but the vigilance of thenurse must know no pause. I cannot express by figures,but cannot put too strongly in words, the difference in thechance of recovery from some of the disorders I have referredto under such nursing as this hospital affords and thatwhich is to be found in the homes of the poor. I havewarrant for saying that the mortality of typhoid is hereconsiderably less than the general average belonging to thetime of life, and no doubt the statement could be extendedto other disorders of the inflammatory and febrile type. Ihave to thank Mr. Priestley, our medical registrar, forsome particulars with regard to typhoid, a disease as towhich the question is not so much medicine as nursing.Since the foundation of this hospital in 1852, 506 cases oftyphoid have been treated in it, of which forty-nine endedfatally, giving a mortality of 9-68 per cent. Dr. Murchisontells us, with regard to the London Fever Hospital, that atthat excellent institution the mortality of typhoid under the1ge of ten was 11 ’36 per cent. The age of our cases rangedTom two to twelve, the extra age being somewhat to ourlisadvantage. Without pushing this comparison too far,ve may, at least, be satisfied with this testimony as to themature of our nuising, and the influence which such nursinglas upon some of the diseases of children.Let me place together the conclusions we have come to.

children differ from grown people in their greater sus-;eptibility both to exhaustive and recuperative influences.such of their diseases as are of the nature of growths)artake of the rate of progress which belongs to the period)f development. This applies to the fibroses as well as tosolated tumours, though the fibroses are far more infrequentban afterwards. Many inflammatory disorders, particularlyf the brain, are more common in childhood than later, butvith regard to many inflammations the power of recoverys greater. Those of the lungs are more frequent and causenore deaths, but in the individual the prospect is better.cute rheumatism is comparatively infrequent, but whent occurs it brings greater danger to the heart. Some febrileomplaints are more frequent and some less so than after-vards, but as a rule their proportionate mortality is less.?here are special differences in the action of drugs, thenost important of which is the greater influence of alcoholor good and evil. Finally, cliildren respond to treatment,Is they often succumb to disease, more readily than dolder patients, so that with them our responsibility is thereater. Let me end as I began by begging all who arebout to enter upon the duties of miscellaneous practice totudy for themselves the peculiarities to which I havedverted, as well as many others which their own observa-ion will reveal to them ; and to do so there are no betterpportunities than those which this hospital affords.

UNIVERSITY OF OxFO.D.-1BTOtice is given that theQuaere Professor of Human and Comparative Anatomyeing temporarily disabled for the performance of the dutiesf his office, a deputy will be appointed to perform theuties for one year from January lst, 1889. The deputy’ill be appointed by the persons who would appoint therofessor if his place were vacant.