LIBRARY OF CONGRESS, ffljjapjCL. ©ojnjrtglji !f n. Shelf ^s£)jJ5 UNITED STATES OF AMERICA. ft 4 '■■ 1 n V ■I A TREATISE ON THE MEDICAL AND SURGICAL DISEASES INFANCY AND CHILDHOOD J. LEWIS SMITH, M.D., CLINICAL PROFESSOR OF DISEASES OF CHILDREN, BELLEVUE HOSPITAL MEDICAL COLLEGE J PHYSI- CIAN TO CHARITY HOSPITAL; PHYSICIAN TO THE N. Y. FOUNDLING ASYLUM; PHYSICIAN TO THE N. Y. INFANT ASYLUM: CONSULTING PHYSICIAN TO THE N. Y. CITY HOSPITAL; CONSULTING PHYSICIAN TO THE FRENCH HOSPITAL; CONSULTING PHY'SICIAN TO THE DEPARTMENT OF CHILDREN'S DISEASES, BUREAU FOR THE RELIEF OF THE OUT-DOOR POOR, BELLEVUE; CONSULTING PHYSICIAN TO THE NURSERY AND CHILD'S HOSPITAL, COUNTRY BRANCH; CONSULTING PHYSICIAN TO THE INFANT'S HOSPITAL, RANDALL'S ISLAND. EIGHTH EDITION, THOROUGHLY REVISED AND GREATLY ENLARGED. WITH TWO HUNDRED AND SEVENTY-THREE ILLUSTRATIONS AND FOUR COLORED PLATES. 1% LEA BROTHERS & CO., NEW YORK AND PHILADELPHIA. 1896. y Entered according to Act of Congress in the year 1896, by LEA BROTHERS & CO., in the Office of the Librarian of Congress, at Washington. All rights reserved. WESTCOTT &. THOMSON. PRESS OF ELECTROTYPERS, PHILADA. WILLIAM J. DORNAN, PHILADA. PREFACE. Such advances have recently been made in our knowledge of the etiology, pathology, and therapeutic requirements of the diseases of children, that in the preparation of the eighth edition the rewriting of a large part of the book, with the addition of new chapters, has been necessary. Hence an increase in the number of pages was unavoidable, although the material has been condensed so far as was compatible with clearness of description. Fortunately, Prof. Stephen Smith, whose large experience in the surgical wards of New York hospitals renders him eminently fitted for the task, has added to the text many pages descriptive of the sur- gical diseases of children. His reputation as a surgeon and writer is sufficient to give the impress of authority, and the certainty of clearness and effectiveness, to whatever emanates from his pen. The dedication to Dr. Frederic M. Warner becomes the more ap- propriate in view of his lamented and untimely death. His large clinical experience, careful and accurate study of symptoms, and judi- cious selection of remedies especially fitted him for the preparation of the chapters assigned to him, which he was unable to finish. The proofs of what he had written arrived as he was passing into the fatal coma of typhoid. The author gratefully acknowledges the assistance rendered by Dr. Joseph O. Dwyer, physician to St. Vincent's Hospital and the New York Foundling Asylum, in preparing the Section on Intubation ; also the assistance of Dr. A. R. Robinson, Professor of Dermatology in the New York Polyclinic, whose illustrations, generously loaned, and his contributions to the text, have greatly increased the value of the Section on Skin Diseases. J. LEWIS SMITH. M. D. 64 West 56th Street, New York City. CONTENTS. PART I. INFANCY AND CHILDHOOD. CHAPTEE I. PAGE Their Anatomy and Physiology 17 CHAPTER II. Care of the Mother in Pregnancy 19 CHAPTER III. Mortality of Early Life : Its Cause and Prevention 22 CHAPTER IV. Weight, Growth, Temperature, Pulse, Respiration 26 Wet-nursing: its Advantages and Hindrances; Physical Conditions rendering it Improper — Colostrum — Human Milk — Modification of Milk in Consequence of the Diet — Modification of Milk from its Retention in the Breast — Modifica- tion of Milk by Age and by Mental Impressions — Modification of Milk by the Cataraenial Function, Pregnancy, and other Causes — Effect of Medicine on the Mother's Milk — Differences in Women as regards Quantity and Quality of Milk — Rules in regard to Lactation. CHAPTER V. Selection of a Wet-nurse 42 CHAPTER VI. Course of Wet-nursing— Weaning 45. CHAPTER VII. Quantity of Food Required in Infancy and Childhood 47 CHAPTER VIII. Artificial Feeding 53 CHAPTER IX. Bathing, Clothing, Sleep, Exercise 65 V vi CONTENTS. CHAPTER X. PAGE Diagnosis of Infantile Feeding 70 General Observations — Features; External Appearance of the Head, Trunk, and Limbs in Disease — Attitude — Movements — The Voice — Respiratory Sys- tem — Circulatory System — Animal Heat — Digestive System — Nervous System. CHAPTER XL Therapeutics 80 PART II. DISEASES OF THE NEWLY-BORN. CHAPTER I. Malformations. 82 Acrania — Meningocele, Encephalocele, Hydrencephalocele — Spina Bifida — Congenital Abnormalities in the Circulatory System — Cyanosis — Caput Succe- daneum — Cephalhematoma. CHAPTER II. Local Diseases 101 Hematoma of the Sterno-cleido-mastoid Muscle — Mastitis — Conjunctivitis — Ophthalmia Neonatorum — Umbilical Vegetations — L T mbilical Hemorrhage — Icterus — Septicemia of the New-born — Thrush. CHAPTER III. Diarrhcea, Constipation, and Tetanus of the New-born 128 Diarrhoea of the Newly-born — Constipation of the Newly-born — Tetanus Neo- natorum — Sclerema Neonatorum — (Edema Neonatorum — Pemphigus Neona- torum — Osteogenesis Imperfecta. PAET III. CONSTITUTIONAL DISEASES. SECTION I. DIATHETIC DISEASES. CHAPTER I. Rachitis 156 CONTENTS. vii CHAPTEK II. PAGE Scrofula 186 CHAPTER III. Tuberculosis 202 CHAPTER IV. Syphilis 230 SECTION II. ERUPTIVE FEVERS. CHAPTER I. Measles 242 CHAPTER II. Scarlet Fever 250 CHAPTER III. ROTHELN 298 CHAPTER IV. Variola — Varioloid 306 CHAPTER V. Vaccinia 316 CHAPTER VI. Varicella 326 CHAPTER VII. Diphtheria 32S CHAPTER VIII. Pertussis 381 CHAPTER IX. Mumps 395 SECTION III. OTHER GENERAL DISEASES. CHAPTER I. Intermittent Fever 399 viii CONTEXTS. CHAPTEE II. PAGE Remittent Fever 405 CHAPTER III. Typhoid Fever 407 CHAPTEE IV. Cerebrospinal Fever 421 CHAPTEE V. Acute Eheumatism 455 CHAPTEE VI. Erysipelas 463 SECTION IV. MALFORMATIONS AND DEFORMITIES. CHAPTER I. The Digestive Organs 476 Lips and Palate — The Tongue — The Eectum — The Anus. CHAPTER II. The Urinary Bladder 489 CHAPTEE III. The Extremities 490 The Upper Extremities — The Knee — The Leg — The Feet. PAET IV. SECTION I. DISEASES OF THE BLOOD. CHAPTER I. Mel^na Neonatorum . 504 CONTENTS. ix CHAPTER II. PAGE Simple or Secondary Anemia 507 CHAPTER III. Primary Anemia 511 Leukaemia (Leucoeythaeruia) — Pseudoleukemia (Lymphatic Anaemia; Hodg- kin's Disease) — Splenic Anaemia — Pernicious Anaemia (Anaemic Fever, Idio- pathic Anaemia) — Haemophilia — Purpura — Scorbutus (Scurvy). PAET V. LOCAL DISEASES. SECTION I. INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. CHAPTER I. Caries of the Vertebra 519 CHAPTER II. Lateral Curvature of the Spine 525 CHAPTER III. Injuries of Bones 530 Injuries of the Skull — Injuries of Long Bones. CHAPTER IV. Diseases of Bone 538 CHAPTER V. Diseases of the Joints 552 The Shoulder-joint— The Elbow-joint— The Wrist -joint —The Hip-joint— The Knee-joint — The Ankle-joint — The Tarsus— The Foot. SECTION II. DISEASES OF THE CEREBRO-SPINAL SYSTEM. CHAPTER 1. Congestion of the Brain 578 x CONTEXTS. CHAPTEK II. PAGE Intracranial Hemorrhage (Meningeal Hemorrhage, Cerebral Hem- orrhage) , 581 CHAPTEK III. Congenital Hydrocephalus 589 CHAPTEK IV. Acquired Hydrocephalus 595 CHAPTEK V. Meningitis (Tubercular and Non-Tubercular) 596 CHAPTER VI. Spurious Hydrocephalus 611 CHAPTER VII. Eclampsia 614 CHAPTER VIII. Epilepsy 622 CHAPTER IX. Internal Convulsions (Spasm of the Glottis; Laryngismus Stridulus) 634 CHAPTER X. Tetany 640 CHAPTER XI. Chorea 650 CHAPTER XII. Paralysis 664 CHAPTER XIII. Poliomyelitis Acute Anterior .... - 664 CHAPTER XIV. Facial Paralysis 671 CHAPTER XV. Pseudo-Hypertrophic Paralysis 672 CHAPTER XVI. Diseases of the Spinal Cord and its Coverings 676 CHAPTER XVII. Congestion of the Spinal Cord and its Membranes 677 CONTENTS. xi SECTION III. DISEASES OF THE DIGESTIVE APPARATUS. CHAPTER I. PAGE Simple Stomatitis, Ulcerous Stomatitis, Follicular Stomatitis - . . . 680 CHAPTER II. Gangrene of the Mouth 684 Efflorescence, Furring, and Eruptions upon the Tongue. CHAPTER III. Dentition 691 Ranula — Alveola — Tonsil. CHAPTER IV. Catarrhal Pharyngitis, Peripharyngeal Abscess, (Esophagitis .... 701 CHAPTER V. Indigestion, Congestion of Stomach, Gastritis, Follicular Gastritis, Diphtheritic Gastritis 714 CHAPTER VI. Gastro-intestinal Bacteria 723 CHAPTER VII. Simple Diarrhcea 726 CHAPTER VIII. Intestinal Catarrh of Infancy (Entero-Colitis) 730 Cholera Infantum, or Choleriform Diarrhoea. CHAPTER IX. Enteritis and Colitis in Childhood 752 CHAPTER X. Constipation 754 CHAPTER XI. Intestinal Worms 765 CHAPTER XII. Intussusception 779 CHAPTER XIII. Appendicitis and Peritonitis 799 xii CONTENTS. CHAPTER XIV. PAGE Hernia of the Abdomen 809 SECTION IV. DISEASES OF THE RESPIRATORY SYSTEM. CHAPTER I. Coryza 818 CHAPTER II. Laryngitis • 820 CHAPTER III. Diseases of the Larynx 828 CHAPTER IV. Pseudo-membranous Croup (True Croup) 831 CHAPTER V. Intubation 839 CHAPTER VI. Tracheotomy 848 CHAPTER VII. Bronchitis 851 CHAPTER VIII. Atelectasis 861 CHAPTER IX. Pneumonia 864 CHAPTER X. Pleurisy 876 SECTION V. DISEASES OF THE CIRCULATORY SYSTEM. CHAPTER I. Diseases of the Heart 912 Functional Disorders. CHAPTER II. Pericarditis 913 CONTENTS. xm CHAPTEE III. PAGE Myocarditis 916 CHAPTEE IV. Endocarditis 917 CHAPTEE V. Ulcerative Endocarditis 919 CHAPTEE VI. Chronic Endocarditis 920 CHAPTEE VII. Diseases of the Vessels 923 SECTION VI. DISEASES OF THE GENITO-UEINAEY OEGANS. Calculi ; Dysuria ; Cryptorchia — Vulvitis — Preputial Dilatation — The Kidneys — The Urinary Bladder— The Urethra— The Penis— The Scrotum— The Testicles 927 SECTION VII. DISEASES OF THE SKIN. Erythema — Urticaria — Prurigo — Eczema — The Pathogenic Effects of Microbes — Parasites of the Skin 949 THE DISEASES OF CHILDREN. PART I. INFANCY AND CHILDHOOD. CHAPTER I. THEIR ANATOMY AND PHYSIOLOGY. Infancy and childhood are, in certain respects, the most important and interesting periods of life. To the physiologist they are especially interest- ing, because they are the periods of development and of greatest functional activity ; to the pathologist, because in them many diseases occur which are rarely or never observed in the other periods, or which present in these periods peculiar features ; to the physician and vital statistician, because in them the greatest amount of sickness and the largest number of deaths occur. Infancy extends from birth to the age of two and a half years, or till the completion of the first dentition. In infancy the organs are delicately organized, containing a large proportion of water, and hence are easily injured. In this period the brain is rapidly developed — more so than any other organ ; animal matter predominates in the bones ; the arteries are rel- atively large, the muscles small ; the superficial veins are small. Fat is absent from the interior of the body, but abundant, in well-nourished infants, underneath the integument. The skin is delicate, and its temperature not much below that of the blood. At birth it has a reddish hue and is covered with soft, fine hairs (lanugo). The reddish hue gradually fades into the healthy tint of infancy, and the hairs fall out. In the first two months the sweat-glands have little functional activity, sensible perspiration being quite rare. Subsequently, perspiration is freer, and in certain diseased states (rachitis, etc.) is abundant. The sebaceous glands in the first half of infancy are active, particularly upon the scalp, producing often a pale-yellow incrusta- tion consisting of sebaceous matter and epidermic cells. The secretions from the mucous surfaces commence at an early period. At birth the surface of the digestive tube is covered with more or less mucus, often in considerable quantity. The meconium is not considered, as formerly, to be a product of intestinal secretion. It consists of flat epithelial cells, fine hairs, oil-globules, crystals of cholesterin, and brownish or yellowish masses of coloring matter, probably from the liver. It is sup- 2 17 18 INFANCY AND CHILDHOOD. posed that, with the exception of the coloring matter, the meconium is derived mainly from the amniotic fluid which the foetus has swallowed. The most wonderful change occurring in the system at birth, through the exigencies of the new life, is that in the circulation. The flow of blood being interrupted, thrombi form in the umbilical vein and arteries, and in the ductus arteriosus and ductus venosus, and these vessels gradually atro- phy, becoming finally shrivelled but permanent cords. I have many times at autopsies removed the plug from the ductus arteriosus when death had occurred as late as the third week. The foramen ovale closes slowly. I have ordinarily found it open till near the end of the first half year, but the valve covers fully the aperture, so that there is no detriment to the cir- culation. Both the pulse and respiration are more frequent during infancy than childhood, and are more accelerated by moral and physical causes. The stomach has a smaller relative size and emesis is more readily caused than in the adult. The liver is large, occupying at birth nearly half of the abdominal cavity, but its proportionate size becomes less in subsequent months, from a less rapid growth. The appetite is good and digestion active, so that hunger, when appeased, soon returns. The thymus gland, at birth about the size of an unexpanded lung, slowly atrophies, but it does not totally disappear till after infancy. The kidneys, distinctly lobulated at birth, gradually change their form, so as to present in the last part of infancy nearly the shape of the organ in the adult. The renal secretion commences early, even before birth. The kidneys seldom undergo degenerative changes as in the adult, but they are liable to congestions and inflammations. During the first month, and espe- cially the first fortnight, crystals of uric acid and the urates are often found in the urine in a state of apparent health, causing more or less fretfulness in their elimination, staining the diaper, and not infrequently being arrested in the tubules of the pyramids, where they can be seen as pink-colored spots or lines (uric-acid infarction). These deposits of uric acid and the urates may even occur in the foetus, producing obstruction and inflammation of the renal tubes. Congenital cystic degeneration of the kidneys is, in the opinion of Virchow, due to them. In early infancy the senses are imperfectly devel- oped, the eyes being attracted only by bright objects, and the sense of hear- ing affected only by loud noises. Sleep is the normal state in the first weeks of life : as the age of the infant increases, less and less sleep is required ; but the oldest infants need more than children and several hours more than adults. The new-born infant is apparently destitute of mental faculties. It seeks the breast by instinct, and it exhibits no perception or reflection. The loud cries with which it commences its existence are not from anger or suffering ; they appear to be normal, like the act of nursing, and providentially designed to expand the lungs. It is not till the close or near the close of the first month that the gray substance of the brain begins to appear — the probable seat of the mind and the source of all mental phenomena. Perception and curiosity are early manifested. The infant, as Edmund Burke has remarked, is constantly seeking new objects for its amusement, rejecting old playthings for such as possess more novelty. Reflection, a higher faculty of the mind, appears at a later period. The mind and the bodily organs in infancy are, in a high' degree, impressionable. Anger is excited by trivial causes, but is easily appeased, and the various functions in the system are disturbed by agencies which in youth or manhood would have no appreciable effect. Childhood extends from infancy to the age of fifteen years or puberty. It is a period of great physical activity and of rapid growth. The functions of the various organs are performed with more moderation than in infancy, CARE OF THE MOTHER IN PREGNANCY. 19 and are less frequently deranged. The volume of the brain continues to increase rapidly, and it becomes firmer than in infancy. It is estimated that by the seventh year the weight of this organ has doubled. The mind now exerts a controlling influence over the actions of the individual. The digestive organs have changed, so that solid food is required. Most of the grandular organs are less active than in the greater part of infancy. The pulse and respiration gradually become less frequent as the child advances in age. CHAPTER II. CAKE OF THE MOTHER IN PREGNANCY. The frequency of miscarriages and stillbirths, and the large number of ill-formed and puny infants born to a precarious and short existence, render imperative, on the part of the mother, a strict observance of the laws of health, and an avoidance of all exciting or perturbating influences during the time when the foetus is being developed. The diet should be plain and easily digested, but nutritious. There is often a craving in pregnancy for unusual articles of food. These may sometimes be allowed within certain limits, provided that they are such as do not derange the stomach. Meats and animal broths, together with vegetables and farinaceous food, should con- stitute the ordinary diet and should be taken at regular intervals. Daily exercise, never violent, but moderate and gentle, is requisite. No exercise is better, none safer and more likely to contribute to cheerfulness and healthy functional activity of the organs, than the ordinary household duties. Lifting heavy weights or work which, like washing and ironing, causes great and continued action of the abdominal muscles, should be avoided. Such exercise is highly injurious, and it may produce premature labor. Exercise in the open air on foot or by an easy conveyance conduces to the health of the mother and the growth and development of the foetus. On the other hand, rapid riding over rough roads is one of the most dangerous modes of exercise. It has been known to destroy the foetus, which up to that time had been apparently vigorous. When such a result occurs there is probably more or less detachment of the placenta. It being a matter of the utmost importance that the health of the mother should continue good during gestation, any disease which she may have in this period, and which affects her nutrition or the character of her blood, should be promptly cured if practicable, and with the least possible reduction of the vital powers. Intermittent fever, occurring during gestation, should never be allowed to continue. It seriously retards foetal development and may produce miscarriage. Unless it be controlled by proper measures, the offspring, though born at term, is puny and emaciated. Syphilis in the preg- nant woman also requires treatment. This disease, readily transmitted from the mother to the foetus through the ovum or the uterine circulation, may be eradicated by antisyphilitic treatment of the mother, or at least so modified that the infant is born vigorous and healthy. The pregnant woman should avoid all causes of undue mental excite- ment. This is almost as necessary as the avoidance of great physical exer- tion. There is, during pregnancy, unusual susceptibility to mental impres- sions, and this should be borne in mind not only by the woman herself, but by those who associate with her. 20 INFANCY AND CHILDHOOD. Strong emotions, whether of joy, sorrow, or anger, affect primarily the nervous system, but indirectly most of the organs of the body. Observa- tions have long established the fact that such emotions influence the state and functions not only of the digestive and glandular, but also of the mus- cular, organs, as the heart and uterus. Physicians are familiar with cases in which vivid mental impressions produced uterine contractions, and even miscarriage, or have disturbed the catamenial function. Therefore, the asso- ciations and cares of pregnant women should be such as conduce to cheerful- ness and equanimity. It is the popular belief and the belief of many physicians that vivid mental impressions sometimes have a direct effect on the development of the foetus. Many cases are on record in which infants were born with marks or deformities corresponding in character with objects which had been seen and had made a strong impression on the maternal mind at some period of gestation. Whether the mind of the mother exerts a controlling influence on the form and color of the foetus is a subject of great interest to the psy- chologist as well as the physiologist and physician, since it involves no less a question than the power and scope of the human mind. Violent emotions, it is admitted, may affect directly most of the important organs in the system. They may derange the liver, causing jaundice, accelerate, or for a moment suspend, the heart's action, stimulate the kidneys, causing diuresis, or even the intestinal follicles, causing watery evacuations. But with all these organs the brain is connected by nerves which anatomy reveals. On the other hand, the mother and foetus have a distinct existence as regards their nervous sys- tems, and even their blood. Still, the multitude of facts which have accumu- lated justify the belief that deformity or other abnormal development of the foetus is, at times, due to the emotions of the mother. Some of the cases related by Dr. Whitehead in his work on hereditary diseases are very strik- ing and difficult to explain on the ground of coincidence. I have met the following cases : An Irish woman of strong emotions and superstitions was passing along a street in the first months of her gestation, when she was accosted by a beggar, who raised her hand, destitute of thumb and fingers, and in " God's name " asked for alms. The woman passed on, but reflecting in whose name money was asked, felt that she had committed a great sin in refusing assistance. She returned to the place where she had met the beggar, and on different days, but never afterward saw her. Harassed by the thought of her imaginary sin, so that for weeks, according to her statement, she was made wretched by it, she approached her confinement. A female infant was born, otherwise perfect, but lacking the fingers and thumb of one hand. The deformed limb was on the same side as, and it seemed to the mother to resemble precisely, that of the beggar. In another case which I met a very similar malformation was attributed by the mother of the child to an accident occurring to a near relative which necessitated amputation during the time of her gestation. I examined both of these children with defective limbs, and have no doubt of the truthfulness of the parents. In May, 1868, I removed a supernumerary thumb from an infant whose mother, a baker's wife, gave me the following history : No one of the family and no ancestor, to her knowledge, presented this deformity. In the early months of her gestation she sold bread from the counter, and nearly every day a child with double thumb came in for a penny roll, presenting the penny between the thumb and the finger. After the third month she left the bakery, but the malformation was so impressed upon her mind that she was not surprised to see it repro- duced in her infant. Mrs. S , West Fiftieth street. New York, when in the Beventh week of gestation, saw a child with fingers united, so that they resem- bled the palm of the hand extended. She was much excited at the appear- CARE OF THE MOTHER IN PREGNANCY. 21 anee. and clutclied the window-sill with such force as to cause abrasion of the fingers. The malformation of the child made a deep and lasting impres- sion on her mind, and her child, born at term, had the index, middle, and ring fingers of the left hand webbed and ending with the first phalanges, while the little finger was normal. Mrs. D , Eighth avenue, New York, seven months before the birth of her child, when visiting at a distance, accident- ally broke the plate of a full set of upper teeth. The line of fracture was antero-posterior and through the centre of the plate. Being away from home, she was much annoyed by the accident, and retained the fragments of the plate in situ by pressure with the tongue. As she could not open her mouth without the plate falling out, except it was retained by pressure with the tongue, her mind was dwelling almost constantly on the accident during the few days of her visit. Her boy, born seven months subsequently, had a hare-lip and cleft palate. The mother stated that the deficiency in the lip and palate cor- responded precisely to the location of the fracture in the plate. Dr. G-reenley relates five similar cases in which infants at birth presented marks or arrested development corresponding in appearance with objects which produced strong mental impressions in the mothers {Aimer. Prac. and News, Oct. 29, 1887). Dr. William A. Hammond of Washington, in an interesting paper on the "Influence of the Maternal Mind," etc. {Quarterly Journal of Physiological Medicine, January, 1868), says: " The chances of these instances, and others which I have mentioned, being due to coincidence are infinitesimally small, and though I am careful not to reason upon the principle of post hoc, ergo propter hoc, I cannot, nor do I think any other person can, no matter how logical may be his mind, reason fairly against the connection of cause and effect in such cases. The correctness of the facts can only be questioned ; if these be accepted, the probabilities are thousands of millions to one that the relation between the phenomena is direct." Professor Dalton also says {Human Physiology} : " There is now little room for doubt that various deform- ities and deficiencies of the foetus, conformably to the popular belief, do really originate in certain cases from nervous impressions, such as disgust, fear, or anger, experienced by the mother." The observations on which this belief is based relate both to man and the lower animals. A very strong argument in its support is, as Professor Hammond remarks, the popular opinion, which dates back to the time of Jacob (Genesis xxx.). An almost universal senti- ment, running through centuries, is rarely wholly fallacious. It has some truth for its foundation, especially when, as in this instance the subject is one of observation. If maternal emotions affect the development of the exterior of the foetus, as observations show and physiologists admit, the presumption is strong that they may affect also the proper development and adjustment of the parts of the brain, an organ so complex and delicate, and may therefore give rise to idiocy. Dr. Seguin {Idiocy and its Treatment, etc., New York, 1866) thus remarks on this point : " Impressions will sometimes reach the foetus in its recess, cut off its legs or arms or inflict large flesh wounds before birth from which we surmise that idiocy holds unknown though certain relations to maternal impressions as modifications to placental nutrition." In volume i. of the Cyclopsedia of Disease* of Children (Philadelphia, 1889) Dr. W. C. Dabney has published the statistics of 90 cases showing that both mental and bodily defects in the infant sometimes result from vivid mental impressions in the mother during the early months oi" her ges- tation. These cases are mostly collated from recent medical literature, and many of them are striking instances showing the effect of maternal impres- sions in causing malformations in the foetus, not only in the human race, but also in quadrupeds. Dr. Dabney also relates the remarkable statement of 22 INFANCY AXD CHILDHOOD. Baron Larrey, that 92 enceinte women who had experienced extreme mental and physical suffering at the siege of Landau in 1793 brought forth infants with the following result : born dead, 16 ; born alive, but dying in ten months, 33 ; born idiotic, 8 ; born with bones ununited or in a fragmentary state, 2. It is an interesting fact that abnormalities of structure occurring from whatever cause are sometimes propagated to descendants. Dr. Carpenter and others relate instances among the lower animals, and similar instances of transmission have now and then been observed in the human race. Thus, in the issue of Nature for March 7, 1878, it is stated on the authority of M. Lenglen, a physician of Arras, that a certain M. Gamelon in the last century had two thumbs on each hand and two great toes on each foot : this peculi- arity did not appear in the son, but it reappeared in the three succeeding generations, so that some of the great-great-grandchildren possessed it in as marked a degree as their ancestors. In view of such important facts the duty of the pregnant woman is ren- dered the more imperative to avoid the presence of disagreeable and unsightly objects, as well as all causes of excitement, and to remove, as soon as possible, vivid and unpleasant impressions by quiet diversion of the mind. CHAPTER III. MORTALITY OF EARLY LIFE: ITS CAUSES AND PREVENTION. No fact is better known in the profession than that the first years of life constitute the period of greatest mortality. In England, where there is an accurate registration of births and deaths, statistics show fifteen deaths in every hundred infants in the first year of life, and between four and five deaths in the first month. Statistics on the Con- tinent correspond with those in England as regards the periods of greatest mortality. Quetelet says :...." There die during the first month after birth four times as many children as during the second month after birth, and almost as many as during the entirety of the two years that follow the first year, although even then the mortality is high. The tables of mortality prove, in fact, that one-tenth of children born die before the first month has been completed." In this country, in consequence of deficient registration of births, the per- centage of deaths to births cannot be accurately ascertained. In New York City 53 per cent, of the total number of deaths occur under the age of five years, and 26 per cent, under the age of one year. According to the census of 1865, there were in New York City 95,020 children under the age of five years, and during the five years ending with 1865, 49,000 children five years old and under had died. Therefore, according to these statistics, more than one-third of all the infants born in this city die under the age of five years. An error, however, occurs from the fact that, while the death-statistics were complete, it is known that there were more children in the city than were em- braced in the census returns. Still, it may, I think, be safely stated that one- fifth of the children born in New York City die before the age of five years. In less-crowded cities and the rural districts it is known that the percent- age of deaths in the first years of life to the total number of deaths is con- siderably less than in New York City, but it is nevertheless large. As the child advances toward puberty the liability to sickness and death MORTALITY OF EARLY LIFE. 23 gradually diminishes, but even the last years of childhood present a con- siderably larger percentage of deaths to the population than does youth or manhood. The causes of this great mortality of infants and children, and the means of diminishing it, deserve careful consideration. Some of the causes which conspire to produce it are to a considerable extent unavoidable. Such are congenital vices of formation of internal organs. Many of the internal malformations necessarily occasion an early death. Cases of anencephalus, most cases of congenital hydrocephalus, of spina bifida, of cyanosis, are fatal before the close of infancy. These defects of formation we cannot detect before birth, and their causes are often obscure. Some of them seem to result from inflammation, believed to be, occasionally, syphilitic, developed at some period of foetal existence. Other internal mal- formations are attributable to perturbating influences operating temporarily on the mother during gestation. But in a large proportion of cases we can- not assign the cause. Obviously, only partial success attends our efforts as regards prevention in these cases, and almost no success as regards the use of remedial measures. Another obvious cause of the great mortality of early life is natural fee- bleness of system, especially in infancy. The younger the patient prior to the middle period of life, the sooner are the vital powers exhausted by dis- ease. Hence a larger proportion of infants succumb to the same malady than children, and a larger proportion of children than adults. This state- ment is true of infancy and childhood in general. It is a law in nature, and cannot be changed by art. But there are many infants born with hereditary disease or a strong predisposition to disease through a fault which is, in a degree, curable in the system of one or both parents ; as, for example, the syphilitic, scrofulous, or tubercular diathesis. Parents seriously affected by such diseases cannot, without corrective treatment, have healthy offspring. Their children are among the first to droop and die, either directly from the inherited disease or from feebleness of constitution which such disease entails, and which renders them an easy prey to other diseases. The duty of the physician as regards such parents is obvious. He may, by therapeutic and hygienic measures, secure a more healthy progeny, and so far as he can do this he aids in diminishing the infantile mortality. He may sometimes, by timely measures directed to the infant, establish a better state of health. The subject of hereditary disease is one of great interest and importance, especially as regards the city population. Inherited affections are less com- mon in the country, but in the city they contribute largely to the number of deaths in early life. Another important cause of the great mortality of children is the fact that they are peculiarly liable to certain severe and fatal maladies. I allude particularly to the acute communicable diseases, which, as a rule, occur but once, and then in childhood. Some of them, as scarlet fever, greatly increase the number of deaths. They extend and become epidemic through the inter- course of children. We are constantly witnessing in New York the spread of the acute contagious diseases, especially of whooping cough, measles, scar- let fever, and diphtheria, through the schools. Measures employed, thus far. by Boards of Health or other local authorities to prevent the dissemination of these and kindred diseases have been but partially successful, except in regard to small-pox. In the large public schools especially these maladies are most frequently contracted, and from them they radiate over the school districts : for if, as is now common, at least in New York City, a child comes to school wearing clothes which at home have lain in a room where a brother or sister has been sick with diphtheria or scarlet fever, or if he enter the class with a 24 INFANCY AND CHILDHOOD. mild pertussis or measles, certain of his classmates will probably return home infected with the virus of the disease. The same remarks are applicable, though with less force, to private schools. From both such schools I have over and over again witnessed the dissemination not only of the maladies mentioned, but also of the milder infectious diseases, as mumps and varicella. The Health Board of New York City has recently, by stringent enactments regulating the schools, accomplished much in suppressing this source of the infectious diseases. In hospitals and asylums for children much can be done to prevent the occurrence of the infectious diseases by strict surveillance and prompt isola- tion of all suspicious cases. Without such care scarcely a year passes in which these institutions are not scourged by one or more of these maladies. Much has been said of the crowding of families in tenement-houses so com- mon in New York and other large cities, by which a large number of children are brought under one roof, of the uncleanliness of person and apartment to which it leads, and of the insufficient air and space which it allows to each. But one of the strongest objections, in my opinion, to the present plan of building and crowding tenement-houses is the facility which it affords for the spread of the contagious diseases of childhood ; and it is in such houses, as shown by statistics, that these maladies are the most frequent and fatal. The much-needed enactments or rules in relation to the construction and occu- pancy of such houses would, among other salutary effects, greatly diminish the death-rate from the infectious maladies. Over the most loathsome, and formerly the most fatal, malady of man- kind — namely, small-pox — we now have, or can have, complete control by statutory enactments enforcing vaccination. It is only by carelessness or the lack of sufficiently stringent regulations relating to the matter that small- pox is not "stamped out." Again, some of the most fatal inflammatory diseases of life occur chiefly in childhood, as croup and capillary bronchitis. These and kindred diseases can only be prevented by proper hygienic man- agement on the part of families, and measures calculated to educate fam- ilies in reference to the management of children cannot fail to diminish the number of cases of such inflammations, and, consequently, of the deaths from them. Another obvious and important cause of the mortality of early life is the antihygienic condition or state in which many children live in consequence of the poverty or gross negligence of parents. Residence in insalubrious localities, personal and domiciliary uncleanliness, exposure without proper protection to vicissitudes of weather, are fertile causes of sickness and death. Hence one reason for the great infantile mortality among the city poor, who live in damp and dark alleys and in crowded and filthy tenement-houses, breathing night and day an atmosphere loaded with noxious gases. All physicians are aware how the most fatal diseases, such as Asiatic cholera, cholera infantum, diphtheria, and scarlet fever, seek the quarters of the city poor, and what terrible havoc they make there. All are aware, also, what wonderful recoveries result when feeble and attenuated infants, gradually sinking with chronic diseases, induced in great measure by the foul air, are transferred from such localities to the pure air of the country. Careless management of young children as regards dress increases greatly the liability to local diseases, such as commonly occur from exposure to cold. These are inflammatory affections seated chiefly upon the mucous surfaces, but sometimes in parenchymatous organs. Adults, aware of the effect of sudden change of temperature from warm to cold or of exposure to currents of air, protect themselves by additional clothing. Such precautionary meas- MORTALITY OF EARLY LIFE. 25 ures are often lacking in the management of young children, and hence one cause of their liability to local affections, both of the respiratory and diges- tive organs. Eonth, in his excellent treatise on Infant Feeding, says : " Among the most pernicious influences to young children, however, we may include cold ; the change of temperature from 45° to four or five below zero, as before stated, producing an increase of mortality in London alone of three to five hundred. As out of 100 deaths, however, from all specified causes, nearly 24 occur to children under one year, and 36 to children under five, the great increase of mortality to children by cold is thus at once made obvious. Indeed, it is a household word among us, which takes its origin from the Registrar-General's returns, that a very cold week always increases the mortality of the very young and the very aged." Lastly, a very important cause of mortality in early life is the use of improper food. In infants artificial feeding in place of the aliment which nature has provided for them, and in children the use of innutritious or indi- gestible articles of diet, give rise to diarrhceal maladies, emaciation, and death in numerous instances. Sometimes, also, defective alimentation is the cause of scrofulous or tuberculous ailments, and sometimes it gives rise to a cachexia or feebleness of system which, without engendering any positive disease, renders those thus affected less able to support disease induced by other causes. A committee, of which Professor Austin Flint, Jr., was chair- man, appointed in 1867 to revise the " dietary table of the children's nurseries on Randall's Island," states with much truth and force : " Children .... are not capable of resisting bad alimentation, either as regards quantity, quality, or variety. At that age the demands of the system for nourishment are in excess of the waste, the extra quantity being required for growth and development. If the proper quantity and variety of food be not provided, full development cannot take place, and the children grow up, if they sur- vive, into puny men and women, incapable of the ordinary amount of labor and liable to diseases of various kinds." Improper feeding, like other causes of mortality, is much more injurious, much more frequently the cause of death, in the city than in the country. Statistics in Europe, as well as on this side of the Atlantic, establish this fact. It is in infancy, and especially in the first year, that the use of unwholesome food entails the most serious consequences. No artificially-prepared food is a good substitute for the mother's milk, and hence artificial feeding of the infant, unless under the most favorable circumstances, results disastrously. In the country, where salubrious air and sunlight conspire to invigorate the system, where a robust constitution is inherited, and where cow's milk, fresh and of the best quality, is readily obtained, lactation is not so necessary for the well-being of the infant ; but in the city its importance cannot be too strongly urged. The foundlings of cities afford the most striking and convincing proof of the advantages of wet-nursing. In some cities foundlings are wet-nursed T while in others they are dry-nursed, and the result is always greatly in favor of the former. Thus, on the Continent, in Lyons and Parthenay, where foundlings are wet-nursed almost from the time that they are received, the deaths are 33.7 and 35 per cent. On the other hand, in Paris, Rheims, and Aix, where the foundlings were wholly dry-nursed at the date of the statis- tics, their deaths were 50.3, 63.9, and 80 per cent. In New York City the foundlings, amounting to several hundred a year, were formerly dry-nursed, and, incredible as it may appear, their mortality with this mode of alimentation nearly reached 100 per cent. Xow wet-nurses are employed for a portion of the foundlings, with a much more favorable 26 INFANCY AND CHILDHOOD. result. Several years ago, before the New York Foundling Asylum existed, the foundlings of New York were taken eare of by the pauper women of the almshouse, and the medical board of Charity Hospital assigned me to the service in the almshouse. Foundlings were received nearly every day, and were given cow's milk prepared by these pauper women. When my duties commenced in the almshouse the deaths corresponded with the admissions : only one infant was pointed out that had survived the first half year in the almshouse. These facts, to which others might be added from the experience of European cities, show the importance of wet-nursing as a means of reducing infantile mortality in the cities. What has been stated as regards the result of artificial feeding of foundlings is true, in great measure, in reference to all city infants. The ill-effect of artificial feeding is well known in city families, and it is the common practice to employ a hired wet-nurse if, for any reason, the mother's milk is insufficient. When the infant has reached the age at which it is proper to wean, the digestive organs are less frequently deranged by errors of diet. More sub- stantial food, and considerable variety in it, may now be not only safely allowed, but are required by the wants of the system. CHAPTER IV. WEIGHT, GKOWTH, TEMPERATUBE, PULSE, RESPIRATION. Dr. K. Parker, resident physician of the New York Infant Asylum when these observations were made, weighed, immediately after birth, 170 infants— 89 male and 81 female — born consecutively and at term, with the following result : Average male weight 7 lbs. 11 oz. female " 7 " 4 " Fifty of these, who were wet-nursed and apparently well taken care of, were weighed when one week old, with the following result : Increase of weight in 32 cases. Loss of weight in 13 " Average gain 4 T 8 o oz. " loss 3£ " Greatest gain 12° " " loss 6 " Average Gain. From birth to age of 4 months (25 cases) 4 lbs. 8| oz. " 3 to 6 months (6 cases) 3 " 3i " " 6 to 9 " " 2 " 7* " " 9 to 12 " " i « 151 « WEIGHT, GROWTH, TEMPERATURE, PULSE, RESPIRATION. 27 Statistics of Temperature, Pulse, and Respiration of Healthy In- fants, OBTAINED BY DRS. PARRY AND HODGE, N. Y. INFANT ASYLUM. Age. Under 6 mos. 6 to 12 mos. 12 to IS mos. 18 to 30 mos. Table I. — Temperature in Health. J Rectal average of 313 observations in 14 children, 98.5°. \ Axillary f Rectal \ Axillary l Rectal \ Axillary f Rectal 1 Axillary 144 55 39 70 35 102 54 14 98.3°. 2 98.6°. 2 98.3°. 2 98.4°. 2 98.3°. 3 98.9°. 3 ' 98.1°. The difference in the temperature of healthy infants in the morning and evening was found to be trivial, as is seen by the following statistics : Morning and Evening Temperatures. 6 to 12 mos. | Rectal average, a. m. 12 to 18 mos. { Ee( * al av ^ e > £• £ 18 to 30 mos. { Ee( * al ave ™ ge ' p ' £" 98.44 (observations, 436). 98.56 ( " 414). 98.43 (observations, 185). 98.34 ( " 181). 98.34 (observations, 206). 98.59 ( " 199). No. of infants, 6 6 4 4 3 3 Table II. — Pulse in Quiet, Health?/ In/ants. Under 6 mos., observations 90, No. of infants 27, average 125 6 to 12 " " 11, " " 2, " 124 12 to 18 " " 23, " " 4, " 115.5 18 to 30 " " 37, " " 7, " 111.8 Respirations. Under 6 mos., observations 90, No. of infants 27, average 44.8 6 to 12 " " 11, " " 2, " 34.8 12 to 18 " " 24, " " 4, " 35.4 18 to 30 " " 37, " " 7, " 29.8 Average Pulse. When awake. Under 6 mos 141.77 . 6 to 12 " 136.2 . 12 to 18 " 129.8 . 18 to 30 " When asleep. . . 128.23 . . 120.37 . 110.71 131.6 108.35 Respirations. Awake. Asleep. Under 6 mos 53.47 40.23 6 to 12 " 41.66 32.13 12 to 18 " . 38.25 26.18 18 to 30 " 39.33 25.49 Lactation. — It is desirable that the infant as soon as it requires nutriment should receive breast-milk. If it be fed for a few days with the bottle or spoon, it may be difficult finally to induce it to take the breast ; therefore it is well to determine early whether the mother will be able to wet-nurse her infant, so that, if unable, suitable provision may be made. The matter of determining beforehand the capability of the mother for wet-nursing has been investigated by Dr. Donne of Paris, and in his treatise on Mothers and Infants he describes the mode in which it may be ascertained. The desired information, in his opinion, may be acquired by examining the 28 INFANCY AND CHILDHOOD. colostrum, which is secreted in small quantity in the last months of gesta- tion, and which can be squeezed from the breast in sufficient quantity for inspection. In some women, according to Dr. Donne, the colostrum is so scanty that only a drop or half a drop can be obtained from the nipple by careful pres- sure. This will be found by the microscope to contain but few milk-glob- ules, ill formed, and a few granular bodies, such as the colostrum ordinarily contains. Such women almost invariably furnish poor milk and in small quantity. In other women the colostrum is abundant, but thin, resembling gum-water ; it lacks the yellow streaks and viscous character of ordinary colostrum, and it flows readily from the nipple. The milk of such women is sometimes scanty, sometimes abundant, but it is watery and deficient in nutritive principles. In a third class of women the colostrum is pretty abun- dant, and it contains yellowish streaks of more or less consistence, which are found to be rich in milk-globules of good size. Women furnishing such colostrum in the last weeks of gestation will have sufficient milk and of good quality. These latter women make the best wet-nurses. Wet-nursing: its Advantages and Hindrances; Physical Condi- tions rendering it Improper. During the first year of the infant's life the natural mode of alimenta- tion — that by the mother's milk — should always be recommended, except in those instances in which mothers are incapacitated by physical ailments or mental derangement. The practice common in New York, and probably in other cities, of employing wet-nurses, in the belief that suckling their infants deprives mothers of social enjoyments and by the drain upon the system impairs their general health, should be discouraged. Wet-nursing by the mother, if properly regulated, with sufficient undisturbed sleep at night, and with the maintenance of good appetite and digestion, does not impair her health, but, on the other hand, tends to promote her physical well-being. But there are unavoidable conditions which render wet-nursing by the mother injudicious or impossible. These will be considered hereafter. The primipara often experiences difficulty in wet-nursing in consequence of a depressed state of the nipple. It is not sufficiently prominent to be readily grasped by the mouth, and after ineffectual attempts the infant becomes fretful when applied to the breast, and perhaps for a time refuses it altogether. Multipara occasionally experience the same inconvenience, but it is not common when there has once been successful lactation. By calmness and perseverance on the part of the mother the nursling can usually be made to seize the nipple in the course of a week. Depression of the nipple is, to a certain extent, the result of pressure upon it by the dress during gestation. The state of the nipple should indeed, in those who have never suckled, receive early attention, even before the birth of the infant. Tightness of dress around the breast, as also upon every part of the body, should be avoided, and from time to time gentle traction should be made upon the nipple if it be depressed. It may be drawn out by the fingers of the mother several times each day, or by a com- mon breast-pump, or by suction with a tobacco-pipe, the edge of the bowl having been smoothed. Occasionally, in these cases of depressed nipple the mother, fatigued and discouraged by her frequent ineffectual attempts to induce the infant to nurse, becomes feverish and excited, so that the quan- tity of her milk is sensibly diminished. The physician should assure her, as he usually can with confidence, that in a few days, as the baby becomes a little stronger, there will be no difficulty in its nursing. Some women are unre- WET-NUESING. 29 mitting in their endeavors to procure nursing. This should be forbidden, since the lack of sleep and the nervousness which such constant endeavor produces tend to defeat the object which they have in view, by diminishing the secretion of milk. Sufficient sleep, freedom from anxiety, and no more frequent application of the infant to the breast than is required in success- ful lactation should be enjoined. Occasionally, we can best succeed in pro- curing lactation under these circumstances of discouragement by the aid of another infant older, more vigorous, and better able to seize the nipple. An exchange of infants a few times may remedy the difficulty. Occasionally, suckling is rendered difficult and painful by too long delay before applying the infant to the breast. When the mother has rested a few hours after her confinement — about six in ordinary cases — lactation may com- mence. There is at first but very little milk, often only a few drops, but the secretion is promoted by nursing, so that the requisite amount is sooner obtained than when the infant is kept from the breast till the second or third day. If, as some physicians advise, suckling be deferred till the breasts are full and tender, and if, as is often the case with primiparse, the nipples are also tender ; many mothers lack the fortitude required to allow their infants to obtain a sufficient amount of milk. Excoriated and fissured nipples con- stitute a serious impediment to wet-nursing. They are very sensitive on pres- sure, and are long in healing. They are fully described in works which relate to female diseases, and their treatment pointed out. Occasionally, fissured nipples do harm to the infant by the blood which escapes and is swallowed with the milk. A case is related in which positive indigestion was caused in this way, the infant vomiting, after each nursing, milk mixed with blood. The local hindrances to lactation described above can in most instances be relieved in the course of a few weeks. To what extent menstruation and pregnancy are detrimental to the nursing, and therefore contraindicate lacta- tion, will be considered in another section. There is occasionally a constitutional state of the mother which necessi- tates either the employment of a hired wet-nurse or weaning. This is the case when there is a strong tendency to tuberculosis. If the complexion be pallid, the system at all emaciated, and suckling be attended by more or less exhaustion, and if with fair trial of wine and tonics no improvement follow, the physician is justified in forbidding further attempts at wet-nursing. If, under such circumstances, an hereditary tendency to tuberculosis exist, it is his duty positively to interdict nursing. The opinion of the physician in such a matter should be formed after mature deliberation. There are many women who, suffering temporarily from illness and discouraged, are ready at once to abandon their infants to the care of others with the least encouragement on the part of the physician to do so, but who, by attention to their own health, and especially by taking more sleep, soon recover from their depression and become good wet-nurses. On the other hand, night-sweats, a cough, and pro- gressive decline in health show the need of immediate suspension of wet- nursing. Sometimes women prior to pregnancy present indubitable evidence of tuberculosis, but by the improved general health which attends pregnancy the disease is temporarily arrested. Such women should never suckle their infants. If they do, they soon lose all that was gained and the disease advances rapidly. These objections to wet-nursing in such a state of health apply to the mother. There are also objections as regards the infant. The milk of those in decidedly infirm health is deficient in nutritive principles. Their infants, therefore, are ill-nourished, and if they have inherited a pre- disposition to tuberculosis, there is great danger that this disease will be developed in them; whereas with healthy wet-nursing even a strong predis- 30 INFANCY AND CHILDHOOD. position may remain latent. M. Donne relates the following instructive cases,, which show the danger which sometimes attends suckling and the imperative necessity which may arise of discontinuing it : " A very light-complexioned young mother, in very good health and of a good constitution, though some- what delicate, was nursing for the third time, and, as regarded the child, successfully. All at once this young woman experienced a feeling of exhaustion. Her skin became constantly hot ; there were cough, oppression, night-sweats ; her strength visibly declined, and in less than a fortnight she presented the ordinary symptoms of consumption. The nursing was immedi- ately abandoned, and from the moment the secretion of milk had ceased all the troubles disappeared." "A woman of forty years of age, .... having lost, one after another, several children, all of whom she had put out to nurse, determined to nurse the last one herself. .... This woman, being vigorous and well built, was eager for the work, and, filled with devotion and spirit, she gave herself up to the nursing of her child with a sort of fury. At nine months she still nursed him from fifteen to twenty times a day. Having become extremely emaciated, she fell at once into a state of weak- ness from which nothing could raise her, and two days after the poor woman died of exhaustion. '" A very similar case recently occurred in my practice. A young and healthy woman from the country, suckling her second infant, on coming to the city lived in a dark and very imperfectly ventilated room on the first floor and in the rear of a crowded tenement-house. She soon lost her appetite, but continued suckling for three months, when she became so ansemic and feeble that she was compelled to seek medical advice. She died without local disease, notwithstanding the most nutritious diet and free use of stimulants and tonics. Constitutional syphilis in the mother does not contraindicate wet-nursing. It is probable that the infant also has it. The mother should take antisyph- ilitic remedies, which will eradicate the disease in herself, and also, if it be present, in the infant. Febrile affections also do not in general contraindicate wet-nursing. They may, however, for a time diminish, the quantity of milk or impair its quality. If,' however, the mother be in a critical state or much reduced, whatever the disease, suckling should cease. Whether or not the infant should be taken from the breast if the mother be suffering from one of the essential fevers depends on the severity of the malady and the degree of her exhaustion. Twice I have known newly-born infants to be suckled by mothers while the latter had scarlet fever without contracting it, but suffer- ing immediately afterward from protracted and severe eczema. In rural localities, where artificially-fed infants, as a rule, do well, it might be best to wean if the mother have such a disease ; but in the city eczema is less dan- gerous than the diarrhoeal affections which early weaning is likely to entail. In most cases of typhus and typhoid fevers weaning or procuring a wet- nurse is necessary, on account of the depression of the vital powers which these diseases produce. Mothers with organic diseases, of whatever kind, which impair the general health or diminish the appetite, should never be allowed to wet-nurse their infants. Wet-nursing under such circumstances is likely to aggravate the disease, and the milk which such mothers furnish, even if sufficient in quantity, is deficient in nutritive properties. Inflammatory affections, unless of a dangerous character. _do not ordinarily interfere with wet-nursing, except that the quantity of milk is somewhat dimin- ished. In severe inflammation it may be so necessary to husband the strength or to keep the patient perfectly quiet that suckling her infant would be inju- dicious. It should then be transferred to a wet-nurse or weaned. Inflam- mation of the breast often presents an impediment to lactation. It is a HINDRANCES TO LACTATION 31 common and painful affection, suspending or greatly diminishing the secre- tion of milk in the affected gland. Wet-nursing should cease as soon as there are evident signs of inflammation, unless it be limited to a small part of the gland. General heat of the breast, with tenderness and induration extending over a considerable part of it, indicates the need of the immediate removal of the infant from it. Suckling must be restricted to the unaffected side. It is often the case that the volume of the inflamed gland is considerably increased from the afflux of blood to it and from the interstitial exudation, while it contains little or no milk, and attempts at suckling under such cir- cumstances are injurious to the mother as well as to the infant. The cause of the swelling should be explained to the mother, who commonly attributes it to the accumulation of milk, and worries herself and the infant by attempts to make it nurse. As the inflammation abates by resolution, or more com- monly by suppuration, and the normal secretion returns, the first milk, which is usually thick and stringy, should be rejected, after which the infant may nurse as usual. Occasionally, the abscess which has formed in the breast connects with a lactiferous tube, so that pus may, on suction, escape from the nipple. If this occur, of course nursing should be interdicted until pure milk is obtained. Pus in the milk can sometimes be detected by the naked eye. It presents a yellowish or greenish color, occurring in streaks when not intimately mixed with the milk. When it is intimately mixed and in small quantity, it cannot be detected by the naked eye, but the microscope reveals the pus-globules. M. Donne relates a case in which he discovered these globules by the microscope, although there were at first no other evidences of an abscess, and doubts were expressed in reference to the accuracy of his observation. Finally, an abscess pointed and discharged. Sometimes when the inflammation abates the secretion does not return, and, worse still, occasionally the inflammation has occurred so near the nipple that the lactiferous tubes are permanently closed by it, so that, though milk form in the breast, there is no escape for it. Thenceforth only one breast can be used. If erysipelas occur in the mother, the infant should be immediately taken from her breast and from her arms. If this disease should not be communi- cated to the infant through the* milk or through fissures in the nipple, of which there is danger, still the milk usually undergoes such a change in con- sequence of the erysipelas as to endanger the health of the child. Thus, one of the wet-nurses in the New York Infant Asylum sickened with severe facial erysipelas on the 24th of April, 1875, eight days after the death of her baby. She was wet-nursing a foundling, aged seven weeks, at the time of the com- mencement of the erysipelas, and, as it was very important that her milk should be preserved for the coming hot months, it was deemed best to allow the nursing to continue, the infant being placed in a crib at a little distance as soon as it dropped the nipple. On the 27th the baby was troubled with diarrhoea. April 28th its morning temperature was 101°, and that of the evening 103°, the diarrhoea continuing. It was now removed entirely from the breast and was given artificial food. On the 29th there was a decided general icteric hue of the infant's surface, which continued till its death on May 1st. The stools numbered about eight daily till April 30th. when they ceased. The record which I preserved does not state whether there was vomiting, but it had probably been slight on account of the speedy prostra- tion. Death occurred from exhaustion. At the autopsy from half an ounce to one ounce of pus was found in the peritoneal cavity, newly-formed fibrin was observed upon the spleen and liver, and the peritoneum generally had lost much of its lustre : a careful microscopic examination of the liver and its ducts, made by Dr. Heitzmann, revealed no anatomical change which would 32 INFANCY AND CHILDHOOD. explain the icteric hue, and it seemed propable that this was due to the altered state of the blood. The mucous membrane of the intestines exhibited vascular streaks and its follicles were distinct. The lesions, therefore, indicated intes- tinal catarrh. Nothing unusual was observed in the heart and lungs of the infant. Its life had been apparently sacrificed by the unhealthy nursing. Colostrum. The milk secreted during gestation and immediately after the birth of the infant ordinarily diifers in its gross appearance, as well as chemical and microscopical characters, from that which is subsequently secreted. It is termed colostrum. It has a turbid and yellowish appearance, and is some- what viscid. It is decidedly alkaline, and undergoes lactic-acid fermentation more readily than common milk, and it also contains more solid matter. 1+ has an excess of fat, of salts, and, according to Simon, also of sugar. J > appears from Simon's analysis that the solid matter of colostrum is about 17 per cent., while that of the ordinary breast-milk is about 11 per cent. Examined by the microscope, the colostrum is seen to contain oil-globules and a viscid substance which often assumes an ovoid or globular form, but which also exists in irregular masses of considerable size. This substance has been thought by some to be mucus, but it is dissolved by acetic acid and potash and is tinged yellow by a watery solution of iodine. It is therefore to be regarded as albuminous. Imbedded in this substance are oil-globules, which are for the most part of small size, while the free oil-globules of colos- trum are larger than those occurring in healthy milk. The viscid substance, with the imprisoned oil-globules, constitutes what has been designated the " colostrum-corpuscles." The colostrum is replaced by milk of the normal character in six to eight Fig. 2. Fig. 1. Oo G ' Co & Aquse, Jj. — Misce. This wash should be applied four or five times daily, and continued for a time after the disease has disappeared from sight, since the roots of the plant must be destroyed or the branches are rapidly reproduced. It should be applied by a camel's-hair pencil or with a soft cloth upon the finger or a stick. It should be so freely used in extensive and severe forms of the disease that the infant will swallow some, since the entire oesophagus may be also the seat of sprue in such cases. In the intervals between the applica- tions of borax, if the buccal surface be hot, dry, and tender, so as to increase the fretfulness of the infant, it is well to use mucilaginous washes, as the mucilage of acacia or mallows. If the disease continue notwithstanding the use of the borate of sodium, the acidum boricum may be properly employed with it, as in the following formula : R . Sodii borat. , Acidi borici, da. ^j ; Glycerini, jjij ; Aquae anisi, q. s. ad ^iv. — Misce. For a mouth-wash, applied hourly or every two hours. In many cases, however, the treatment of thrush is of less importance than that of the disease which the thrush complicates. The remedial meas- ures which I have mentioned then become subordinate to those employed for the graver disease. When this disease is relieved and the general health improves, thrush is more easily and permanently cured than during the state of feebleness and ill-health. CHAPTEE III. DIAEEHCEA, CONSTIPATION, AND TETANUS OF THE NEW-BOEN. Diarrhoea of the Newly-born. The colostrum, or the first secretion of the mammary glands after partu- rition, contains more oily matter and sugar than occur in the subsequent secretion. In consequence of this peculiarity in its composition the colos- trum has a laxative effect by which the meconium is expelled. If the mam- mary glands continue to secrete colostrum after the first week, diarrhoea is likely to result. A more common cause of diarrhoea of the newly-born is the employment of various sweetened mixtures by mothers or nurses in the belief that the breast-milk is inadequate, or they are employed for the purpose of relieving the supposed colicky pains whenever the baby frets. Cane-sugar added to the various mint teas not only gives rise to diarrhoea, but also in time to more or less gastro-intestinal catarrh and stomatitis, with the occur- rence of sprue. Sprue is more common in the newly-born than at any other period of life, and it can usually, according to my experience, be traced to DIABEHCEA AND CONSTIPATION. 129 the use of improper sweetened mixtures. The infant immediately after birth may be given a little sweetened water or a teaspoonful of sweet oil to aid in the expulsion of the meconium, but subsequently, in the great majority of cases, no carminative or nutritive mixtures are required. The breasts of the mother if she have the usual health furnish all that is needed. The neonatus requires almost no nutriment during the first three days, and the breasts fur- nish but little during this time, but frequent traction upon the nipple pro- motes the mammary secretion, and after the third day, in ordinary cases, sufficient nutriment is obtained from the breasts to supply the wants of the system and promote a healthy growth. If what is natural were left to itself, and no artificial measures were employed, the result in most instances would be good ; but the unfortunate practice of filling the infant's stomach with various admixtures disturbs normal digestion, impairs the appetite, causes colicky pains, vomiting, and diarrhoea, and, if persisted in, gastro-intestinal catarrh. In many cases green fermenting and unhealthy stools cease, and a more normal state of the digestive apparatus is produced by forbidding the use of superfluous and injurious food and drinks which had been given to supplement wet-nursing in the mistaken belief that more food was required. Food in excess, even if it be of the proper quality or it be breast-milk, usu- ally causes diarrhoea if it be not vomited, since, not being digested, it under- goes fermentative changes, and acts as an irritant until it is expelled. We have treated of this subject elsewhere. Diarrhoea in the newly-born, whatever its cause, should be immediately arrested. After the meconium is removed by the action of the colostrum, three daily evacuations from the bowels are sufficient. A larger number is usually attended with loss of flesh and strength. The use of sweetened mix- tures, which nurses are in the habit of administering when infants are not well, as catnip, fennel, or aniseed tea, we repeat, must be strictly forbidden. A mother with a sick and fretful' infant usually applies it to the breast too frequently, even every half hour during the day. This should also be strictly forbidden. The infant, like the adult, should take food at stated intervals, so that the digestive organs may have some respite from the task of diges- tion. The application of the new-born infant to the breast twelve times in twenty-four hours is sufficient for its nutrition, and the mother's health is better preserved and her milk of better quality than when she is deprived of the needed rest by more frequent suckling. If the infant be unfortunately deprived of breast-milk and be bottle-fed, the utmost care is required in the selection and preparation of the food, as well as in determining the amount of food to be given and the frequency of feeding. Facts relating to this important subject have been presented in preceding pages. If the diarrhoea do not cease by the use of the proper diet given in suit- able quantity at proper intervals, medicinal treatment is needed. I have found the following prescriptions very useful for the diarrhoea of infants under the age of one month, as well as for those that are older: R . Bismuthi subnitrat. , sjiij ; Pepsini puri in lamellis, &j. — Misce. Give as much as goes on a ten-cent piece before each suckling or feeding. R. Bismuthi subnitrat., oil > Wyeth' s elixir of digestive ferments, or Fairchild' s essence of pepsin, oj ; Aquae destillat., ^iij.— Misce. Shake bottle. Give 20 drops before each suckling or feeding. 9 130 DISEASES OF THE NEWLY-BORN. A clyster of bismuthi subnitrat., gr. v to x ; resorcini, gr. iij ; aquas purge, ^j — Misce, is also frequently useful for the diarrhoea. Constipation of the Newly-born. In the infant constipation results from several different causes. The most serious and obstinate form of it, to which the term obstipation is more appro- priately applied, arises from intestinal malformations. In rare instances con- genital obstruction occurs in the small intestines. It is sometimes produced by cystic tumors or twisting of the intestine. Congenital stenosis occasion- ally occurs at the ileo-cascal orifice. Thus in the Transactions of the London Pathological Society for 1870 is the history of a case in which there was such narrowing of the ileo-csecal orifice, believed to be congenital, that a No. 9 catheter could barely be passed through it. The patient lived until his thirty-second year, but throughout his life suffered from constipation and colic. After his death the ileum next to the ileo-caecal valve was found to have a diameter of seven inches, while the large intestine was much atrophied and its entire lumen contracted from disuse. Occasionally the stenosis occurs a little above the ileo-cascal orifice, and rarely in the duodenum at the point of union of the pancreatic or bile-duct with the intestine. The obstacle in some instances appears to be hypertrophied valvulae conniventes, the edges of two opposite folds being more or less adherent. Such congenital intestinal obstructions— whether, as is probable, produced by inflammations in the foetus or from simple perverted nutrition ; whether arising from the syphilitic cachexia or other cause — of course retard the evacuations according to their location and the amount of closure. The same degree of stenosis in the colon or rectum obviously causes a more constipating effect than in the small intes- tines, since the latter have more mobility than the former and their contents are more liquid. But the most common of the congenital obstructions in the intestines occur from malformations of the rectum. These malformations vary con- siderably in different cases. They may be classified in at least four different groups : 1st. The anus may appear normal, but instead of the normal rectum two cul-de-sacs are present, representing the upper and lower ends of the rectum, and connected by an occluded segment of the rectum or by a firm fibrous cord. 2d. The anus is absent, and the rectum has a fistulous opening in the perineum, or through the scrotum in the male or vulva in the female. In the embryonic development the outlet of the rectum was formed too near and encroached upon the sexual apparatus. 3d. The anus is absent and there is no external fistulous opening representing the anus, but the rectum opens at some point upon the mucous membrane of the genito-urinary apparatus. 4th. Anus absent and the entire lower part of the rectum obliterated. The upper portion of the rectum terminates in a cul-de-sac in the neighborhood of the promontory. Some of these malformations do not prevent the dis- charge of fecal matter, but when there is closure of the rectum and no fistu- lous opening, of course no evacuation of the intestines can occur unless relief be obtained by surgical measures. In the ordinary form of occlusion a por- tion of the rectum is represented by a cord, or a firm, unyielding septum shuts off the lower part of the rectum from that above, so that defecation is impos- sible. The infant with this serious malformation takes the breast for a time like other infants, but the intestines soon become distended with fecal matter, and restlessness from the distention and vomiting occur. The only mode of relief is by an incision or puncture through the obstruction ; but a large pro- portion of infants with this obstructive malformation die whether operated on or not. The surgical treatment of these cases will be discussed elsewhere. BIABBHCEA AND CONSTIBATION. 131 The great length of the sigmoid flexure in infancy, and the curvatures which occur in consequence, more in number than in older children, tend to retard the descent of fecal matter and promote constipation. In the adult numerous depressions and inequalities in the colon retard the downward movement of the intestinal contents, but in infancy the surface of the colon is comparatively smooth and even, and the detention, so far as any exists, occurs from the curvatures or loops, which are sometimes twisted partially on their axes. The sigmoid flexure is so long in infants under the age of ten. and especially of six months, that the curvatures usually lie in part to the right of the median line, and even in the right iliac fossa. Those who have witnessed the post-mortem examinations of young infants in the asylums find no difficulty in accepting the statements of certain writers that the cur- vatures or loops in the sigmoid flexure, which sometimes extend as high as the umbilicus and laterally to the right iliac fossa, cause habitual constipa- tion in some infants. Occasionally in young infants, as well as in those who are older, the intes- tines act sluggishly from insufficiency of food. Thus the infant sometimes hangs an unusually long time on the breast, and the mother or wet-nurse believes it to be a hearty nurser, when there is really a deficiency of milk, and the stools are scanty and infrequent from lack of material : under such circumstances the infant is restless when away from the breast, or, not being fed, loses flesh, and soon has the appearance of one in ill-health. These symp- toms disappear upon the supply of a more liberal allowance of food of proper quality. Again, a constipated state of the bowels occasionally occurs in infants who nurse heartily and seem to obtain a sufficient quantity of milk ; and the cause of it appears to be in the state of the digestive organs, and not in the milk. We find now and then that breast-milk has a constipating effect, although we discover nothing in the mother's diet or health to cause this result. The comparison of ordinary breast-milk with colostrum may furnish an explanation of the constipation under such circumstances. Colostrum is known to be more laxative than ordinary milk, and it differs from it chemi- cally in containing more butter, sugar, and salts. Hence the theory seems plausible that when breast-milk is constipating these elements occur in less than the normal quantity, and we will find that treatment suggested by this theory tends to obviate the constipation. Constipation has also been attributed to a deficiency in the intestinal secretions and to too great viscidity of them from lack of water. Deficient peristalsis, whether from congenital weakness or other cause, also leads to constipation. The use of starchy foods without sugar or with but little sugar also sometimes has a constipating effect. Gautier of Geneva, Switzerland, states that an anal fissure is a common cause of constipation, whether in the newly-born or older infants. If such a fissure be present, pain in defecation might instinctively lead the infant to resist the desire to evacuate the bowels and to postpone the act, so as to estab- lish a constipated habit; but if such fissures are common in this country, except in the syphilitic, they have escaped our notice. Finally, constipation has a tendency to perpetuate itself, since retained feculent matter becomes more consistent and firmer, and the contractile power of the muscular tissue becomes weakened by over-distention. Symptoms. — When there is a mechanical cause of scanty and infrequent defecation, the acuteness of the symptoms and the suffering are usually pro- portionate to the degree of obstruction. In cases of complete obstruction of the intestines, as in imperforate rectum, fecal accumulation occurs above the obstruction. Under such circumstances distention of the abdomen, vomiting. 132 DISEASES OF THE NEWLY-BORN. fret-fulness apparently from the abdominal pain, 'and progressive loss of flesh and strength, indicate the serious nature of the disease. In constipation from other causes — that is, without obstruction except such as arises from fecal accumulation — the condition of the infant may attract little attention at first ; but if it do not have proper evacuations, it soon begins to suffer in its health. Fretfulness, an unhealthy physiognomy, vomiting, and more or less fever occur until the patient is relieved of the ailment. The treatment of constipation in the new-born, as well as in older chil- dren, we will consider elsewhere. Tetanus Neonatorum. Several years ago Humboldt wrote that there is no subject in the whole range of scientific investigation more obscure than the causation and spread of the acute infectious diseases. Humboldt did not live long enough to witness the wonderful discoveries by the microscope and the light thrown by this instrument on the obscure subject which puzzled him whose investiga- tions embraced the whole universe. In the decade commencing with 1880 the bacillus which causes tetanus was discovered by the conjoined labors of distinguished bacteriologists, among the earliest and most successful of whom was Nicolaier, so that the bacillus was at first designated by his name. In November, 1886, Bosenbach produced tetanus in two guinea-pigs by inserting under their skin small por- tions of gangrenous material from the ulcer of an individual having tetanus. He also demonstrated the fact that the bacillus of Nicolaier is capable of causing tetanus in animals. These discoveries excited great interest, and were soon followed by the important chemical researches of Brieger, by which he isolated a toxine occurring in the cultures of the bacilli of tetanus and generated by them. This toxine has the formula C I3 ,H 30 ,Az 2 ,O 4 , and it produces tetanus when injected under the skin of an animal susceptible to this disease, while the bacilli deprived of this toxine by filtration are inert. Brieger also states that he extracted from the same cultures two other toxines of great activity, which he designates tetanotoxine and spasmotoxine. The setting free of these toxines was accomplished, according to Brieger, with the disengagement of sul- Fig. 14. phuretted hydrogen. Bac- teriologists describe the * A* bacillus of tetanus as hav- o o^ ing twice or thrice the ^ '** length of the tubercular a - J 3 ^ bacillus, but thicker and £ vj straighter, and knobbed or '/ ^ S* enlarged at one extremity A so as to be designated pin- B shaped. Bonome, among The tetanus bacillus. others, made microscopic examinations and cultures of this bacillus obtained from the wounds or sores of human beings, horses, and sheep. Among micrococci and bacilli of various sizes and forms he observed the constant presence of the fine bristle-shaped, pin-headed bacillus identical with that described by Nicolaier. Bonome endeavored in vain to obtain pure cultures of the bacillus, and concluded that it did not thrive except in company with the germs of putrefaction. The recent cultivation of the tetanus bacillus in the laboratory of the < TETANUS NEONATORUM. 133 Fig. 15. chemist is a fact of great interest, and one that throws light on the causa- tion of tetanus, whether in the infant or adult. The process is described by Mr. R. T. Hewlett, demonstrator of bacteriology in King's College, in the London Lancet, July 14, 1894, as follows : " In order to obtain the chemical products for inoculation and other purposes, the bacillus of tetanus may be grown without the use of any complicated apparatus in an atmosphere of hydrogen, in the following manner : Yeast-flasks of about 90 c. c. capacity are made use of, and are filled three parts full with a 2 per cent, grape- sugar bouillon. The neck is corked with a perforated rubber cork through which a glass tube passes to the bottom of the flask, projects two inches above the rubber cork, and is plugged near its top with cotton wool, care being taken that the plugs are loose enough to allow air to pass freely. The whole is sterilized and inoculated and allowed to remain. The glass tube, which passes through the rubber cork, is then connected with a Kipp's or other hydrogen-generating apparatus by means of a rubber tube, and a current of hydrogen is passed through the flask. The hydrogen bubbles through the bouillon and escapes by the lateral tube. After the gas has escaped for about an hour, a small capsule containing mercury is applied to the end of the lateral branch, so that the open end just dips below the surface of the mercury, and the tube which passes through the rubber cork is sealed off in the blow- pipe flame, care being taken that all the air has been expelled from the flask by a free current of hydrogen. The flask, with the capsule of mercury applied to the end of the lateral branch, can then be placed in the incubator. Thus the mercury forms a valve ; air cannot enter, while gases formed by the growth of the organism have free exit." By this simple apparatus the bacillus of tetanus is grown in the flask of the chemist in an atmosphere of hydrogen. Air or oxygen is totally excluded, this microbe being anaerobic. Prof. "Win. H. Welch of Johns Hopkins University, in his address before the American Medical Association at Newport, June 28, 1889, said : "Among the pathogenic bacteria which have their natural home in the soil the most widely distributed are the bacilli of malignant oedema and those of tetanus. I have found some garden-earth in Baltimore extremely rich in tetanus bacilli, so that the inoculation of animals in the laboratory with small bits of this earth rarely fails to produce tetanus." The fact, as stated by Prof. Welch, that the bacillus of tetanus has its natural home in the soil, throws light on many interesting observations which have been recorded in the literature of tetanus. Several years ago that large part of New York Island now occupied by the Central Park, and between the Central Park and the Hudson River, was occupied by the laboring class, living in shanties of the simplest construction. The streets were not sew- ered, and refuse matter from the shanties and stables, the two being often built together, was dumped upon the open spaces. The stables were occupied by horses and cows. As might be expected, these simple and primitive domi- ciles and their surroundings were filthy as were the habits of most of the families. Tetanus neonatorum was not uncommon in this part of ihe island. I recollect that in one of the shanties in this locality two infants died o\' this disease at an interval of about fifteen to eighteen months. These observa- 134 DISEASES OF THE NEWLY-BORN. tions correspond with the fact that many have stated that the bacilli of tetanus thrive best among the germs of putrefaction and in a soil mixed with the excreta of horses. Another fact, showing that the soil is the natural home of the tetanus bacillus, was observed some years ago by surgeons of Bellevue Hospital. The surgical patients entering this hospital from a certain part of Long Island were very liable to have tetanus at the time of entering or to manifest it soon after. There are or have been localities in every climate where tetanus neona- torum was the most prevalent and fatal of the infantile diseases. The bleak and barren islands of Hiemacy and St. Kilda in the far north, nearly destitute of vegetation and with guano for fuel, probably containing the tetanus bacillus, the dirty negro cabins of the Southern States, Fulda, Demerara, and Bombay, may be mentioned among the places where tetanus neonatorum is or has for lengthened periods been so common as to materially check the increase of population, and afford evidence of the correctness of the theory that the natural home of this bacillus is the soil. Several cases have recently been reported throwing light on the etiology and pathology of tetanus. Paul Berger states that he requested the late distinguished surgeon M. Nelaton to see a case of tetanus. Nelaton sat on the edge of the bed, watched the undressing of the wound, and withdrew without having touched the patient. A boy of eight years had been run over by a fiacre and brought to the hospital, having multiple contused wounds. Nelaton and the associate surgeon washed their hands in a solution of cor- rosive sublimate and partly dressed the wounds, an externe completing it. Seven days subsequently the boy began to exhibit unmistakable symptoms of tetanus, such as trismus, lockjaw, the sardonic grin, and opisthotonos, but eventually recovered (La France medicale, June 21, 1888). Dr. Adam reports the case of Chas. S- , who was admitted into the Foochow Native Hospital Sept. 28, 1887, with a crushed toe, which was am- putated, being gangrenous. On the following evening tetanus appeared. Case II. — S. I , aged thirty-one years, was admitted into the same hospital on Oct. 8th, having internal bleeding piles. These were ligated on the 10th, and the improvement was so rapid that he returned home, apparently well, on Oct. 19th. On the following day he returned to the hospital, complaining of stiffness of the back and jaws. The disease was recognized. He became despondent, and died on the 26th. Tetanus not being common in Southern China, the occurrence of the above cases is strongly suggestive of the com- municability of the disease. Rochelot has also narrated (La Semaine med., Sept., 1888) two cases, the second of which evidently resulted from the first. They occurred in the laparotomy ward of a hospital, and, as the flower-beds of the hospital had recently been manured, it was believed that the first case originated from the infected soil. The fact familiar to army surgeons that after certain sanguinary battles the wounded who have fallen to the ground have been very liable to tetanus is most satisfactorily explained on the supposition that the soil of the battle- field contains the specific microbe. Sometimes tetanus follows injuries which are not attended by any breach of surface through which the bacillus could enter, and in some instances the intervals are so short between the injury and the commencement of the tetanus that it seems very improbable that the tetanus could be due to the agency of the bacilli, but rather to injury of the peripheral nerves, and consequent excitation of the reflex spinal system. Thus cases have been reported in which only twenty-four or twelve hours, or even a shorter time, elapsed between the injury and the tetanus — too short a time, it would seem, for the development of bacilli. In studying the causa- TETANUS NEONATORUM. 135 tion of tetanus, whether of the neonati or of older patients, we should not overlook the fact that there is a form of the disease designated puerperal, of which form the late Sir James Y. Simpson collated the histories of over twenty cases. (See Simpson's Obstetrical and Gynecological Works, vol. i.) Puerperal tetanus occurs after abortion or labor at term, or after intra-uterine operations, and is probably correctly attributed to decaying animal tissue, which, excluded from oxygen, generates hydrogen and other poisonous gases. Such cases have given rise to the opinion held by some that the germs of tetanus are occasionally received into the system by inhalation, and are developed in the putrid substance with which they come in contact. Another theory held by some distinguished specialists in nervous diseases is that exposure to cold is an important cause, and is sufficient in itself to produce the disease. Hence Gower states that there is a variety of tetanus which is caused by exposure to cold, and which he designates idiopathic or rheumatic. By this theory it is easy to find an explanation for the origin of cases of tetanus neonatorum, several of which have been reported, in which the umbilicus and its vessels seemed normal and there was no injury of the cutaneous surface. In my opinion the time is not far distant when the bacillus of tetanus will be regarded as the cause of endemic, epidemic, and a large proportion of single cases. Occurring without traumatism or any appreciable cause, we may accept the theory of Gower, that in these cases of obscure origin the cause is " taking cold." But it seems to me not unlikely that the investigations in reference to the causation of tetanus may end in a similar way to those in regard to diphtheria ; that is, that true tetanus is always produced by the bacillus of Nicolaier, but there is a spastic muscular contraction in infancy as well as in adults which is due to a cause or causes distinct from the bacillus. In examining the literature of tetanus it is evident that the tonic con- traction of the muscles in certain cases which has been supposed to indicate the presence of tetanus has been due to spinal or cerebro-spinal meningitis, and not to tetanus. Thus, Billard reported a case in which tonic contraction of the muscles occurred in an infant three days old, and the anatomical characters observed after death were those of spinal meningitis. That tonic muscular contractions frequently occur in infancy and childhood in conse- quence of meningeal inflammation is well known, and in some of the epi- demics reported as tetanus meningitis was present, and was doubtless the cause of the muscular contractions. Such an epidemic was observed by Prof. Cederschjold in Stockholm in 1834. Within a few months he treated forty- two cases, and in the bodies examined after death he found a fibrinous exuda- tion at the base of the brain. I see no reason to doubt that the epidemic, which he describes as one of tetanus, was one of cerebro-spinal fever, more frequently designated cerebro-spinal meningitis. Time of Commencement in Fatal Cases. €ase 1. Male ; taken when three days old ; lived sixty hours. Labatt, Edin, Med. and Surg. Journ., April, 1819. " 2. Female ; taken when three days old ; lived forty hours. Ibid. " 3. Taken when five days old ; lived fifty hours. Ibid. " 4. Taken when three days old ; lived one day. Ibid. " 5. Male ; taken when two days old ; lived two days. Billard, Treatise on Diseases of Children, Stewart's trans., p. 477. " 6. Male ; taken when three days old ; lived two days. Romberg. il 7. Male ; taken when six days old ; lived ninety-three hours. Dr. Imlach, Month. Journ. of Med. Sci., Aug., 1850. " 8. Female; taken at five days ; lived four days. Caleb Woodworth, M. D., Boston Med. and Surg. Journ., Dec. 13, 1831. 136 DISEASES OF THE NEWLY-BORN. Case 9. Negro; taken at seven days ; lived twenty-four hours. P. C. Gaillard, M. D., South. Journ. of Med. and Phar., Sept., 1846. " 10. Male ; taken when seven days old ; lived one day. Augustus Eberle, M. D., Missouri Med. and Surg. Journ.. 1847. " 11. Taken when seven days old. D. B. Nailer, N. 0. Med. Journ., Nov., 1846. " 12. Male; taken when three days old; lived one day. N. 0. Med. and Surg. Journ., May, 1853. " 13. Negro; taken when three days old; lived three days. Robert H. Chinn, M. D., N. O. Med. and Surg. Journ. " 14. Taken when two days old ; died in four hours after the doctor's visit. Ibid. " 15. Taken when seven days old ; lived one day. C. H. Cleveland, New Jersey Med. Rep., April, 1852. " 16. Negro ; taken when seven days old ; death finally. Greenville Dowell, Amer. Journ. of Med. Sci., Jan., 1863. " 17. Taken when twelve days old; lived one day. Thomas C. Boswell, com- municated to Dr. Sims. Amer. Journ. of Med. Sci., 1846. " 18. Taken when about five days old; died at about the age of nine days. B. R. Jones, Ibid. " 19. Taken at or soon after birth ; lived two days. Dr. Sims, Amer. Journ. of Med. Set, April, 1846. t; 20. Taken at the age of six days ; lived one day. Ibid. " 21. Taken when two days old ; lived two days. Ibid. 11 22. Male ; taken at the age of eight days ; died in three hours. Communi- cated to the writer. " 23. Taken at the age of twelve hours ; lived two days. Communicated to the writer. " 24. Female ; taken when seven days old ; lived forty-five hours. The writer. " 25. Male taken at the age of seven days ; lived forty-eight hours. Ibid. " 26. Female ; taken at the age of eight days ; lived three days. Ibid. " 27. Female ; taken at the age of five days ; lived three days. Ibid. " 28. Female ; taken when four days old ; lived two days. Ibid. " 29. Taken when six days old; died next day. Ibid. " 30. Taken when five days old ; lived twenty-four hours. Ibid. 11 31. Taken when eight days old ; lived two days. Ibid. " 32. Male : taken when five days old ; lived one day. Ibid. Favorable Cases. Case 1. Negro female ; taken when three days old ; recovered in a few days. Robert S. Baily, Charleston Med. Journ. and Rev., Nov., 1848. 2. Negro ; taken at eleven days ; recovered in fifteen days. W. B. Lindsay, N. 0. Med, Journ,, Sept., 1846. 3. Negro ; taken when ten days old ; recovered in thirty-one days. P. C. Gaillard, Charleston Med, Journ. and Rev., Nov., 1853. 4. Male ; taken at the age of eight days ; recovered in twenty-eight days. Ibid. 5. Negro ; taken at seven days ; recovered in fifteen days. Augustus Eberle, Missouri Med. and Surg. Journ., 1847. 6. Taken when eight days old ; recovered in four weeks. Furlonge, Edin. Med. and Surg. Journ., Jan., 1830. 7. Taken at the age of one week ; recovered in two days. Dr. Sims, Amer. Journ. of Med. Sci., April, 1846. 8. Female ; taken at the age of three days ; recovered in five weeks. The writer. Period of Commencement. — Finckh, 1 who saw cases of tetanus of the newly-born in the Stuttgart Hospital, states that it began in 1 case on the second day after birth, in 8 on the fifth, and in 7 on the seventh. Copland 2 says that it generally commences on the first seven or nine days 1 Hecker's Annalen, vol. iii. No. 3, p. 304. 2 Medical Dictionary. TETANUS NEONATORUM. 137 after birth, and rarely later than the fourteenth. Romberg states that it commences between the fifth and ninth days. In 200 cases observed by Reicke in Stuttgart in the course of forty-two years it was never found to commence before the fifth, rarely after the ninth, and never after the eleventh, day. Schneider says that the disease occurs oftenest between the second and seventh, and rarely after the ninth, day. In 6 cases reported by Dr. C. Levy of Copenhagen it began in 2 on the third day, in 2 on the fifth, and in 2 on the sixth. Dr. Greenville Dowell, 1 who has seen much of tetanus neonatorum among the negroes in Mississippi and Texas, says it is almost sure to come on between the fifth and twelfth days after birth. In the 40 cases embraced in the above table the disease began as follows : Age. Cases. Under two days 2 Two davs . 1 Three days 9 Four days 2 Five days 6 Six days 3 Seven davs 8 Eight days 6 Ten days 1 Eleven days 1 Twelve days 1 Pathology. — It is an interesting fact that in the warm regions of the United States the victims are chiefly negro infants. L. S. Grier, M. D., 2 of Mississippi says : " The first form of disease which assails the negro among us is trismus. The mortality from this disease alone is very great. No sta- tistical record, we suppose, has ever been attempted, but from our individual experience we are almost willing to affirm that it decimates the African race upon our plantations within the first week of independent existence. We have known more than one instance in which, of the births for one year, one- half became the victims of this disease, and that, too, in spite of the utmost watchfulness and care on the part of both planter and physician. Other places are more fortunate, but all suffer more or less ; and the planter who escapes a year without having to record a case of trismus nascentium may congratulate himself on being more favored than his neighbors, and prepare himself for his own allotment, which is surely and speedily to arrive." Dr. Wooten 3 says: " It is a disease of fatal frequency on the cotton plantations in this section of Alabama." He has, however, never seen a white child affected with it. While tetanus infantum prevails in regions wide apart and presenting very diverse climatic conditions, there is a similarity as regards the personal and domiciliary habits of the people who suffer most from its occurrence. It occurs chiefly among those who are filthy and degraded in their habits — who live, either from choice or necessity, in neglect of sanitary requirements. It is now demonstrated beyond all doubt that the bacillus of tetanus, like most pathogenic germs, is fostered and rendered more virulent by filth, and especially the soil which has been occupied by old stables and saturated by the excreta of horses, is the richest of all in the development of this microbe. That uncleanliness and impure air are causes of tetanus is as fully demonstrated as most facts in the etiology of diseases. The attention of the profession was forcibly directed to this cause by Dr. Joseph Clarke in a paper * Amer. Journ. of Med. Sri., Jan., 1863. 2 iV. 0. Med. and Surg. Journ., Max, 1854 3 Ibid., May, 1846. 138 DISEASES OF THE NEWLY-BORN. read before the Koyal Irish Academy in 1789. This physician was in charge of the Dublin Lying-in Asylum, and had rightly concluded that the mortality among the new-born infants was due to imperfect ventilation. Through his advice, apertures (twenty-four inches by six) were made in the ceiling of each ward ; three holes, an inch in diameter, were bored in each window-frame ; the upper parts of the doors leading into the gallery were also perforated with sixteen one-inch apertures, and the number of beds was reduced. The results of these simple sanitary regulations may be seen from Dr. Clarke's own statement. He says : " At the conclusion of the year 1782, of 17,650 infants born alive in the Lying-in Hospital of this city, 2944 had died within the first fortnight — that is, nearly every sixth child." The disease in nine- teen cases out of twenty was tetanus. After the wards were better ventilated — namely, from 1782 till the time of the preparation of Dr. Clarke's paper — 8033 children were born in the hospital, and only 419 in all had died, or about one in nineteen. So impressed was Dr. Evory Kennedy, who at a later period had charge of the same asylum, with the belief that Dr. Clarke had discovered the true cause, and had been able in great measure to prevent it, that he enthusiastically writes : " If we except Dr. Jenner, I know of no physician who has so far benefited his species, making the actual calculation of human life saved, the criterion of his improvements." The cases occur- ring in my own practice have almost all been in tenement-houses, where habits of cleanliness are not observed, and I have not yet seen in the prac- tice of others nor heard of a case which occurred in the better class of dom- iciles. The statements of physicians in the Southern States, who speak from extensive observation among negroes, are strongly corroborative of the belief that the disease is in great measure due to uncleanliness and lack of pure air. Dr. Greenville Dowell of Texas states that he has been able to trace tetanus infantum to the bed-clothes, saturated with excrementitious matters, which are found in the negro cabins. In a paper published by Prof. John M. Wat- son 1 the frequency of this disease among negroes is accounted for as follows : " When called to see their children we find their clothes wet around their hips, and often up to their armpits, with urine The child is thus pre- sented to us, when, on examination, we find the umbilical dressings not only wet with urine, but soiled, likewise, with faeces, freely giving off an offensive urinous and fecal odor, combined at times with a gangrenous fetor arising from the decomposition, not desiccation, of the cord." In the bodies of the new-born who die of tetanus lesions are observed which doubtless result from the spasms. Again, others are found which from their nature could not be a result, and which, being observed in different cases, are believed to have a causal relation. The most frequent of such lesions is inflammation of the umbilicus or umbilical vessels. Moschion, who lived in the first century of the Christian era, stated, in writings still extant, that stagnant blood in the umbilical vessels sometimes is associated with dangerous disease in the new-born infant, and it is supposed, though this is doubtful, that he referred to tetanus. In modern times the attention of the profession has been more particularly directed to tetanus neonatorum by a paper published by Dr. Colles. 2 The observations contained in this paper were made in the Dublin Lying-in Hospital during a period of five years. In each of these years he witnessed from three to five post-mor- tem examinations in cases of infantile tetanus, and the lesions, he states, were in all much alike, as follows : The floor of the umbilical fossa was lined by a membrane apparently formed by suppurative inflammation, and in the centre of this fossa was a large papilla. This papilla consisted of a soft yellow sub- 1 Nashville Journ. of Med. and Surg., June, 1851. 2 Dublin Hospital Reports, vol. i., 1818. TETANUS NEONATORUM. 139 stance, apparently the product of inflammation, and in all the cases the um- bilical vessels were in contact with this substance and were pervious. In a few instances superficial ulcerations were found near the mouth of the umbili- cal vein, and occasionally the skin surrounding the umbilicus was raised. The peritoneum covering the vein was highly vascular, often not to a greater dis- tance than an inch above the umbilicus, but sometimes as far as the fissure of the liver. The peritoneum in the course of the umbilical arteries pre- sented the inflammatory appearance in still greater degree, sometimes as far as the bladder. The connective tissue lying along the arteries and urachus anteriorly was loaded with a yellow watery fluid. The inner surface of the umbilical vein was not inflamed, but its coats in general were thickened. On slitting open the arteries a thick yellow fluid, resembling coagulable lymph, was found within their coats, and in all cases these vessels were thickened and hardened as far as the fundus of the bladder. Dr. Finckh, who observed 25 cases in the Stuttgart Hospital, believes that the most frequent pathological state was suppuration or ulceration of the umbilical cord. In 10 of the 25 cases the navel was dry and cicatrized; in the remainder it was either wet or swollen, with a bluish-red inflamed edge at the margin of the navel ; a dirty viscid pus covered the umbilical depression. Dr. Levy, physician at the Foundling Hospital in Copenhagen, attended 22 cases in that institution in 1838 and 1839. Of these 20 died, and 15 were examined carefully after death. In 14 there were decided marks of inflam- mation of the umbilical arteries, especially of those portions lying along the urinary bladder ; in several cases the peritoneum over the arteries was much injected, and in 3 adherent either to the omentum or intestine by coagulable lymph ; the coats of the arteries were thickened, their cavities dilated and con- taining dark reddish-brown or greenish puriform matter, always fetid. Some- times the arterial tunica interna was found ulcerated and absent in places, and there was spongy thickening of the subjacent connective tissue. In 2 cases the ulcerative process had extended from the tunica interna to the peritoneum, and there was a deposit of thick ichorous matter around the ulcer ; in 1 case both arteries were so softened that their coats were scarcely distinguishable, and in another these vessels had become gangrenous. The appearance of the umbilicus was unchanged in 4 cases ; in 10 the fundus was red and filled with puriform fluid, which quickly reappeared when removed, and, in general, shortly before death the navel presented a greenish color. According to Romberg, Dr. Scholler made post-mortem examinations in 18 cases of tetanus infantum, and in 15 found inflammation of the umbilical arteries. The vessels were swollen near the bladder, in 1 case to the diameter of four lines, and were found to contain pus. The lining membrane was eroded or covered with an albuminous exudation. Both arteries were not always equally inflamed, and in 3 cases only 1 was affected. Schneeman 1 found minute points of suppuration in the umbilical vein in 8 cases, and pus throughout the course of this vessel in 1. The observations mentioned above were made, for the most part, in hos- pitals on the Continent, but similar observations have been made in private practice. M. Borian 2 of the Isle of Bourbon says that he has found in every case inflammation around the umbilicus. Dr. Ransom 3 states in a communi- cation to Prof. John M. Watson that he has never seen a case of tetanus of the new-born in which the umbilicus was healthy. In a case related by Robert S. Bailey* there was a hard scab on one side of the umbilicus, and this part 1 Holscher's Annalen, vol. v. p. 484, 1840. 2 Gazette medimle, Paris, July 11, 1841. 3 Nashville Journ. of Med. and Surg., June, 1851. 4 Charleston Med. Journ. and Rev.. Nov., 184S. 140 DISEASES OF THE NEWLY-BORN. was much distended. A discharge followed the removal of the scab, and the child recovered. In a favorable case related by W. B. Lindsay l the umbilicus was tumid and not disposed to heal. Dr. H. 0. "Wooten 2 attributes the disease to the condition of the umbilicus and umbilical vessels, and states that he has found the umbilicus gangrenous. A case has been reported in which the umbilical vessels were blocked up by purulent matter. 3 At a meeting of the Obstetrical Society of Edinburgh, held April 24, 1850, Dr. Imlach related a case in which there was a dark and gangrenous appearance on the integument around the umbilicus, and the peritoneum underneath was also dark, but not inflamed ; umbilical vein healthy ; a little fibrin in the left umbilical artery ; right umbilical artery much diseased ; its two inner coats apparently destroyed, and in their place a yellow pultaceous slough in which pus-globules were dis- covered with the microscope. It is evident that the pathological state of the umbilicus and umbilical vessels described above, which has been noticed by so many observers in different countries, cannot result from the tetanus. It is possible that the puriform substance noticed in the umbilical vessels was disintegrated fibrin, which had coagulated at the time of ligation of the cord, and the cells seen by Dr. Imlach and others may sometimes have been white corpuscles still remaining from the stagnated blood. 4 Still, the evidences of inflammation, in at least a part of the cases related above, were of a positive character. The belief that umbilical lesions occasionally cause tetanus infantum com- ports with the well-known traumatic causation of tetanus in the adult. This belief is strengthened by the fact which will appear farther on in our remarks that tetanus of the new-born, from being frequent in certain localities, has become infrequent through greater care in dressing and managing the umbili- cal cord. But there are cases of tetanus infantum in which there is no disease in or about the umbilicus. Dr. Finckh of Stuttgart examined the umbilical vessels in eleven cases without discovering any pathological change. Dr. Samuel B. Labatt, 5 master of the Dublin Lying-in Hospital, published a paper entitled " An Inquiry into the Alleged Connection between Trismus Nascentium and Certain Diseased Appearances in the Umbilicus." This paper was designed as a reply to the essay of Dr. Colles. Dr. Labatt relates several cases in which there was no disease of the umbilicus and umbilical vessels, and others in which the disease was so slight that it probably pro- duced no injurious effect on the health of the child. Dr. James Thompson, 6 who spent considerable time in the tropical regions, says : " I have myself examined nearly 40 cases of infants that have sunk under this complaint. In many I have looked at no other part than the navel, and have found it in all states — sometimes perfectly healed, especially if the infants had lived several days ; at other times a simple clean wound. When death occurred on the fifth or sixth day the wound was frequently in a raw state. I never yet saw it in a sphacelated condition." The writer concludes from his observations that there are cases in which the cause is located elsewhere than in the umbilicus or umbilical vessels. Dr. John Breen 7 remarks: "From dissections .... we have never been able to discover any peculiar morbid appearance which would justify us in offering any explanation of the pathol- ogy of the disease." In my own cases there was no evidence of disease of the umbilicus or umbilical vessels, so far as could be ascertained by external 1 N. 0. Med. and Surg. Journ., Sept., 1846. 2 Ibid., Mav, 1846. 3 Ibid., May 1, 1853. * VirchonJ s Cellul. Pathol. 6 Edin. Med. and Surg. Journ., April, 1819. 6 Ibid., Jan., 1822. 7 Bub. Journ. of Med. and Chem. Sci., January, 1836. TETANUS NEONATORUM. 141 examination, and in one (No. 32) a careful post-mortem examination dis- closed no lesion of these parts. Other observations might be related showing that the bacillus of tetanus does in most instances enter the system of the newly-born through the umbilicus and umbilical vessels, but a lacerated or wounded surface may be the gateway of infection whatever the age. Symptoms. — In many cases premonitory symptoms are absent or are so slight as to escape notice. In some patients fretfulness precedes the attack, but no more than is often observed in those who continue in good health. The first symptom which alarms the parents and shows the grave nature of the commencing disease is inability to nurse or evident pain and hesitation in nursing. Commencing with rigidity of the masseters, the disease gradually extends to the other voluntary muscles, and in the course of a few hours the muscles of the limbs as well as of the trunk are involved. Persistent mus- cular contraction, which is the pathognomonic feature of infantile tetanus, is developed not fully in the beginning, but by degrees in each aiFected muscle, so that it is not till after the lapse of several hours, perhaps even a day, that the greatest amount of rigidity is attained. Therefore in the commence- ment of the disease the limbs can be flexed and the jaw pressed open more readily than at a subsequent stage, though with manifest pain to the infant. During the period of maximum rigidity the jaws are fixed almost immov- ably, often with a little interspace between them, against which the tongue presses and in which frothy saliva collects. The head is thrown backward and held in a fixed position by the stiffness of the cervical muscles. The fore- arms are flexed ; the thumbs are thrown across the palms of the hands, and are firmly clenched by the fingers ; the thighs are drawn toward the trunk ; the great toes are adducted and the other toes flexed. Occasionally opisthot- onos results from the extreme contraction of the dorsal and posterior cervical muscles. The infant can sometimes be raised without any yielding of the muscles by the one hand under the occiput and the other under the heels. The rigidity is liable to variation in its intensity even after the full devel- opment of the disease. If the infant be quiet, especially if asleep, the mus- cles are partially relaxed to such an extent sometimes, in the first stages of the complaint, that the features have a placid and natural expression, though only for a short time. Frequent exacerbations occur in the muscular con- traction, sometimes without any apparent cause, and sometimes produced by anything which excites or disturbs the child. Attempts to open the lips or jaws or eyelids or to bend the limbs, blowing on the face, and even the crawling of a fly upon it, occasion the paroxysms. During the paroxysm the eyelids are forcibly compressed, as well as the lips, which are either drawn in or are pouting ; the forehead and cheeks are thrown into wrinkles and the physiognomy is indicative of great suffering. The unnatural positions of the trunk and limbs which result from muscular contraction are increased for the moment ; the head is more forcibly thrown back and the limbs more strongly flexed. The muscular movements which occur during the paroxysms are sometimes described as clonic spasms. There is indeed occasionally some quivering of the limbs, and yet. as I have on differ- ent occasions noticed, so far from the muscular action being a clonic spasm, it is clearly tonic and is intensified during the paroxysm. In fatal cases the paroxysms occur more and more frequently until the period of collapse. The crying of the child affected by tetanus is never loud, however great the suffering. It is variously described by writers as " whimpering " or " whining." It is of this suppressed character in consequence of the rigid state of the respiratory muscles and their imperfect movement. 142 DISEASES OF THE NEWLY-BORN. During the exacerbation respiration is suspended, or so imperfect and the circulation so retarded that the surface becomes of a deep-red, almost livid, color. Sometimes epistaxis occurs, affording partial relief to the congestion, and sometimes, though less frequently, the blood forces itself from the con- gested liver along the umbilical vein and escapes from the umbilicus. The intense passive congestion consequent on the tetanic spasm is general through- out the system, but extravasation of blood appears to be more common around the brain and spinal cord than elsewhere. The frequency of the pulse and respiration varies in different cases and at different stages of the same case. They are often somewhat accelerated, but at other times are natural, or are even slower than in health. While the appetite of the infant, to appearance, is not diminished, the pain which it experiences in nursing is such that alimentation is necessarily deficient. It can be fed with a spoon for a time after it ceases to take food in the natural way, but artificial feeding soon fails. The milk placed in its mouth is in great part pressed back through the violence of the spasm which is induced by the attempt to feed it. In consequence of imperfect nutrition the infant rapidly wastes away. There is no other disease, except the diarrhoea! affections, in which the ema- ciation is so rapid. In a case related by Dr. W. B. Lindsay l the record states that " the infant was fat three days before, but was now emaciated." Rom- berg, who saw tetanus neonatorum in European hospitals, and Robert H. Chinn 2 of Texas, both speak of the rapid emaciation. The trunk and extrem- ities lose their fulness and the features become pinched. Several observers have noticed the appearance of miliaria in this reduced state of system, especially around the shoulders, and sometimes a decidedly icteric hue appears on the skin. The condition of the intestines is not uniform. They may be relaxed, particularly if the disease be due to some irritation in them ; in other cases the stools are natural or constipated. It is often difficult to ascertain the state of the eyes, since attempts to open the eyelids bring on spasms and cause firm compression of the lids against each' other. According to Sir Henry Holland, one of the first symp- toms which occurred in cases on the island of Heimacy was strabismus, with rolling of the eyes. But this statement must be received with caution, since these cases were not seen by any physician and the information was obtained from the parents and priests. If true, the proximate cause of the disease in Heimacy would seem to be located in the cerebro-spinal axis. Contraction of the pupils commonly occurs in the stage of collapse. Mode of Death. — Death in infantile tetanus may occur from apnoea in the paroxysms, from extreme congestion of the cerebral vessels, or apoplexy ; and, lastly, it may occur from exhaustion. The last mode is probably the most frequent. Prognosis. — All writers till recently agree that tetanus of the infant rarely terminates favorably. Cullen attributes the ignorance of physicians in regard to this disease to the fact that it is so little amenable to treatment that they are not usually summoned to attend those affected with it. In the island of Heimacy, of 185 cases occurring during a series of years about the commencement of the present century, not one survived; and in the same locality, at Westmannoe, a small islet, 64 per cent, of all the infants born died of trismus (report of Dr. Schleisner). Similar statements in regard to the mortality of tetanus infantum are given by physicians in the Southern States. Dr. H. 0. Wooten 3 of Alabama says that he has " never seen a X N. 0. Med. Journ., Sept., 1846. 2 iV. 0. Med. and Surg. Journ., Sept., 1854. 3 N. O. Med. Journ., May, 1846. TETANUS NEONATORUM. 143 decided case of tetanus nascentiurn that did not prove fatal, .... and that it is very generally deemed useless to call in medical aid after the initiatory symptoms are well declared." Mr. Maxwell, 1 speaking in reference to the West Indies, says : ; ' From observations which I have made for a series of years, .... I found that the depopulating influence of trismus nascentium was not less than 25 per cent. It scarcely has a parallel within the bills of mortality." Dr. D. B. Nailer 2 says : ki About two-thirds of the deaths among the negro children are from this disease, and so uniformly fatal is it that a physician is never sent for." Yet death does not always result : eight of the forty cases in my collection recovered ; but a correct opinion cannot be formed from this of the actual ratio of favorable to unfavorable cases, since favorable cases are much more likely to be published. In the history of these 8 cases two interesting facts are noticed, which when present may serve as a ground for hope of a success- ful termination. These were, the age at which the disease began and the fluctuations of the symptoms. With two exceptions, the infants who recov- ered were about a week old when the initiatory symptoms appeared, and there were fluctuations in the gravity of the symptoms ; whereas fatal cases ordi- narily grow progressively worse. Yet in favorable cases the symptoms are never so severe as they become in a Jew hours in those who succumb. Duration in Fatal Cases. — Of 18 cases observed by Finckh in the Stuttgart Hospital, 15 died in two days, 2 in five days, and 1 in seven days. During the epidemic in the Stockholm hospitals in 1834, where 42 cases were treated, the disease seldom lasted more than two days. Romberg says : " It generally lasts from two to four days, but its duration is at times limited at from eight to twenty-four hours, and occasionally, though rarely, it extends from five to nine days." In 31 fatal cases in my collection, in which the duration is mentioned, 1 lived 3 hours. 11 others lived 1 day or less. 12 lived 2 days. 4 lived 3 " 3 lived 4 " Both Underwood, who published a treatise on diseases of children in 1789, and Dr. Elsasser at a more recent date, recorded fatal cases which were unusually protracted. The one described by Underwood was treated in the British Lying-in Hospital, and, although all the others treated in this institu- tion died by the third day, this lived six weeks ; but it is suggested by the author that death was due in part to some other affection. The child treated by Elsasser lived thirty-one days. Duration in Favorable Cases. — In the 8 favorable cases in my col- lection the duration of the disease, reckoned from the time when the infant ceased nursing till it began again, was as follows: In 1 case, two days; in 1, a few days; in 1, fourteen days; in 2, fifteen days; in 1, twenty-eight days ; in 1, twenty-one days ; and in the remaining case, about five weeks. Diagnosis. — To one who has seen this disease in the new-born or is familiar with its symptoms diagnosis is easy. The symptoms which possess diagnostic value are more manifest and reliable than in most other infantile maladies. Permanent rigidity of the voluntary muscles, with temporary exacerbations, such as have been described above, which are induced by any cause which disturbs the infant, as attempts to open the mouth or eyelids, is pathognomonic. 1 Jamaica Phys. Journ., copied into the London Lancet, April 11, 1S35. 2 N. 0. Med, Journ., November, 1846. 144 DISEASES OF THE NEWLY-BORN. Let us stop for a moment and consider the facts related above which have a bearing on therapeutics : (1) With possibly a few exceptions tetanus, whether occurring in man or animals, whether in the infant or adult, is the same disease, and is caused by the entrance into the system of a rod-shaped microbe two or three times the length of the tubercular bacillus. One end of the bacillus is somewhat rounded, so as to give it a pin-shape, and is enlarged by the presence of a spore. (2) The tetanus bacillus, as stated above, thrives most luxuriantly, and probably is most virulent, where dirt and filth abound. We have said also that its natural home is the soil, and not so much the virgin soil as soil which is rendered impure by the proximity and drainage of barnyards, and especially horse-stables. (3) Of the domestic animals, the horse and, to a less degree the sheep, are liable to tetanus, and hence those who are exposed by their occupations to these animals or to the soil infected by their excretions are more liable to tetanus from injuries, even from slight bruises or wounds, than are those whose occupations do not bring them into constant contact with these animals or with infected soil. (4) We have stated that the bacillus of tetanus is widespread, so that this disease occurs in every climate from the Arctic regions to Demerara or Bombay. But this bacillus, like that of diphtheria, has remarkable vitality and power for propagation, so that it has continued for an indefinite time to survive and multiply in certain localities, as in parts of Long Island, not- withstanding constant tillage. (5) As regards tetanus neonatorum, the observations which I have related show beyond doubt that in most instances the specific bacillus obtains entrance into the system through the umbilical blood-vessels and lymphatics, and within these vessels the toxine described and analyzed by Brieger and others, and which is so fatal, is produced. Preventive Treatment. — While tetanus neonatorum, if fully developed, is ordinarily fatal in spite of any remedial measures heretofore used, there is no doubt of the efficacy and value of preventive measures when properly employed. This was shown by the great reduction in mortality in the Dub- lin Lying-in Hospital through the thorough ventilation introduced by Dr. Clarke. Dr. Meriwether 1 of Montgomery, Ala., says: "When the disease appears endemically on a plantation it may be arrested by having the negro houses whitewashed with lime inside and out ; by raising the floors above the ground ; by removing all filth from under and about the houses ; by par- ticular attention to cleanliness in the bedding and clothing of the mother and in the dressing of the child, so as to prevent any of the matter from the umbilicus lying long in contact with the skin." Many physicians, especially in the Southern States, speak confidently of care in dressing the cord and attention to the umbilicus as a means of prevention. Graften 2 says that he has " never known the disease to occur in any child whose navel had the tur- pentine dressing." He uses turpentine as follows : "At the first time a few drops of undiluted turpentine are applied immediately to the umbilicus around the cord, and it is anointed at every succeeding dressing, the turpentine being diluted one-half or two-thirds with olive oil, lard, or fresh butter." This use of turpentine has also been recommended by other practitioners in warm regions. Dr. John Furlonge 3 of St. John's, Antigua, believes that no case would 1 Amer. Journ. of Med. Sci., April, 1854. 2 N. 0. Med. and Surg. Journ., July, 1853. 3 Edln. Med. and Surg. Journ., January, 1830. TETAXUS NEONATORUM. 145 occur with the following treatment : " The cord, when divided, should be wrapped in clean linen. Every night for two weeks one or two drops of tinct. opii and spts. vini, equal parts, should be given, and castor oil, with a little magnesia, every morning. The child must be washed in tepid water every morning and the funis dressed." If this treatment be attended by the success which is claimed for it by Dr. Furlonge, so great care in dressing the cord is certainly well repaid in localities, as at Antigua, where a large pro- portion of the infants die of tetanus. But since it is now known that tetanus neonatorum, like that at a more advanced age, usually has a microbic origin, an antiseptic and germicide dressing of the cord is evidently preferable, as by filling the umbilicus and dusting the cord with aristol. Some experienced observers go so far as to assert that it is possible to ward off tetanus neonatorum after the occurrence of premonitory symptoms. Dr. Dowell l says : " Some with slight twitchings of the muscles have recov- ered without any trouble by being put into a mustard-bath, washed clean, and put in a clean and well-ventilated cabin." Treatment. — In considering the effect of medicinal agents which have been employed in the treatment of infantile tetanus, the great difficulty which the child experiences in swallowing should be borne in mind. Without care a considerable part of the dose is lost by the spasm of the muscles of degluti- tion, which ordinarily occurs when the spoon is placed in the mouth, so that, unless special attention be given to this matter, it is uncertain whether the prescribed dose is fully administered. The treatment employed by different physicians has been very diverse. Antiphlogistic remedies were prescribed by Finckh, but every case so treated was fatal. He states that whenever blood was abstracted, even in small quan- tities, the symptoms were aggravated. The same result has followed depletory measures in the practice of other physicians. The internal remedies which have been most frequently prescribed are opiates and antispasmodics. Furlonge in a favorable case gave laudanum in doses of one drop every three hours alternately with two grains of Dover's powder. Woodworth also gave one-drop doses of laudanum ; Eberle, one- sixth of a drop hourly. The opiate has generally been given in combination with an antispasmodic. The Dover's powder given every three hours by Furlonge was combined with five grains of sulphate of zinc. The hourly doses of laudanum by Eberle were combined with six drops of tincture of asafoetida. When anaesthetics began to be employed in the treatment of diseases it was believed that they would be especially useful in cases of tetanus. Accord- ingly, chloroform has been used in tetanus in the infant, with the effect of controlling the spasm during the time of its use, but without curing the dis- ease. In Case 7 in our first table it was employed several times, but appar- ently without delaying the fatal result. The editor of the New Orleans Medical and Surgical Journal states, in the May issue of that periodical for 1853, that he has used chloroform in tetanus neonatorum, with the effect, he believes, of prolonging life. Anaesthetics certainly relieve the suffering of the infant, and on this account, even if they do not prolong life, their judi- cious employment seems proper. The remedy which has been more efficient than those mentioned above has been the hydrate of chloral, given with or without one of the bromides. Since the introduction of this agent into therapeutics it has been employed by several physicians in the treatment of this disease with so good a result that it will probably supersede all other medicines for this purpose. Dr. Widerhofer of Vienna states that he has saved six out of ten or twelve bv 1 Amer. Journ. of the Med. Sci., January, 1863. 10 146 DISEASES OF THE NEWLY-BORN. the use of chloral. He prescribes it in doses of one to two grains by the mouth, or, if there be great difficulty in swallowing, two or four grains by the rectum. Dr. F. Auchenthales relates a case in which he gave even six- grain doses, and in nine days the disease had entirely disappeared. I have recently employed hydrate of chloral in a case of tetanus, giving it in half- grain or one-grain doses every two hours, except when there was profound sleep. The disease was fully developed and the symptoms severe when I was called. I did not believe that the infant with the old remedies would live more than two days, but by the use of chloral life was prolonged nearly one week. Moreover, by the use of chloral the suffering of the infant is greatly diminished. The frequent inhalation of sulphuric ether also aids materially in controlling the spasms. The administration of alcoholic stimulants is required at short intervals on account of the rapid emaciation and great prostration. Local treatment directed to the umbilicus in those cases in which there is evidence of inflammation of the umbilicus or umbilical vessels should not be neglected. The application of an emollient poultice to the umbilicus has been followed by apparent improvement, if we may believe the statement of some physicians who have made use of this treatment. Dr. Meriwether of Alabama says if there be no improvement from the medicine which he orders he applies a blister, larger than a dollar, to the umbilicus, and with this treat- ment the child generally improves — a remarkable statement since so few improve at all. No one can fail to observe the need of early and continuous antiseptic treatment of the umbilicus, as in septicaemia. Aristol, iodoform, boracic or salicylic acid should be constantly and as deeply applied in the umbilical fossa as possible, mixed with a liquid, perhaps glycerin, to make it penetrate more deeply. A warm foot-bath, repeated at intervals of a few hours, and stimulating embrocations along the spine, are proper adjuvants to the treatment. The apparent encouraging results of the treatment of diphtheria by the subcutaneous injection of the serum of an animal rendered immune to this disease by repeated inoculations led to observations and experimentation to determine whether a similar treatment might be useful in tetanus. We have seen how the bacillus of tetanus can be propagated and obtained in the flask of the chemist, and it is easily communicated to the horse by inoculation. Tizzoni and Cattani, followed by others, have employed the antitoxine treat- ment of tetanus. It is obviously best, in order to determine its efficiency, to learn the results of its use whatever the age, for it is the same disease in infancy, childhood, and adult life. Escherich reports ( Wien. Jdin.Woch., Aug. 10, 1893) four cases of tetanus neona- torum treated by Tizzoni's antitoxine. The following are the statistics of these cases : In the four cases the umbilical cord was detached on the sixth, third, fourth, and fourth days : the incubation was two, nine, one, and seven days ; the duration, two, five. two. and twelve days. The fourth or last case only recovered. In all who died septic inflammation of the umbilical cord was present, and all exhibited septic symptoms. A little of the tissue at the umbilicus, taken from the bodies of the first and third cases and inoculated in mice, caused tetanus in them. In Case 1 (fatal) only 0.015 by 2.0 of antitoxic serum was injected; in Case 2 (fatal) the injections of 0.25 were discontinued on account of the occurrence of septic pneumonia ; in Case 3 (fatal) the tetanus was exceptionally severe, so that a good result could not be expected. In the case that recovered an injection (0.3) was given on the third and twice on the fourth day. Lesi (Rif. Med., Aug. 18, 1893) : A man wounded his foot with a piece of glass while walking over a heap of stable manure. Six days later tetanic phenomena appeared, which rapidly involved the muscles of the legs, neck, and back, and TETANUS NEONATORUM. 147 caused marked trismus and dysphagia. On the afternoon of the second day after the appearance of the symptoms the patient received a hypodermic injection of 50 cc. of serum obtained from one of Tizzoni's immunized horses, 1 gramme of which serum had been found sufficient to protect 10,000,000 grammes. After this injec- tion there was no further spread of the tetanic symptoms, which remained confined to the parts already affected. In these parts, indeed, the spasms became somewhat more pronounced during the first and second days of treatment. During the even- ing of the second day a further injection of 20 cc. was given, after which the patient had a fair night's rest. The next day another injection of 10 cc. was given. The patient was almost free from pain, except for the trismus and difficulty in swallow- ing. On the fourth day a last injection of 20 cc. was given, after which the patient rapidly convalesced and was able to leave the bed six days after the admission. In the British Med. Jowm., January 19, 1895, the case of a man is related who was injured by a catapult, and six days afterward began to have tetanic symptoms. The wound was half an inch below the symphysis of the lower jaw, and gave rise to a foul discharge containing shreds of string and shoemaker's wax. Trismus, inability to open the mouth, prominence and rigidity of the muscles of the neck and back followed. The symptoms gradually increased, and on the third day of the tetanus 2.5 grammes of Tizzoni's antitoxine in sterilized distilled water were introduced by punctures in the abdominal walls. Each puncture was painful and was attended by strong opisthotonic spasms. On the following day, October 7, or fourth day of the tetanus, 1 gramme (15 grains) was injected. On each of the fol- lowing days. October 8, 9, 10, 11, 12, and 13, either one-half or one gramme (7J or 15 grains) was injected, but none was used on the 15th. On October 16 his tongue was caught between the teeth, and could not be released by the attendants. Violent and almost continuous spasms followed, with laceration of the tongue and great dyspnoea. When the patient appeared to be dying, grain ^ of physostigmine and grain k of morphine were injected, and in less than a minute the masseters were so relaxed that the lacerated tongue was released and the lividity, dyspnoea and violent opisthotonic spasms ceased. On this eventful day the antitoxine was not employed, so that forty-eight hours elapsed without its use. On October 17th, 18th, and 19th one gramme each day was administered, and on October 20th half a gramme. From this time the patient steadily improved. Mr. Marriott, who reported the above case, summarizes the treatment as follows : •• Antitoxine, with the exception of the three injections of the phy- sostigmine and morphine, was the only remedy used in this case, as, though chloral was at first prescribed, only a very small quantity was swallowed. The patient certainly seemed much relieved by the treatment, and it is to be remarked that the severe and nearly fatal relapse occurred after the diminu- tion of the close on October 14th and its suspension on October 15th. He states also that the two injections of physostogmine and morphine when given together had a most salutary effect in diminishing the spasms." In the same number of the British Med. Journal a case is related better adapted to our purpose, for it is one of tetanus neonatorum treated with tetanus antitoxine, reported by Mr. Firth. The infant was born on Septem- ber 18, 1894, and after ligation of the cord the navel was dressed with a clean piece of linen. On the sixth day it was dressed with a scorched piece of linen soaked in castor oil. On the eighth day the infant was fretful and took the breast with difficulty. On the eleventh day after birth or fourth of the disease it was admitted into the Bristol General Hospital, and on the fifth day of the disease it was more carefully examined. It was icteric ; its eyelids tightly closed, the conjunctivae could not be seen ; the face was wrinkled; no risus sardonicus ; masseters hard; lower jaw rigidly fixed; head slightly retracted ; neck and spine very rigid ; arms and forearms adducted and rigid; fingers firmly flexed into the palm, and thumbs firmly flexed over them ; it swallowed with great difficulty, and became cyanotic when a little milk was placed in the mouth ; spasms, lasting three or four minutes and beginning and ending gradually occurred ; temperature normal 148 DISEASES OF THE NEWLY-BORN. or slightly subnormal ; pulse 12.8, resp. 36 ; chloral hydrate gr. i and potas. bromide, gr. 1 to 2, were administered every four hours. On the sixth, seventh, and eighth days no improvement occurred, but spasms of tonic muscular contractions severe and attended by cessation of respiration and very frequent, weak, or inappreciable pulse were present. At one time it was thought to be dead. On the eighth day of the disease the tetanus antitoxine was employed, six grains being injected under the skin of the abdomen in five places. On the ninth day a similar injection was made at 4 p. m., and the third at 8.30 P. m. On the tenth day the patient had eight of the spasmodic attacks of muscular rigidity lasting from five to fifteen minutes, and the longest suspension of respiration in the attacks was seven minutes. A last injection of twelve grains of tetanus antitoxine was made at 1 p. m., and death occurred at 8 p. m. It will be seen that the infant had four injections of the antitoxine, two grammes or thirty grains in all, without any appreciable controlling effect on the tetanus. No post-mortem examination was allowed, and nothing in the external appearance indicated that the navel or umbilical vessels sustained any causal relation to the tetanus. From the above cases, and from others of a similar nature which have been published, it appears that the tetanus antitoxine in order to be efficient must be used early, and more observations are required in order to ascertain what power it possesses in the treatment of tetanus even at an early stage. The tetanus antitoxine, like that of diphtheria, is still on trial, and many more observations will be required before its efficiency is determined. With or with- out this new remedy it is evident that the hydrate of chloral, with perhaps one of the bromides, should still be employed. The method of preparing and using the antitoxic serum is as follows : The toxine employed for immunizing the horse is prepared in a flask contain- ing grape-sugar bouillon and hydrogen, in the manner described by Mr. Hew- lett, which I have already related. The toxine of tetanus prepared in this manner in the flask of the chemist is such a powerful poison that in employ- ing it to immunize the horse by subcutaneous injections it is first diluted by admixture with an equal quantity of Grain's iodine solution. Hewlett in immunizing the horse employed three injections weekly, beginning with .5 c.cm., and gradually increasing to 8 c.cm. or 10 c.cm. from May 2d to June 22d, after which Mr. Hewlett gradually diminished the diluent until the pure toxine was employed on and after July 2d, but sometimes with dangerous symptoms. " On July 25th, 4 c.cm. were injected into the jugular vein, fol- lowed by rather alarming symptoms half an hour after, the animal falling prostrate with legs extended, labored respiration, and rapid small pulse." The animal recovered in ten minutes. As in preparing the diphtheritic anti- toxine, the horse should receive these injections about three times weekly for three to six months, but before immunized serum is placed in the hands of the physician or pharmacist it should be tested upon animals. Mr. Hewlett writes in reference to the antitoxic serum of the horse prop- erly prepared as follows : " Experimentally, the effects of the antitoxine are little short of marvellous. Minute doses injected into animals will completely neutralize fatal doses of the tetanus toxine injected eight or twelve hours afterward. Thus, 0.0005 c.cm. of the antitoxic serum was found to be suffi- cient to protect a guinea-pig weighing 400 to 500 grammes from the minimum fatal dose of the tetanus toxine, which in the present instance was about 0.01 c.cm. Mixtures of the toxine with the antitoxic serum in the proportion of forty or fifty parts of the former to one of the latter are completely inert, and 2 cubic centimetres of such a mixture, containing nearly 2 c.cm. of the deadly toxine, may be injected into a guinea-pig without producing any effect. The SCLEREMA NEONATORUM. 149 antitoxine also possesses considerable curative power, but much larger doses are necessary when the disease has declared itself than when used as an immunizing agent." •• The antitoxine treatment of tetanus would seem to be the one which gives the best hope of cure. ... I have been able to collect records of 42 cases of tetanus treated with antitoxine, nearly all traumatic, and of these 15 died and 27 recovered, giving a mortality of about 36 per cent. . . . The anti- toxine must be administered by subcutaneous injection. It is difficult to state what the dose should be, for this has varied enormously in recorded cases. — from 10 c.cm. to 165 c.cm. Probably 20 c.cm. to 40 c.cm for the first dose, followed by 10 c.cm. every six to twelve hours, would be found most suitable.' 1 Sclerema Neonatorum. This is a rare disease, and most of the cases which have been observed have occurred in foundling asylums or maternity wards. It is characterized by induration of the skin and subcutaneous tissue over a greater or less extent of the system. The sensation communicated to the finger pressed upon the affected surface is not unlike that produced by the cadaver. Those having the disease are feeble, poorly nourished, and a considerable proportion are prematurely born. Their temperature is below normal. Sclerema of the newly-born was first described by Underwood in the eighteenth century, and following him, in 1781, Andry applied this term to oedema occurring in the first days after birth, and which should not be con- founded with sclerema. Sclerema neonatorum occurs in emaciated or atrophic infants, but the skin over the affected part, instead of lying in wrinkles or folds, as is usual in a state of great emaciation or atrophy, becomes smooth and is firmly adherent to the subjacent parts, from which it cannot be raised. The induration usually first appears in the lower extremities, and it passes upward along the hips and lumbar region, and it may occur not only upon the trunk and upper extremities, but even upon the face. The limbs are extended and immobile, and the soft parts, firm and resisting, do not pit on pressure. The skin has a dusky-yellow color and is perhaps slightly cyanotic. The respiration is feeble and slow. The rigidity when extensive resembles that in tetanus. Nursing from the breast is imperfectly performed, and when the muscles of the face and lips are involved is impossible. The causes of sclerema appear to be prematurity, atrophy or poor nutrition, and great heart failure. This disease, so long as the patient is able to take nutriment, may con- tinue for weeks before the fatal ending, with a constant abnormally low tem- perature. Parrot made post-mortem examinations, and found hardening and atrophy of the skin and rete Malpighii, the cells pertaining to which being indistinct and forming a firm mass. In the adipose tissue underlying the skin the fat had disappeared to a considerable degree, the fat-cells being atrophied, but having distinct nuclei. The fibres of the connective tissue were apparently increased in number and thickness. The blood-vessels, particularly in the papillae, were shrunken or narrowed to such an extent that their lumina were not visible. Henoch made a post-mortem examination of the brain and spi- nal cord in two cases which had lain for weeks in his ward in a rigid state. and found them normal. A clear idea of the symptoms and anatomical characters of sclerema can be obtained by the narration of a typical case that occurred in the New York Foundling Asylum. The curator gave a full and graphic description of this case at the first session of the American Pediatric Society : The patient. 150 DISEASES OF THE NEWLY-BORN. a female, was brought to the asylum as a foundling at age of five days. It was jaundiced, had sprue, and a rectal temperature of 9Qn° F. The efforts to increase its temperature were unavailing, and two days later it was care- fully examined. Its face was cold and rigid, and the coldness and rigidity had extended over not only the features, but the scalp, shoulders, arms, hands, hips, thighs, legs, and feet. The extremities were so stiff that pres- sure upon them or attempts to move them communicated the sensation of a cadaver or half-frozen tissue. Its eyes were closed ; its surface had a dirty, yellowish-brown color. When handled it uttered a feeble whimpering cry, but was otherwise motionless and quiet ; no pulse : rectal temperature below the lowest figure on the thermometer ; respiration feeble and shallow. Death occurred two days later, at the age of nine days. At the autopsy the sclerema was found to be less in the abdominal walls than elsewhere. On incising the hardened tissues no blood or serum escaped from the cut surface. The lungs had been fully inflated, no collapse being present, and they contained dark hemorrhagic points or spots. Nothing unusual was observed in the skull, brain, heart, and great vessels, the stomach, intestines, liver, and kidneys, except the urates in the tubuli uriniferse. The hemorrhagic extravasations in the lungs were found to con- sist of fresh blood in the alveoli and connective tissue. Dr. Northrup made microscopic examinations of the skin and subcutaneous tissues, and found that they took injections well, showing normal vascular network. The microscopic slides have been examined by expert microscopists and derma- tologists, and they can discover nothing abnormal that throws light on the cause or pathology of the sclerema. Sclerema bears considerable resemblance to oedema of the newly-born. In oedema the temperature is low and the cedematous tissues may present con- siderable firmness, but the surface usually pits on pressure, unlike that in sclerema. Of the different opinions expressed by observers in reference to the cause and pathology of sclerema, that expressed by Ludwig Langer in 1881 (Wiener Sitziingsbericht, 1881) is the most plausible. It is as follows: In the adult oleic acid is the chief constituent of the adipose tissue, but in the newly-born the fat contains a large proportion of palmitin and stearin, which solidify when the heat of the body undergoes a moderate reduction below the normal. Infants having sclerema after lingering for days or weeks die in a state of extreme weakness. I am not aware that recovery has occurred in any case of genuine sclerema of the new-born. Still, it is proper to increase the tem- perature by warm applications to the body and limbs and to endeavor to improve the nutrition in every possible way. Perhaps a more abundant breast-milk or breast-milk of a better quality can be obtained, and a few drops of Tokay or other good wine or of brandy may be given every sec- ond hour. (Edema Neonatorum. In this disease thickening of the integument occurs and the subcutaneous connective tissue is infiltrated with serum. The oedema in most cases is at first in the legs, from which it extends along the thighs to the genitals. It may extend over the trunk, upper extremities, and cheeks, but in some cases it appears only in the hands and feet, producing tumefaction of the palms of the one and soles of the other. If the amount of serous infiltration be great, the tissues may be firm and resisting, communicating to the touch a sensation similar to that in sclerema ; but when the infiltration is less in degree the tis- sues are soft and doughy. The skin has a dusky or yellowish color, and sometimes, when much distended, it has a shiny appearance. In cases of PEMPHIGUS NEONATORUM. 151 great oedema the movement of the affected part is diminished, but not to the same extent as in sclerema. As in sclerema, the temperature is below the normal. In fatal cases the adipose tissue is found of a brownish, yellowish, or reddish -yellow color, from which a yellowish serum exudes. (Edema of the newly-born does not appear to result from the same cause in all instances. Occurring in feeble, ill-nourished infants, it apparently results, in most in- stances, from extreme heart-weakness. The feeble circulation leads to venous congestion and consequent serous transudation. Pulmonary atelectasis, occur- ring as it usually does in ill-nourished and feeble infants, is also an occasional factor in producing venous stasis and transudation of serum. Elsasser has shown that occasionally in the newly-born the oedema results from nephritis, as it frequently does in the adult. Henoch relates the case of an infant of four weeks who had " marked oedema of face and limbs," with serous effu- sion in the pleural, pericardial, and peritoneal cavities, and compression of the left lower lobe, resulting from parenchymatous nephritis. Another occasional cause of the oedema is erysipelas. This cause is revealed by the dark-red color of the skin characteristic of erysipelatous inflammation. Recently Prof. Dumas in an elaborate paper on oedema of the new-born arrives at the following conclusions : " 1. (Edema of the new-born is only one of the symp- toms of a phlegmasia alba dolens which is developed during the first days after birth. 2. Its causes are of the same nature as in the adult, and may be divided into predisposins; and determining varieties. Among the latter, the principal one consists in the incomplete establishment of respiration or in the pathological or other causes which this function encounters. 3. The symptoms of phlegmasia in the new-born are the same as in the adult, excepting certain modifications with respect to the special physiology of the first days following birth. 4. The pathological anatomy is also about the same, but the venous thrombosis in the new-born is more frequently located in the inferior vena cava than it is in the same disease in the adult. - ' It does not seem improbable that Prof. Dumas' s explanation is applicable to a considerable proportion of cases, the formation of clots in the veins producing such obstruction and venous congestion that serum transudes as a consequence. Dumas recommends, in order to prevent this disease, " suitable care to effect respi- ration in the new-born at the moment of birth, and not too hasty ligation of the cord.*' (Edema, like sclerema, is ordinarily fatal, but occasionally, as when it results from erysipelas, recovery is possible. The treatment should be largely hygienic and dietetic. An abundant supply of good breast-milk should be obtained, or if this be impossible peptonized cow's milk. As in sclerema, artificial warmth and moderate alcoholic stimulation are required. Pemphigus Neonatorum. Pemphigus occurs in two distinct forms in the newly-born, which may be properly designated pemphigus simplex and pemphigus cachecticus. Pemphigus Simplex commonly occurs between the ages of two and twelve days. The vesicles, which vary in size from that of a pea to a hazel-nut. appear in some cases nearly simultaneously, but in other instances in suc- cessive crops. When fully developed, they ordinarily have a transparent yellowish color, and they may appear upon almost any part of the surface except the palms of the hands and soles of the feet. When the eruption is nearly general upon the surface, as it occasionally is, one or two blebs may even appear upon these parts, but as a rule in pemphigus simplex the palms of the hands and soles of the feet are not affected. In investigating the causes of this form of pemphigus we are struck with the fact that in a considerable proportion of the recorded cases those affected with it appear to be otherwise in perfect health. Occasionally in maternity hospitals it occurs as an epidemic. Thus, Ahlfeld observed twenty-five eases 152 DISEASES OF THE NEWLY-BORN. during two months in an institution in Leipzig. The mothers of these infants were apparently healthy, and the pemphigus commenced in all between the second and fourteenth days after birth.. The palmar surfaces of the hands and plantar surfaces of the feet were not affected in any of these cases, though vesicles appeared on the fingers in some of them. Ahlfeld, from these observations, believed that the disease was infectious or of a miasmatic nature. Koch states that thirty-one cases occurred in the practice of a certain midwife, while in the practice of other midwives no case occurred. Weyl of Berlin, aware of facts like the above, states that the disease is undoubtedly conta- gious. Bohn, on the other hand, regards cutaneous irritants as a cause, and he states that the repeated occurrence of pemphigus in the practice of a cer- tain midwife was traced to the fact that she habitually used water too hot in bathing the infants. But there is now a sufficient number of observations to render highly probable, if they do not demonstrate, the contagious nature of pemphigus in certain cases. Boeser always found micrococci in the serum of the vesicles. Gribier found chain bacteria, single bacteria, and also bacteria in zooglea in the vesicles. Scharlau met the disease in different members of a family, and succeeded in inoculating himself from the vesicular contents. We may conclude, therefore, that pemphigus of the newly-born is probably in cer- tain cases microbic and inoculable, though the microbe which causes the disease has not been fully identified. But in some instances it is not improbable that the disease is produced by causes not microbic, as from cutaneous irritants. Further investigations in regard to the etiology of pemphigus simplex are required before positive statements can be made. Pemphigus simplex is usually attended by little constitutional disturbance, but sometimes, it is said, a slight fever attends the eruption of the vesicles. The skin adjacent to the vesicles may have the normal or a slightly congested or vascular appearance. The vesicular contents escape in a few days by rupture of the vesicle, or disappear by absorption, and the detached cuticle forms a thin scale which is soon thrown off, and in a few days replaced by a new growth of cuticle. Pemphigus Cachecticus. — This form of pemphigus occurs in infants who have a profound cachexia, and this cachexia is in a large proportion of cases due to inherited syphilis. Unlike pemphigus simplex, it attacks by preference the palms of the hands and soles of the feet, It also occurs upon thin por- tions of the skin, as the groin, axilla, and neck. The surface upon which the vesicles are situated presents a reddish or livid appearance, and the vesicles are only partially filled. The exuded liquid is not so clear as in pemphigus simplex, and it is often turbid or even bloody. The vesicles or remains of vesicles are sometimes observed at birth, and are then believed to have a syphilitic origin. When the cause is syphilis other manifestations of this disease may also be present. Pemphigus cachecticus may be prolonged several weeks, if the patient live, by the occurrence of new vesicles. It is important, as regards the selection of remedies, to bear in mind the fact that the profound dyscrasia which underlies and gives rise to an attack of pemphigus cachecticus may occur from other causes than syphilis, as perhaps struma. The evils which attend a family subjected to a life of poverty in a great city, as overwork, scanty and poor diet, overcrowding, and foul air, may be the cause of the dyscrasia in the infant born under such circumstances, even when the parents are actuated by the best motives and endeavor to lead a correct life. Anatomy. — The vesicles occur in the epidermis between the layers of the stratum granulosum and stratum lucidum (Weyl). The contents of the vesi- cles consist largely of serum, but sometimes also of other substances, as pus- cells, epithelial cells, etc. OSTEOGEXESIS IMPERFECTA. 153 Treatment. — This is simple, consisting of cleanliness, the use of abundant pure breast -milk, and frequent dusting of the surface with a powder consisting of bismuth and lycopodium. In the cachectic form of pemphigus, especially if the vesicles have an unhealthy appearance, they should be broken, and their surface may be dusted with a powder of one part of iodoform and ten of bismuth. In syphilitic cases Henoch recommends the addition of 1 gramme (15 grains) of corrosive sublimate to the bath employed. The use of a few drops of Tokay wine or other alcoholic stimulant at each nursing is also required in the cachectic cases. Osteogenesis Imperfecta. Cases have been reported in which bony substance was very deficient in the foetal development, so as to cause curvatures and deformities in the Fig. 16. skeleton. It has commonly been supposed that these cases are rachitic, and from them has arisen the belief that rachitis occasionally occurs in the foetus. 154 DISEASES OF THE NEWLY-BORN. Fig. 18. But recent microscopic examinations have shown that in at least some of the cases of supposed fetal rachitis, rachitis has not been present. Stilling published such a case in Virchow's Archiv. It is represented in Fig. 16 from Sajous' Annual, vol. ii., 1890. The skeleton, which was that of a female born at the eighth month, was very deficient in bone-substance, but without the characters of rachitis. Stilling suggests that the cause of this deficiency and malformation may have been syphilis. In the Wood Museum of Bellevue Hospital is a skeleton which is probably similar to those in the Prague and Wurzburg museums. It shows in a striking manner the deform- ities of this congenital disease. The case occurred in my practice, and the dissection was made by Prof. Francis Delafield. The in- fant, born at term, died a few hours after birth from atelectasis, apparently produced by the con- tracted state of the thoracic walls. The parents were hard-working English people. They were free from syphilitic taint. The accom- panying wood-cut (Fig. IV) repre- sents this skeleton. Fig. 17. Skeleton of an infant which died a few hours after birth (from the Wood Museum). Showing foetal deformity of skeleton without rickets. The following case (Figs. 18, 19) occurred in my service in the New York Infant Asylum. The child lived five hours, being kept alive by artificial res- piration. Its mother seemed healthy, but its father was unknown to the phy- sicians of the Asylum. The longitudinal section of the lower extremities, as is seen in the illustration and was proven by microscopic examination, made by Prof. Prudden, did not exhibit any of the characters of rachitis. OSTEOGENESIS IMPERFECTA. 155 Fig. 19. "~~^~ " / r ■ Longitudinal sections of the bones of the lower extremities k PART III. CONSTITUTIONAL DISEASES. SEOTIONT I. DIATHETIC DISEASES. CHAPTER I RACHITIS. Rachitis is a constitutional disease, but its most conspicuous anatomical characters pertain to the osseous system. The gross nutritive changes which it produces in the bones and cartilages, causing deformities, are well known to physicians and the laity. In addition to these anatomical changes in the skeleton, typical cases exhibit a lack of tonicity with stretching of the liga- ments, causing the knock-knee and flat-foot ; weakness of the muscles, resem- bling paralysis are sometimes mistaken for it in severe cases ; reflex irrita- bility, rendering rachitic patients liable to laryngismus and tetany ; undue perspiration ; anaemia and proneness to catarrhal inflammation ; and certain anatomical changes in the spleen and liver in aggravated forms of the disease. These many and divers anatomical and functional characters indicate the constitutional or general nature of rachitis. Therefore theories which restrict rachitis to the osseous system are inadequate and erroneous. Rachitis is probably an ancient disease. It is said that an old statue of JEsop, who was thrown from a precipice by the indignant Delphians 564 years before Christ, exhibited rachitic deformities ; and Hippocrates, born 460 years before Christ, is believed to have alluded to it in his treatise on the Articu- lations. Occasionally expressions in the works of Celsus and Galen in the second century of the Christian era have led writers on rickets to believe that they also had observed the deformities produced by this disease. But rickets was first investigated in a scientific manner by Whistler, Glisson, and their con- temporaries in the middle of the seventeenth century. During the last few years many excellent monographs have been written on this malady, and its causation, pathology, and treatment are better understood than formerly. Frequency. — Rachitis is a widespread disease, but it is comparatively infrequent in rural localities, where families enjoy the hygienic requirements of pure air, sunlight, and a plentiful diet of good quality. It is most common in crowded and badly-fed families in city tenement-houses, where antihygienic conditions prevail. Mild cases of rickets, not manifested by any prominent signs or symp- 156 RACHITIS. 157 toms are often overlooked, so that the physician is not summoned, or, if he be summoned and have not given particular attention to this disease, he, in not a few instances, does not detect its presence. In the absence of deform- ity, which occurs later, the fretfulness, tenderness of surface, and perspira- tions are likely to be attributed to other causes than the correct one. Hence, according to my observations, rachitis is more common in its milder forms in the asylums and dispensaries and in the tenement-houses of New York, and probably in other American cities, than is commonly believed by the laity, and even by physicians who have given little attention to the disease. A few years since in one of the New York asylums my attention was directed to a rachitic child in whom the anatomical characters of rachitis had become so pronounced that they attracted the attention of the nurses. Prompted by the occurrence of this case, which had developed during my attendance in the asylum, I made an examination of all the infants, and found, what I had previously not suspected, that about one in nine presented unmistakable signs of rachitis, though in a mild form and for the most part in its commencement. The late Dr. John S. Parry of Philadelphia stated that at least 28 per cent, of the children between the ages of one month and five years who came under his observation in the Philadelphia Hospital, during the three years preceding the publication of his paper in 1872, were rachitic. According to Dr. Gee, whose observations were, however, made as far back as 1867 and 1868, of the patients under the age of two years in the London Hospital for Sick Children, 30.3 per cent, were rachitic ; and Ritter von Rittershain, whose observations were also made several years ago, stated that of 1623 out-door patients under the age of five years brought to the Clinique at Prague, 504, or 31.1 per cent., manifested this disease. Recently Prof. Henoch of the University of Berlin has stated that he had seen many thousand cases of rachitis, and he adds that its spread in the large cities of Northern and Mid- dle Europe is enormous. He states that his observations in regard to the frequency of rachitis in dispensary practice correspond with those of Von Rittershain, as many as 31 per cent, being rachitic. In Manchester also, with its large number of operatives, Ritchie's statistics show that of 728 out- door patients 219 were rachitic. The late curator of the New York Foundling Asylum, who served ten years, informs me that he believes, without the accu- racy of statistics, that as many as 20 per cent, of the cadavers examined by him in the dead-house presented the anatomical characters of rachitis, usually in a mild form. The recent large emigration from Europe of destitute families, living from choice or necessity in filth and degradation, who for the most part remain in the cities, occupy small, dark, and dirty apartments, and whose food is of the poorest quality and often insufficient, greatly increases the number of rachitic children in New York and probably in other American cities. In the out- door department of Bellevue, to which many thousand immigrants from the lowest class of European society carry their sick children for treatment, rachitis is not infrequent ; and the fact has been observed in this institution that a larger proportion of severe cases attended by marked deformities occur in the Italian families than in those from other parts of Europe. In families of American parentage it is generally admitted that rachitis is more prevalent in the negro than in the white race. Although this disease occurs most frequently in the families of the desti- tute and poorly fed, nevertheless children of well-to-do families occasionally suffer from it, even in an aggravated form, in consequence, I think, usually of ignorance on the part of parents in regard to the dietetic requirements oi' young children. Merei, in his treatise on the Disorders of Infantile Develop- ment (London, 1850), states that in Manchester, where his observations were 158 CONSTITUTIONAL DISEASES. made, one child in every five in comfortable circumstances presented rachitic symptoms. In the United States rachitis is rare in well-to-do families, who provide sufficient and suitable diet for their children and have a proper regard for sanitary requirements. When it does occur in such, it is due usually, I think, to improper feeding. But this cause will be discussed in another place. Diagnosis. — In preparing statistics relating to rachitis it is obviously important that the diagnosis of mild and incipient cases should be clear and unmistakable. What symptoms and anatomical characters indicate rachitis? The fact that an infant has reached its ninth month without a tooth is regarded by Sir William Jenner as a reliable sign of rachitis. In order to determine to what extent dentition is retarded by rachitis — and retarded dentition may be considered a sign of rachitis — Dr. H. R. Purdy, physician to the Out-door Department of Bellevue Hospital, made the following obser- vations : Table I. — Showing at what Age 200 Infants exhibiting no signs of Rachitis cut the First Tooth — cases consecutive. 3 cut first tooth at 2 months. 28 cut first tooth at 8 months. 14 " " " " 3 " 20 " " " " 9 16 " " " " 4 " 14 " " " " 10 20 " " " " 5 " 15 " " " " 11 24 " " " " 6 " 8 " " " " 12 37 " " " " 7 " 1 " " " " 13 Of these, 132 were wet-nursed. 68 bottle-fed. Table II. — Showing at what Age 50 Infants exhibiting one or more Rachitic Symptoms cut the First Tooth — cases consecutive (18 wet-nursed, 32 bottle- fed). 2 cut first tooth at 4 months. 7 cut first tooth at 11 months. 2 " " " " 5 " 3 " " " " 6 " O a n a (< - u 5 " " " " 8 " 6 " " " " 9 " Table III. — Thirty Infants with Teeth, but with pronounced Rachitic Symp- toms. In all these cases the rachitic rosary, enlarged subcutaneous veins, profuse perspirations, abdominal distention, and enlarged joints were pres- ent. Bottle-fed, 21 ; wet-nursed. 9. Age at which they cut the first tooth. 6 at 7 months. 3 at 12 months. 10 " 8 " 2 " 13 " 1 " 9 " 2 " 14 " 1 " 10 " 1 " 15 " 4 " 11 " It is evident from these interesting statistics that dentition delayed until the ninth, or even the tenth or eleventh month, is not a certain sign of rachi- tis, but slow teething is common in the rachitic, and therefore it aids in the diagnosis. It is one of the diagnostic signs. In order to determine whether rachitis incipient or of a mild form be present, all the signs which characterize it should be considered — the fretful- ness. free perspiration upon the head. neck, face and chest, the tenderness of surface, anaemia and general deterioration of health, delayed dentition, swell- ing of the joints, craniotabes. bending of the long bones, rachitic rosary, mis- 5 " i a "12 * 6 a i a " 13 ' 3 a ( a " 14 < 1 it i a " 16 < 1 " i n " 18 < RACHITIS. 159 shapen head, prominent frontal and parietal bones, deformity of the thorax with depression of the ribs, projecting or misshapen sternum and prominent abdomen, with Harrison's groove. All these signs and symptoms must be considered before making a diagnosis in incipient or mild rachitis. In order to determine the diagnostic value of enlargement of the costo-chondral articu- lations. " the rachitic rosary," I have examined these joints in children sup- posed to be healthy or suffering from other ailments than rachitis in three of the New York institutions. In many young children believed to be healthy who were examined, these joints were not appreciable on palpation. In others a slight prominence could be felt in one or more joints. In order that the beading of these articulations be sufficient to indicate rachitis, it should, I think, be plainly detected by the fingers in most of the costo-chrondral articula- tions. Less than this I would not regard as sufficient evidence of this disease. Age of Occurrence. — Deficiencies and curvatures in the bones of the newly- born have until recently been supposed to result from foetal rachitis. But microscopic examination of some of these cases has demonstrated beyond doubt that the disease present was not the result of rachitis, but an osteo- genesis of unknown origin. This disease is described in the preceding chapter. Enlargement of the costo-chondral articulations, known as the rachitic rosary, has been observed, though rarely, in infants only a few weeks old. Dr. Parry saw it as early as the sixth week after birth, and Dr. Lee at the third or fourth week. The significance of this enlargement as a sign of rachi- tis we have treated of elsewhere. We have stated that with few exceptions rachitis begins before the close of the third year. Though first detected and diagnosticated at a later date, it will ordinarily be ascertained, on inquiry, that its symptoms had an earlier beginning. Still, according to certain observers, it may have a considerably later commencement. Glisson, Portal, and Tripier state that they have seen it commence in children who were well on toward the age of puberty. Sir William Jenner says that he has seen children of seven and eight years who were only beginning to suffer from rachitis. The following are the aggregate statistics of Bruennische, Von Bitters- hain. and Bitsche relating to the age at which rachitis occurs : No. of Cases. During the first half year 99 " " second half of first vear 259 " year . .* 342 " " third year 134 " " fourth year 31 " " fifth year 17 Between the fifth and ninth years 21 Aggregate 903 Etiology. — Inheritance. — Some patients with rachitis appear to have inherited a predisposition to it. Feeble digestion and defective assimilation in the infant — which are, as we will see, important factors in producing the rachitic state — are often traceable to disease or cachexia of one or both parents. Among the parental causes may be mentioned poverty, hardships, and defective nutrition of either parent ; age of father and exhausting dis- charges of the mother, such as purulent, hemorrhoidal, or uterine fluxes. The offspring of a tubercular, syphilitic, or otherwise enfeebled parent is more likely to become rachitic than is one of healthy and robust ancestry. We will especially emphasize the syphilitic dyscrasia in either parent as a potent cause, but M. T. Parrot, in his thesis published in 1872. evidently went too far in attempting to show that congenital syphilis is the common cause oi" rachitis. Most rachitic cases are entirely free from the syphilitic taint, and 160 CONSTITUTIONAL DISEASES. a large proportion of the children who have inherited the syphilitic dyscrasia do not exhibit any signs of rachitis. Antihygienic Conditions. — In the damp, dark, filthy, and overcrowded tenement-houses of the city, rickets occurs most frequently and in its sever- est forms. There can be no doubt that general mal-hygiene is a potent factor in causing this disease, and that it sometimes produces it in those who have inherited good constitutions. On the other hand, many children with healthy parentage and vigorous at birth, reduced by poverty to a life of squalor and privation, do not become rachitic. Food. — Of the antihygienic conditions which give rise to rachitis, the most common and potent appears to be the use of food not sufficiently nutri- tious, or, if nutritious, not suited to the age and digestive powers of the child. The use of thin and poor breast-milk and artificial food of poor quality or not suitable for the stage of growth and development is a common cause of rachitis. Those children who have been prematurely weaned, and who have been given food which is not a proper substitute for the natural aliment, and those too long wet-nursed by scantily-fed and poorly-nourished mothers, and not allowed the additional aliment which they require, are especially liable to this disease. Those children whose digestive power is feeble, from whatever cause, are more likely to become rachitic than those who in a state of robust health have a hearty digestion. Hence we meet with rickets as a sequel of various protracted and exhausting maladies during infancy. I might relate cases of rachitis occurring during the use of certain of the popular proprietary or commercial foods. I have examined the analyses of these foods made by Prof. Leeds in order to determine what ingredient is lacking, and they are found to contain a considerably smaller percentage of fat than occurs in human milk. Too little fat in the food may, as Cheadle observes, be one of the chief dietetic causes of rachitis. Infants suckled by healthy mothers or wet-nurses who have an abundance of milk, of good quality, do not become rachitic as long as their nutriment is derived from this source. But those prematurely weaned and given a diet deficient in nutritive properties, and those who are allowed the promiscuous food of the table or have largely a farinaceous diet during the first and second years, when the food should be chiefly milk, are especially liable to become rachitic. It is an interesting fact, and one that throws light on the dietetic cause of rachitis, that it does not occur in Japan. Physicians who have had abundant opportunities to observe the diseases of the Japanese state that they have never seen or heard of a case among them. M. Remy, in his Notes Medicates sur le Japon, says that the Japanese women have a remarkable abundance of milk, and that they suckle their young until the age of five or six years, but their children are also given artificial food after the first year. Remy's explanation of the immunity of the Japanese from rachitis is as fol- lows : " The Japanese have always eaten plentifully of fats and oil of fishes, the blubber of the whale, the eel and loach especially The universal use of the food under notice from the time of ancient Buddhist flesh-prohibi- tion, but especially the consumption of fish by the lactating women, together with the fish given to the children as supplementary feeding, which at that time is allowed them by Japanese tradition, are, in my opinion, main causes of the non-existence of rachitis in Japan." Observations on the feeding of animals have also aided in the elucidation of the causation of rachitis. Guerin gave certain puppies a diet of meat four or five months, and they became markedly rachitic, while other puppies of the same litter, suckled by their mother, remained well. At a meeting of the section of Diseases of Children of the British Medical Association, held in August, 1888, Dr. W. B. Cheadle read an instructive paper on rachitis, in BACHITIS. 161 which he said that the results of feeding young animals in the Zoological Gardens strongly support the view that a deficiency of animal fats and earthy salts are the most efficient agents in producing rickets. He states that in the Zoological Gardens the young monkeys taken from their mothers and fed with a vegetable diet, chiefly fruits, become rachitic. Such diet is destitute of animal fat, and is deficient in proteids and earthy salts. Two young bears were fed with rice biscuits, and occasionally with lean meat, which they licked but rarely ate. Fat, proteids, and lime salts were practically excluded from their food. The bears died of extreme rickets while still young. Cheadle also states that more than twenty litters of lions had died successively of rachitis, and the next brood were fed with cod-liver oil, pulverized bones, and milk. In three months all signs of rickets had disappeared. The addition of fat and bone-salts caused the change, and after eighteen months, when the last observations were made, the brood of young lions were strong and healthy. They had received in every respect the same treatment as the litters that had perished, except as regards the diet. The latter had been fed with the carcasses of old horses, which are destitute of fat and whose bones resisted the lions' teeth. The theory that lactic acid is the causal agent in rachitis has been strongly advocated by Dr. C. Heitzmann, formerly of Vienna, but now of New York. He administered lactic acid by mouth and subcutaneous injection to five dogs, seven cats, two rabbits, and one squirrel. The lactic acid administered to the dogs and cats, with " restricted administration of calcareous food," produced the characteristic enlargement of the epiphyses, and finally the " curvatures of the bones of the extremities." After four or five months of administration of lactic acid the long bones were very flexible, and repeated inflammations of the conjunctiva, bronchi, stomach, and intestines had occurred. But in many cases of rachitis there is no evidence of an excess of lactic acid, and an objection to the lactic-acid theory apparently valid is that lactic acid, produced by imperfect digestion, would unite with a base, either the soda or potash in the blood, which is always alkaline, before it reached the osseous system. The more the causation of rachitis is elucidated by observa- tions on man and experiments on animals, the stronger is the evidence that its chief cause is dietetic — that there is a failure to receive or to digest and assimilate certain important substances in the food, particularly the fat, phos- phate of lime, and proteids. The deprivation of these alimentary substances produces the rachitic dyscrasia, which is manifested by malnutrition in many tissues. Of course general antihygienic conditions, which lower the vitality, may, as we have stated elsewhere, be a factor in causing rachitis. Pathology. — Distinguished pathologists and clinical observers who have investigated rachitis, and whose investigations have been chiefly, if not entirely, restricted to the osseous system, have regarded this disease as an inflammation affecting the bones and cartilages. i\.mong those who have ex- pressed this opinion may be mentioned Virchow and Niemeyer. Niemeyer says : " It seems to me that the most probable hypothesis regarding the cause of rachitis is that which refers it to inflammation of the epiphyseal cartilages and periosteum." The increased vascularity of the periosteum, the prolifera- tion of periosteum and cartilage, the tenderness and pain on motion, and the elevation of temperature in acute forms of the disease, indicate inflammation rather than any other recognized pathological state. If the rachitic disease of the osseous system be regarded as an inflammation, it obviously presents a subacute or chronic character, like cirrhosis and certain forms oY chronic nephritis, in which proliferation of connective tissue and sclerosis occur. The eburnation, instead of normal ossification, which terminates the rachitic pro- cess, might be considered an osteosclerosis. Moreover, the thickening, hyper- 11 162 CONSTITUTIONAL DISEASES. aemia, and infiltration of the periosteum, exudation and formation of new vessels in the periosteum and underlying cartilaginous and osseous tissues, are conformable with the theory of the inflammatory nature of rachitis. On the other hand, some of the structural changes in the soft tissues in rachitis which are described in this paper are not such as ordinarily result from inflammatory processes. Billroth, seeing the difficulties in the way of the inflammatory theory, wrote of rachitis that it " cannot be exactly classed among the chronic inflammations, although nearest related to this process." It seems most in consonance with the facts to regard rachitis as a constitu- tional or general disease, a dyscrasia affecting the nutrition of various tissues of the body, and producing disease in the osseous system which is either inflammatory or closely allied to inflammation. Changes in the Soft Tissues. — We have stated that although the con- spicuous lesions of rachitis pertain to the skeleton, the soft tissues are also more or less implicated, as might be expected, since the disease is systemic in its nature. The skin in milder cases is but little involved, but as a rule the perspiration of the rachitic is excessive from the head, face, neck, and chest. This may occur before changes are observed in the skeleton. Pyrexia is in some patients absent or slight, but catarrhs of the mucous surfaces are com- mon, and these are likely to give rise to some elevation of temperature. The fever that frequently accompanies severe cases may sometimes result from the disease of the skeleton. In protracted and severe cases the patients become markedly anaemic, but in recent and mild cases the pallor may be so slight as not to attract attention. Emaciation is not pronounced, as a rule, in the rachitic, but in certain patients the muscles throughout the system become shrunken and flabby, partly perhaps in consequence of the gastro- intestinal disorder, indigestion, and malnutrition, partly perhaps from want of use, for the rachitic are likely to be passive. Mucous Membranes. — Rachitis, as we have stated above, increases the liability to catarrh of the mucous surfaces. Writers on this disease have remarked the frequent occurrence of bronchitis, broncho-pneumonia, entero- colitis, and conjunctivitis. Ligaments. — The ligaments become relaxed and flabby, giving unusual mobility to the joints and unsteadiness to the movements. The fibrous bands which unite the vertebras, as well as the ligaments of the extremities, partici- pate in the relaxation. Talipes valgus and knock-knee are especially likely to occur in rickets as a result of the relaxation of ligaments, even when the bones are but slightly involved. Kyphosis, lordosis, and scoliosis — backward, forward, and lateral curvatures of the spine — also result from relaxation of the ligaments, aided by the softening and change in shape of vertebrae and of the intervertebral cartilages. The Spleen and Liver. — The spleen is sometimes enlarged, as ascertained by palpation and percussion. Hitter von Rittershain found this organ de- cidedly enlarged in 10 out of 35 cases which he examined after death. The enlargement is the result of cellular proliferation, common in diseases which are attended by a dyscrasia. In a recent very anaemic and fatal case of rachitis in the New York Foundling Asylum the spleen extended below the level of the umbilicus. But in many cases of rachitis, even when profound, splenic enlargement is slight or is not appreciable. The liver in many patients undergoes no perceptible change, except that it is carried downward by the lateral depression of the ribs. It is occasion- ally enlarged from fatty infiltration, but no special significance attaches to this, for fatty liver is common in various forms of disease attended by innu- trition and wasting. It is common in tuberculosis and in protracted intestinal catarrh, and its pathological significance appears to be the same in these RACHITIS. 163 various diseases. There can be no doubt that Sir William Jenner errs when he states that albuminoid infiltration of the liver is common in rachitis. Parry, Gee. Dickinson, and Senator agree that it is rare, and that when it does occur it is a coincidence. In the discussion of rickets at the meeting of the British Medical Asso- ciation in August, 1888, Dr. Ranke of Munich said that, according to the records of 34 post-mortem examinations of rachitic cases in Virchow's Patho- logical Institute between 1872 and 1880, 13 exhibited changes in the liver, mostly parenchymatous fatty infiltration with increase of volume. In the 34 cases the spleen was recorded enlarged in 9 and small in 2. In the remaining 23 cases the size and appearance of the spleen were probably normal, or some mention would have been made of it. Dr. Ranke also consulted the records of the Munich Pathological Institute under Prof. Bollinger, and in 9 of 25 post-mortem examinations of rachitic cases more or less enlargement of the liver was recorded. We may therefore infer from these carefully conducted examinations that enlargement and structural changes of the liver and spleen only occasional^ occur in rachitis — that in the majority of cases this disease runs its course without any notable alteration in these organs. My own observations lead me to believe that hypertrophy of the spleen, and probably also of the liver, occurs chiefly in decidedly anaemic subjects. The abdomen is protuberant from various causes. The lateral depression of the thoracic walls causes the liver and spleen to descend a little lower in the abdominal cavity than natural, producing at the base of the chest ante- riorly Harrison's groove, which is transverse and corresponds with the inser- tion of the diaphragm. The enlargement of the liver and spleen, the feeble tonicity of the intestinal muscular fibres, and consequent distention of the intestines with gas, and the rachitic shortening of the spinal column, which causes approximation of the ribs and pelvis, necessarily produce abdominal protuberance. The Kidneys and Urine. — Observations thus far have not detected any structural change or disease of the kidneys attributable to rachitis, except that this organ is enlarged in some cases. Moreover, the records of the urine are so conflicting that more exact and more numerous examinations of this excretion are required before any positive statement can be made in reference to its composition. Dr. C. H. Flagge has seen two cases in which there were large quantities of uric acid in the urine. Ephraim also mentions an increased elimination of uric acid up to 18 per cent. Ephraim likewise, as well as Mar- chand and Lehmann, state that there is an increase of phosphate of lime and the occurrence of lactic acid in the urine. Brain and Spinal Cord. — It is not improbable that the symptoms of rachitis which are referable to the nervous system, such as laryngismus stridulus, tetany, convulsions, and weakness or paralysis of the extremities, may be largely due to the pressure exerted in places upon the cerebro- spinal axis by its bony covering. Hence we will postpone their considera- tion until we have described the changes produced by rachitis in the osseous system. Changes in the Osseous System. — A knowledge of the normal anatomy and normal development of the osseous system will enable us to better under- stand the changes which occur in this system in disease, and especially, which concerns us at present, in rachitis. Hence we will give a brief resume of the anatomy of the skeleton in health before we consider the changes produced in it by rachitis. Osseous System, in Health. — In health and when fully developed, bone con- sists of animal matter (chiefly gelatin) and earthy salts, in the proportion, by weight, of about one part of the former to two of the latter. The following 164 CONSTITUTIONAL DISEASES. is the analysis, which may be regarded as approximately correct, of healthy human bone of the adult : Animal matter 33.30 Tribasic phosphate of calcium . . .51.04 Carbonate of calcium 11.30 Fluoride of calcium 2.00 Phosphate of magnesium 1.16 Soda and chloride of sodium . . . . 1.20 100.00 Earthy salts. In childhood the bones are softer, more elastic, and less likely to fracture than in the adult. Of the earthy salts in bone, it is seen that the phosphate of calcium is the most abundant, and it is the most important. Hence it is termed "bone earth." The phosphate of calcium, combined with animal matter, produces a hard compound. The enamel of the tooth consists chiefly of phosphate of calcium (88* per cent.), while the softer egg-shell consists chiefly of the carbonate of calcium. The strength of bone is remarkable, being, according to Holden, when compared with wood, nearly three times that of the elm or ash, and double that of the oak. It is elastic on account of the animal matter which it contains. If a long bone be placed at right angles upon a hard substance, and the projecting end receive a blow from a hammer, the latter will rebound. The Arab children are said to make bows of the camel's ribs. If a longitudinal section be made through a long bone, we observe a hard or compact outer part, and in the interior the medullary canal, containing marrow. In birds of flight the hollow of the bones contains air instead of marrow, and this air communicates with the lungs. The hard or compact portion of bone, though solid like a stone, consists of layers in close apposition, so that there is no interval between them. On approaching the joints the internal layers of the compact structure separate from each other, forming the cancellous tissue, so that the compact wall becomes thinner. If the earthy salts be removed by an acid, the animal matter remaining is found to consist of layers, which can be separated from each other. In inflammation the afflux of blood and the exudation cause separation of the layers and enlargement of the bone. The cancellous tissue occupies the interior of the bone, and is most abun- dant in its articular ends. The bony layers in the cancellous structure are separated from each other, so as to form cavities, which are strengthened by cross-plates like latticework. In the adult the marrow in the interior of the shafts of the long bones is yellow, consisting of 96 per cent, of fat, but in the articular ends of the long bones, in the ribs, cranial bones, and short bones, the marrow has a reddish tinge, and it consists of about 75 per cent, of water and about 25 per cent, of albumin, without fat or only a trace of it. This kind of marrow occurs in all the bones of the foetus and the infant, and it contains cells with many nuclei, designated " myeloid cells." Holden says that bones are as minutely provided with blood-vessels and nerves as are the soft tissues. Near the extremities of the long bones are numerous minute openings through which blood is conveyed to and from the cancellous tissue. On the shafts of the long bones are slight grooves parallel with the shafts, at the bottom of which are minute holes, scarcely visible, through which blood is conveyed to and from the compact tissue. The blood which supplies the osseous tissue is conveyed through these holes by minute arteries from the vessels of the periosteum, and is returned by veins to the periosteum. Xear the middle of the shaft of the long bone is a distinct canal passing obliquely through the shaft. This canal contains the nutrient artery of the RACHITIS. 165 medulla, dividing, after entering the medullary cavity, into two branches, one passing upward and the other downward. The blood-vessels supplying the different parts of the bone from these various sources intercommunicate. Other bones than the long bones are supplied with blood in a similar man- ner, and the nutrient vessels are accompanied by nerves, as in other parts of the system. The microscope is required in order to reveal the minute anatomy of bone. It is found to consist of canals, termed the Haversian, and around each canal the bone is arranged in concentric layers, like the concentric rings of a tree. Between the rings are dark spots, designated lacunae, arranged concentrically, now known to be minute reservoirs containing blood. Minute lines are seen connecting the reservoirs with each other and with the adjacent Haversian canal. The lines are minute blood-vessels, and through them the blood is conveyed to every part of the bone. They are designated canaliculi. They connect externally with the vessels of the periosteum, and internally with the vessels of the medullary membrane or endosteum. In the interspaces between the lacunaB and canaliculi, in the animal matter, an infinite number of osseous granules is deposited, consisting mainly of phosphate and carbonate of lime. Alterations in the Osseous System in Rachitis. — For convenience of descrip- tion the course of rachitis as regards the osseous system is divided into three periods : (1) That of proliferation and altered nutrition of cartilage and perios- teum : (2) That of curvature and deformity ; (3) That of reconstruction. 1. Anatomical Characters in the Stage of Proliferation and Altered Nutrition. — The long bones in normal growth increase in length by the form- ation of bone in the cartilage between the diaphysis and epiphysis, and in thickness by the development of bone from the vascular and cellular under- surface of the periosteum. As regards the flat and short bones, growth in the thickness occurs from the periosteum, and growth in breadth occurs from the development and ossification of the cartilaginous borders and edges, which correspond with the epiphyseal cartilage of the long bones. If we examine the epiphyseal cartilage of a long bone during normal ossification, we observe, beginning at the distal end, a white zone, consisting of the hyaline matrix, in which are the usual cartilage-cells. This consti- tutes most of the cartilage. Underneath this, and nearer the bone, is the zone of proliferation, the cartilage in which is softer and more yielding than that of the distal zone, in consequence of cell-formation and absorption of the matrix to make way for cell-groups. Each cell in the proliferating zone has divided into two cells, and each of these cells into two other cells ; and the division has been repeated, so that eight cells instead of one are observed, surrounded by a common capsule. The capsule becomes distended by the cell-multiplication and swelling of each cell, the size of which is considerably greater than that of the parent cell. Near the bone, along the extremity of the diaphysis, the cell-groups, enclosed in their capsules, nearly touch each other, the matrix having been for the most part absorbed. The end of the diaphysis is covered with a layer of these cell-groups about to undergo ossifi- cation, with almost no intervening matrix. The proliferating zone has very little depth. It appears to the naked eye as a very thin, scarcely perceptible layer of a reddish-gray color upon the end of the shaft. It is so thin that it but slightly increases the thickness of the cartilage. In rachitis the state is different. The zone of proliferation, instead o\' being confined to a single or at most double layer of cell-groups, consists of many layers, involving nearly the whole epiphyseal cartilage. The cells, still enclosed in their capsules, undergo a more frequent division than in health, so that, instead of groups of eight cells, as in the normal state, each group consists of thirty or forty cells enclosed in the distended capsule. There tore 166 CONSTITUTIONAL DISEASES. in rachitis the proliferating cartilaginous zone is a broad cushion, very soft, of a grayish translucent appearance, causing the characteristic swelling observed around the joint. Over the distal end of the proliferating carti- lage there may still be a zone, though perhaps of little depth, of normal cartilage like that in health. While the changes described above occur in the cartilages, the ossifying process is arrested or rendered abnormal. We indeed perceive an effort in the direction of bone-formation. The Haversian canals, surrounded by capillary loops, extend from the bone into the proliferating zone of cartilage. Their extension is effected by absorption of the matrix and appropriation of cell- groups which lie in their way. The cells in these groups, as they enter the Haversian system, become much smaller by rapid segmentation, forming medullary cells. We also find, as further evidence of the attempt at bone- formation, granules and masses of lime scattered through the cartilage, and Fig. 21. Fig. 20. \ n here and there spiculse and nodules of true bone springing up from the bony substance of the shaft. Some of the canals are prolonged far into the carti- lage — nearly, indeed, to its free surface — but most of them terminate in its lowest portions. RACHITIS. 167 We have stated that the growth of bone in thickness occurs from the under surface of the periosteum. In health a soft, vascular germinal tissue springs from the periosteal surface, rapidly receives lime salts, and is trans- formed into bone. This germinal tissue, consisting largely of capillaries rising from the fibrous tissue of the periosteum, is a very thin substance, barely visible, transient, and constantly changing from its conversion into bone. In rachitis this vascular subperiosteal tissue, not undergoing, or under- going slowly and imperfectly, the osseous transformation, and at the same time increasing more rapidly than in health under the irritating influence of the rachitic disease, becomes a thick layer. Its color and appearance are like spleen-pulp, so that the older observers supposed that there was hemorrhagic extravasation between the periosteum and the bone. There is, however, no extravasation of blood, unless it accidentally occurs from the numerous delicate capillaries. The resemblance to extravasated blood or spleen-pulp is due to the abundant growth of large and thin-walled capil- laries from the under surface of the periosteum, as shown by the microscope. This vascular outgrowth is, for the most part, quite uniform over the shafts Fig. 22. of the long bones, while upon the cranial bones its thickness is much greater in one locality than in another. The attempt at ossification also appears in 168 CONSTITUTIONAL DISEASES. this tissue. Lime salts are scantily and loosely deposited through it, forming osteophytes, vascular and fragile, rather than true bone. The question naturally arises, How does rachitis affect bone which is already formed when the rachitic state begins ? Virchow's answer is the following : " Rachitis has by more accurate investigation been shown to consist, not in a process of softening in the old bone, as it has previously been considered to be, but in a non-consolidation of the fresh layers as they form : the old layers being con- Fig. 23. sumed by the normally progressive formation of medullary cavities, and the new remaining soft, the bone becomes brittle/' We have seen that in healthy bone the earthy salts are in excess of organic matter nearly in the proportion of two to one, but in rachitis the proportion is reversed, the organic matter being much in excess. The follow- RACHITIS. 169 ing table gives analysis of rachitic bones by Marchand, Davy, Boettger, and Friedleben : Femur. Radius. Vertebra. Inorganic. Organic. Inorganic. Organic. Inorganic. Organic. Case 1 20.60 74.40 21.24 78.76 18.68 81.32 Case II 37.80 62.20 20.00 80.00 32.29 67.71 Case III 20.89 79.11 Case IV 52.85 47.15 As might be expected, the relative proportion of the inorganic matter (the earthy salts) and the organic matter varies greatly in different cases. In severe rachitis many bones are affected. It is stated that there is no bone in the entire skeleton that may not suffer, but in mild cases only a few are involved, at least to such an extent as to produce structural changes appre- ciable to touch or sight. Rachitic bone, when the disease is still in its active period, presents a bluish or dusky-red appearance from its increased vascularity. After a vari- able time — weeks or months according to the severity of the disease — deform- ities begin to appear. 2. Anatomical Characters of the Rachitic Child.— In typical rachitis the bone seldom retains its normal form or shape : its projecting points are rounded, and as soon as it softens it begins to yield to pressure exerted upon it. Hence the curvatures so common and characteristic. The portion of a long bone which is formed after rachitis commences contains so little earthy matter that it bends readily in its fresh state either by muscular action or by the weight of the trunk, " in the manner," says Vogel, " of a quill or willow stick." The interior of the bone, which was formed before rachitis began, and which contains nearly or quite the normal proportion of lime, is likely to break instead of bend, but, as it is surrounded on all sides by the soft tissue, the fragments are not displaced, and probably do not crepitate. So scanty is the calcareous deposition in typical cases that, says Trousseau, " the bones .... can be cut with a knife with as much ease as a carrot or other soft root,'' and the dried specimen weighs from one-sixth to one-eighth of the weight of normal bone. One writer states that the dried rachitic bone is sometimes so porous from the small amount of lime which it contains that it is possible to respire through it as through a sponge. In ordinary cases the bones which exhibit most strikingly the rachitic change, and which, therefore, should be examined carefully in making the diagnosis, are the cranial bones, the ribs, and the radius — the sternal ends of the ribs and the lower end of the radius. It is seldom that these bones do not give evidence of the disease if it be present, and in greater degree than other bones. They are the first to be affected to an extent that is appreciable to the observer. Changes in the Cranial Bones. — In these bones interesting and important alterations occur. Their edges which correspond with the epiphyseal carti- lages of long bones, undergo proliferation, and become thickened like the latter. This thickening and the delayed union of the sutures produce grooves which can be traced by the fingers between the bones, and which are some- times appreciable to the sight. Rachitis causes enlargement of the cranium. but the enlargement seems greater than it really is, on account of the retarded growth of the facial bones. In a discussion on rachitis in the London Patho- logical Society, reported in the London Lancet (18S8, ii. 1017), it was stated that in seventeen rachitic children with an average age of 4.72 years, the average circumference of the head was 21.22 inches, while in the same num- ber who were non-rachitic. and whose average age was 6.05 years, the aver- 170 CONSTITUTIONAL DISEASES. age circumference was 19.95 inches. The retarded ossification is manifested not only in the open sutures, but also in the large size and patency of the fontanelles, which are not closed until long after the usual time. The ante- rior fontanelle in the healthy infant is closed at about the fifteenth or six- teenth month, but in the rachitic it remains membranous a longer time : in some cases it is still membranous as late as the third or fourth year. Since examination of the anterior fontanelle aids in determining whether or not rachitis be present, it should be borne in mind that in the normal state this space increases in size till the seventh month, when it is at its maximum, and that after the ninth month it becomes progressively smaller. Ossifica- tion in severe rachitis is retarded for a longer period than is stated above, for Gerhard relates a case in which the anterior fontanelle had not entirely closed at the ninth year. The shape of the rachitic head varies. In general, instead of its normal rounded form it approaches a square shape. Another type is sometimes observed in which there is no marked angularity, but in which the antero- posterior diameter is enlarged. In the square head the forehead projects, and both the frontal and parietal protuberances are unusually prominent. The sutures are depressed to a certain extent, as has already been mentioned, and the anterior, lateral, superior, and posterior surfaces are more flattened than in health. The undue prominence of the frontal and parietal eminences is largely due to the exaggerated proliferation of the periosteum and to the vascularity and infiltration underneath. Enlarged veins are seen ramifying in the scalp, which in marked rachitis supports a scanty growth of hair. The free perspiration from the scalp, and in some cases the activity of its sebaceous follicles, will be mentioned elsewhere. Craniotabes. — Thinning of the cranial bones in places, so that the brain lacked proper protection, had long been noticed in the examination of rachitic heads, but the injury that resulted to the infant was overlooked until pointed out by Elsasser. Craniotabes occurs for the most part in infants under the age of one year, and a large proportion are under eight months. Its occur- rence in the foetus, as shown by a case published in the New York Obstetrical Journal in 1870, and by Heitzmann's case, has already been alluded to. The factors in producing this thinning are rachitic softening of the bones and pressure from the brain within and from the pillow without. Consequently, the portions of the cranium in which the thinning is most pronounced are the posterior and lateral, the occipital bone and the posterior half of the parietal. If the infant lie in its crib chiefly on one side, on this side the craniotabes occurs, while those portions of the cranium which are not pressed upon exhibit no thinning or a less degree of it. The soft spots in the cranium are yielding when pressed upon, and in the cadaver they are seen to be trans- lucent when the bone is held to the light. There are in some instances simple depressions like erosions in the bone, a continuous but thin bony layer remain- ing. In other cases, such as have been particularly examined and studied by physicians, the bony absorption has been complete over areas of greater or less extent. On examining a child for craniotabes it should be borne in mind that the margins of the cranial bones, even when there is no thinning, but thickening from the cartilaginous proliferation, are flexible in the rachitic. The pressure must be made in a direction away from the sutures to ascertain whether craniotabes has occurred. The pressure should at first be made lightly and cautiously with the fingers, for if there be total absence, unless of very little extent, deep and forcible pressure might injure the brain, since so soft and delicate an organ, covered only by scalp and dura mater, badly tolerates pressure. If the first examination detect no soft place, the fingers may be pressed more firmly against the scalp, when, if the bone be RACHITIS. 171 much thinned, so that there is only a small layer of lime salts underneath, it will be found to yield. The sensation communicated to the fingers when there is an open space in the cranium, and the dura mater and scalp are in Fig. 24. Head of a rachitic child in the New York Infant Asylum. This child also had laryngismus stridulus. contact, has been likened to that experienced when pressing upon a fully-dis- tended bladder. At a meeting of the London Pathological Society, reported in the Lancet for November, 1880, Dr. Lees presented statistics to show that craniotabes is one of the lesions of inherited syphilis ; but whether it does sometimes result from inherited syphilis or not, the evidence that there is a cranial softening which is strictly rachitic, and which occurs in those who have not inherited syphilis, appears from reported observations to be con- clusive. Changes in the Vertehrse, etc. — The short bones which participate in the rachitic disease become softer and more yielding, and their cancelli are filled with a reddish pulpy substance. In many rachitic cases the vertebrae are but slightly involved, so that no deformity of the spinal column results ; but occa- sionally, when many bones are affected, the vertebrae and intervertebral carti- lages soften, and spinal curvatures result. The curvatures are due to the weight of the shoulders and head on the spinal column. They are, with some deviations, an exaggeration of those present in the normal state. Rachitic curvatures of the spinal column are therefore mainly antero-posterior, often with more or less lateral deflection. When there is much curvature the ver- tebrae become wedge-shaped, narrowed upon the concavity and thickened upon the convexity. The intervertebral cartilages are also more or less changed by the pressure, being thinned where the vertebrae approximate to each other on the concave aspect of the curvature, and of normal thickness or thicker than normal upon the convexity. The accompanying wood-cut exhibits the appearance and nature of rachitic spinal curvature continuing into adult life. Rachitis, having occurred at the usual age, resulted in the permanent deformity here illustrated. In extreme cases, fortunately rare, the functions of important organs may be seriously impaired by the curvature and consequent compression, as they are in Pott's disease. Thus, according to Miller, the aorta has been so 172 CONSTITUTIONAL DISEASES. Fig. 25. doubled upon itself as to materially diminish the flow of blood to the lower extremities, so that their nutrition was sensibly impaired. The effect of so great curvature upon the heart and lungs must ob- viously be detrimental. At first the spinal curva- tures disappear when the child reclines or is lifted by the axillae so as to raise the head and shoulders from the spine ; but when the deformity has con- tinued so long that the vertebrae and cartilages have become wedge-shaped, it remains for life or can only be rectified slowly and with difficulty by mechanical appliances. As seen in the wood-cut, the common curvature in the dorsal region is back- ward (kyphosis), while to compensate the patient instinctively carries the neck forward with the head thrown back, causing cervical lordosis, a sim- ilar anterior curvature being common in the lum- bar region. Lateral curvature (scoliosis) may or may not be present even when there is consider- able antero-posterior flexure. Scoliosis is some- times produced by the nurse in carrying the infant habitually over one arm. Changes in the Maxillse. — Fleischmann has investigated the changes which rachitis produces in the maxillary bones. Stunted growth of the facial bones, generally, has long been known, and has been remarked upon by various writers ; but, according to Fleischmann, other interesting changes occur in the jaw-bones which affect the direction and position of the teeth. According to this ob- server, the arched shape of the lower jaw becomes polygonal, and the direc- tion of its alveoli also changes, so that they incline inward. This devia- tion in the arch and in the alveolar border of the lower jaw, which begins in the region of the canine teeth, necessarily causes softening of the jaw. Commencing soon after, a change is observed in the upper jaw-bone from the zygomatic arch forward, so as to cause lengthening of this bone, changing the shape of the arch and the position of the teeth. The external incisors, instead of being in front, have a lateral position, and when the jaws are closed the superior incisors and molars overlap the corresponding teeth of the lower jaw in front and upon the sides — a condition opposite to that seen in the jaws of old people. Fleischmann attributes these changes in the lower jaw to the action of the masseter and the mylo-hyoid muscles, and perhaps the genio- glossus, and to pressure of the lip, the deficiency of earthy salts in the bone rendering it more easily acted on by the muscles. The change in the upper jaw-bone he attributes largely to lateral pressure of the zygomatic arches. Changes in the Ribs. — The ribs are easily affected in rachitis. The swell- ing of their anterior ends, where they unite with the costal cartilages, pro- ducing the ' ; rachitic rosary," has been already alluded to as one of the first and most conspicuous signs of rachitis. The costochondral articulations are enlarged in all directions, appearing as nodules under the skin. If at an autopsy an opportunity of inspecting the pleural surface of the articulation occur, the nodular prominence is seen to be even greater and more distinct than under the skin (Fig. 26). The deformity of the thorax, consequent upon softening of the ribs, is Commencing with the spine, the ribs extend nearly directly out- Rachitic spinal curvature in an adult (from a specimen in the Wood Museum, Belle- vue Hospital). RACHITIS. 173 ward : at the union of the dorsal and lateral portions they make a short curve Fig. 26. Rachitic child with characteristic deformity of head and ribs. (From a patient in the New York Foundling Hospital.) forward and then turn inward, also with a short curve, toward the sternum (Fig. 22). This abrupt bending of the ribs, which in their softened state has Fig. 27. Deformity of chest in rachitis. been caused by atmospheric pressure during respiration, produces a depres- sion in the thoracic wall at about the point where the ribs and their cartilages 174 CONSTITUTIONAL DISEASES. unite. A groove extends on the antero-lateral aspect of the thorax from the second or third rib downward and a little outward. In some cases the costo- chondral articulations are in the line of greatest depression in the thoracic walls ; in other cases they are a little inside or outside of the deepest part of the groove. The transverse diameter, therefore, of the anterior half of the thorax is less than that in the normal rotund form of health. This neces- sarily diminishes the antero-lateral expansion of the lungs in inspiration and causes unusual prominence of the sternum. Hence the expressions " pigeon- breasted," " resemblance to the prow of a ship," etc. applied to this deformity. The presence of the heart renders the depression or groove less on the left side between the fourth and sixth ribs than on the opposite side, since this organ affords partial support to the chest-wall. That portion of the pericar- dial surface of the heart upon which the pressure is greatest becomes thickened and whitish from the rubbing or attrition. On the other hand, the depression on the right side below the sixth or seventh rib is, on account of the support given by the liver, less than on the left side. But on the left side, as well as on the right, the lower part of the thorax, that below the eight or ninth ribs, widens, being pressed outward and supported by the abdominal viscera. This gives rise to an antero-lateral furrow or groove near the base of the chest, sometimes designated Harrison's groove, the site of which is supposed to correspond with that of the insertion of the diaphragm. The ribs with their attached muscles are important agents in respiration, but their soft and yielding nature in the rachitic retards, and to a great extent prevents, the lateral expansion of the thorax which is necessary for normal and full inspiration. The action of the respiratory muscles and the pressure of the air from within descending along the air-passages is not suffi- cient to fully overcome the external atmospheric pressure in the absence of the proper resiliency of the ribs. Consequently with each inspiration we observe more or less sinking of the thorax on each side, just as when a moderate obstruction to the entrance of air exists in the larynx or trachea. As the ribs become firmer from the deposit of lime salts, respiration is more regular and normal. Changes in Bones of Upper Extremities. — Although swelling of the lower end of the radius is one of the earliest signs of rachitis, the bones of the upper extremities are less frequently curved and distorted than those of the lower extremities. The clavicle sometimes softens and bends, pro- ducing two curvatures — one backward near the scapula, and another, of larger radius, nearer the sternum, directed forward and a little upward. Careful examination shows, in some rachitic patients, thickening of the margins of the scapulae like that of the cranial bones. The humerus is occasionally bent, and usually at the insertion of the deltoid in consequence of the power- ful action of this muscle in raising and supporting the arm. The radius and ulna are bent outward and twisted. This deformity is attributed by Sir William Jenner to the fact that rickety children support themselves while in the sitting posture upon the palms of the hands pressed upon the floor or couch. Supporting the weight of the body in this manner not only, in his opinion, causes bending of the ulna and radius, but also aids in producing the deformities of the humerus and clavicle. Changes in the Bones of the Pelvis. — The deformities of the pelvic bones resulting from rachitic softening are very important in the female infant, since pelvic deformities during the procreative period are the common cause of tedious or instrumental labor and stillbirth. These deformities, which elongate some and contract other axes of the pelvis, necessarily occur when the rachitic child is in the erect position, since the pelvic bones support the RACHITIS. 175 weight of the trunk, head, and shoulders. A common deformity produced in this manner is the carrying forward of the promontory of the sacrum, which sustains the weight of the spine. There is, moreover, twofold pres- sure from below — that caused by the heads of the thigh-bones in standing, Fig. 28. Fig. 29. Fig. 30. Rachitic deformities of the pelvis (from specimens in Wood's Museum). and that exercised by the tuberosities of the ischia in sitting. Both these forms of pressure have a tendency to narrow the outlet of the pelvis. Hence the marriage of the female who has been rachitic in infancy may involve serious consequences. Many of the tedious instrumental labors in the families of the city poor, which severely tax the patience and endurance of young practitioners, are attributable to rickets in early life. Changes in the Bones of the Lower Extremities. — The curvature of the femur is usually forward or forward and outward. The neck of the femur sometimes bends by the weight of the body or by use of the legs, so that the Fig. 31. Rachitic deformities of the femur (Wood's Museum). angle which it forms with the shaft is changed. The accompanying wood-cuts show the rachitic bend of this bone in an adult, years after rachitis had ceased and when the bone had become consolidated by the new deposition of lime salts. (Figs. 31 and 32.) 176 CONSTITUTIONAL DISEASES. Fig. 33. Fig. 34. The curvature of the tibia and fibula varies in different cases. In those under the age of one year it is likely to be outward, so that the knees are separated from each other. In those old enough to stand, the weight of the body usually determines a forward bending of these bones. In one case in my practice an anterior curvature, so abrupt that an angle of about 70° was formed, existed about five inches above each ankle. This patient, although old enough to walk, almost constantly sat during the day with the feet extended beyond the sofa, so that the edge of the latter corresponded with the abrupt curvature or angle of the legs. It seemed that the weight of the feet, unsupported beyond the edge of the sofa, had caused these cur- vatures, especially as the case was one of very marked rachitic softening of the different bones. Still, tibial and fibular bending at this point has been noticed by different observers, who have attributed it to the weight of the body in walking. Various other curvatures besides those mentioned occur in the bones of the lower extremities, the di- rection in which the limbs bend being determined by the particular circumstance of the case. In mild cases of rickets most of the deformities de- scribed above may be lacking, but in typical cases certain of them stand out prominently, so as to be readily detected by one familiar with the disease. In all such cases the nature of the malady is ap- parent, for the changes that occur are not only conspicuous, but pathognomonic. Rachitis produces another important effect on the skeleton. Its growth is stunted, not only during the rachitic period, but subsequently, so that those who have been rachitic in childhood, unless very mildly, have less than the average stature in adult life. The stunted growth is apparent, though ample allowance be made for curvatures. The arrest of development is greater in some bones than in others. It is greatest in the bones of the face, pelvis, and lower extremities. As a rule, the older the child is when rachitis begins, the less is the skeleton affected and the less, consequently, is the deformity, Effect of Rachitis on Dentition. — As might be expected from the nature of rachitis, dentition suffers severely. The delay in dentition has been con- sidered elsewhere in this paper. Teeth which appear during the rachitic state are frail, deficient in enamel, and crumble readily. They decay and break before the usual time. If certain teeth have appeared before rachitis begins, several months elapse before others cut the gum. It is even said that a child who has rachitis severely for a lengthened period may never have a tooth, and may remain toothless for life ; but I have never observed such a case. Ordinarily, when the rachitic state ceases and the health is fully restored dentition goes on in the normal way. 3. Anatomical Characters of the Stage of Reconstruction. — This stage will be better understood if we recollect what has occurred during the first and second stages. The very vascular periosteum is drawn tightly over the con- vexities, the pressure upon which diminishes the hyperasmia and the amount of exudation underneath. Over the concavities the periosteum is loose : it is hyperaemic with abundant new capillaries, the interspace between it and Rachitic deformities of the fe mur, tibia, and fibula (Wood's Museum). BACHITIS. 177 the bone being filled with the exuded soft material having a gelatiniform appearance. The reparative process goes forward rapidly, the deposition of lime salts being more abundant upon the concave surfaces, where there has been free exudation with no compression of the capillaries, than elsewhere. The lime salts are deposited from the blood. Consequently, from the increased capillary circulation and hyperaemic state of the periosteum produced by rachitis, the earthy material is rapidly deposited wherever there is an open space under the periosteum and where the capillaries are in a state of enlarge- ment. Hence the reconstructed bone is thicker and firmer upon the concave aspect of the long bones than elsewhere, and thinnest upon the convex aspect, where the periosteum is more tense and its capillaries more or less com- pressed. Xormal ossification does riot at first take place during the reparative stage. The deposition of the earthy salts is designated by some writers as a petrifac- tion rather than a true bone-formation. Trousseau likens it to the formation of a callus upon a fracture. A deposition occurs of lime salts more compact than in ordinary bone. The term " eburnation " has been applied to this new osseous formation, and I have designated it osteo-sclerosis. It resembles, as regards its hardness and morphological appearance, the enamel of the tooth rather than true bone, the Haversian canals and lacunae being small and im- perfectly formed. Of course after complete recovery the subsequent form- ation of bone is normal. Recovery from rickets is gradual. Little by little the cartilaginous and periosteal proliferations cease, the hypereemia abates, and the various parts of the osseous system and the soft tissues resume their normal function and development. General Symptoms of Rachitis. — Preceding and accompanying rachitis symptoms may be present which are due to indigestion and intestinal catarrh, such as flatulence, unhealthy stools, and poor and capricious appetite. When rachitis begins the infant becomes fretful ; its sleep is frequently restless and disturbed, and it awakens often. It repels attempts to amuse it, and is apparently annoyed by them. Nurse and mother speak of it as a cross child. It perspires freely from the head and neck both when awake and when asleep, while its extremities and trunk are dry. Its pillow is wet with perspiration during sleep, and sweat-drops may be seen upon forehead and face. If the surface be dry, a little excitement or elevation of temperature causes perspira- tion to appear. The rachitic child does not well tolerate the bed-clothes, and it attempts to throw them off from its limbs, even in cool weather, lying ex- posed and causing considerable annoyance to the nurse, who strives to pre- vent its taking cold. Sometimes miliaria due to the moist state of the skin appears upon the face and neck. We have elsewhere stated that the sub- cutaneous veins that return blood from the head are large and the jugular veins full. Another symptom is soon observed, to wit : tenderness over a considerable part of the surface, perhaps largely due to the morbid state of the periosteum over so many bones, though it is also experienced when pres- sure is made upon soft parts, as the abdomen. The tenderness is probably the cause in part of the fretful disposition. The little patient appears to dread to be touched ; its flesh is sore ; it repels attempts to amuse it, and wishes to be quiet. Dangling it upon the arms, swinging it, or even walking with it. which delights the healthy child and elicits a smile or notes of glee, only adds to its discomfort. It is most at ease when left alone upon a soft cot or pillow, or, if it have craniotabes, when quietly held over the shoulder. Lan- guor, disinclination to use the limbs or to play, moderate thirst, with other symptoms referable to the digestive apparatus which are present in many cases, and which have already been described, are soon followed by changes in the skeleton that are perceptible to the sight and on palpation. The pulse 12 178 CONSTITUTIONAL DISEASES. and temperature in a large proportion of the ordinary chronic cases do not deviate from the healthy state, except that in some patients there is a moderate rise in temperature and acceleration of the pulse in the latter part of the day, indicative of a slight fever. A bruit de souffle of greater or less intensity, synchronous with the pulse, has frequently been heard in rachitic cases by applying the ear over the ante- rior fontanelle. Drs. Whitney and Fischer, New England physicians, first called attention to this murmur, believing it to be a sign of chronic hydro- cephalus. MM. Rilliet and Barthez heard it in cases of rachitis, and therefore concluded that the American physicians had confounded the two diseases. More recent observations have established the fact that this bruit has little diagnostic significance. It is heard whenever there is sufficient patency of the anterior fontanelle both in health and disease. It is conducted from the base of the brain through the brain-substance to the membranous covering of the fontanelle. Dr. Wirthgen heard the bruit in 22 of 52 infants, of whom all except 4 were in good health. I have auscultated the anterior fon- tanelle in 29 infants who were, with two exceptions, between the ages of three or thirty months. All were well or affected merely with trivial ail- ments which did not disturb the cerebral circulation. In most of them a murmur could be distinctly heard synchronous with the respiratory act, and in 15 of the 29 cases no other sound could be detected, while in the remain- ing 14 a bruit could be detected synchronous with the pulse. As might be expected, craniotabes gives rise to symptoms quite distinct from those of the general rachitic disease. It usually occurs during the first year of infancy, and most frequently prior to the tenth month. The brain at this age is soft and yielding, since it contains a large percentage of water. Unless handled with care at an autopsy, it is readily lacerated, and moderate pressure upon it is seen to disturb and move it a considerable distance from the point of contact. It will assist to a proper understanding of the symp- toms referable to the cerebro-spinal system to which the rachitic are liable, to recall to mind the fact, well known to surgeons, that slight depression of even a small portion of the skull is likely to produce grave consequences. It is not surprising, therefore, that craniotabes, when there is a space of consider- able size in the cranial arch destitute of bone, is attended by symptoms due to the mechanical effect of external pressure whenever a substance less yielding than the brain comes in contact with the unprotected part. Every rachitic child is fretful, but one with craniotabes is especially so if the open spaces, in which the lime salts are lacking or constitute a thin and yielding layer, are of considerable size. If the child lie upon the pillow in the position that is most natural for it, the unprotected portion of the brain may be so pressed upon by the weight of the head that it is uncomfortable and restless. It does not have quiet sleep because the cerebral circulation and functions are disturbed since the cranial arch no longer protects the brain from undue pressure. Carefully placed in an apparently comfortable position, it awakens often and frets until it is taken in the nurse's arms. Sometimes it instinctively seeks a position on the edge of the pillow, with its face down- ward, and it becomes more quiet when resting over the nurse's shoulder with no pressure or support upon the cranial arch. But if fretfulness, disturbed sleep, and the necessity of closer attention on the part of mother and nurse were the only ill effects of craniotabes, it would possess much less pathological significance than pertains to it. Pressure upon so delicate and important an organ as the brain involves risks and produces serious symptoms in proportion to its degree. Even a slight injury of the skull which causes depression, though it may be of trifling amount, will cause serious forms of nervous disorder. Rachitic RACHITIS. 179 craniotabes sustains a causal relation in not a few instances to one of the most dangerous of the neuroses — to wit, laryngismus stridulus, or spasm of the glottis. Pressure on the cardiac and vaso-motor centres of the medulla in the rachitic infant, in whom reflex excitability is exaggerated, causes con- traction of the muscles that close the glottis. It is certain that a large proportion of those who suffer from laryngismus stridulus are rachitic, so that it is more common and severe where rachitis is prevalent, as in England, than where it is rare, as in the rural districts of America. It is not often the cause of death in America, and the fatal cases that do occur are, I think, nearly always in the cities, whereas in parts of Europe, where rachitis is much more common than with us, it is said to cause not a few deaths. Certain infants when in a state of excitement have what are termed " holding-breath spells." The face is flushed and breathing ceases for some seconds, after which respiration returns and is normal. The attacks are unimportant, but they appear to be the same in nature with the more severe and dangerous seizures of laryngismus stridulus. They have no pathological significance, excepting that they show the same neuropathic state as that in laryngismus, and that they may be precursors of it. Laryngismus stridulus, or glottic spasm, is usually preceded by more or less impairment of the general health and often by fretfulness, which is characteristic of the rachitic state ; but the attack occurs suddenly, without premonition, and is of short duration. It begins with an arrest of respiration, a true apncea, as if from paralysis of the respiratory centre in the medulla ; the lips may be livid, a pallor spreads over the face ; sometimes more or less rigidity of the limbs occurs, with carpo-pedal contractions. After a few seconds, a quarter or half minute, a long and deep but difficult inspiration through the narrow chink of the glottis follows, accompanied in many patients by a whistling or crowing sound, and the attack ends with perhaps a moment- ary appearance of bewilderment or dread on the child's face. Laryngismus stridulus, like eclampsia, does not have a uniform causation. In certain cases it is a reflex phenomenon due to an irritant in some part of the system, as in the intestines, but many observations establish the fact that rachitis is prob- ably its most common cause. A large proportion of the infants affected with it exhibit unmistakable rachitic signs ; and it has been held that the exposed state of the brain in craniotabes affords explanation of the symptom. But from observations which I have made and from those of other observers, like Senator, it is certain that laryngismus stridulus is common in the rachitic who do not have craniotabes, so there must be a causal relation in rachitis to spasm of the glottis independent of the cranial softening. Distinguished British observers, as Gee and Jenner, have noticed the fact that rachitic infants are especially liable to eclampsia. The immediate or exciting cause seems to be in many cases the severe catarrh of the respira- tory and digestive systems to which rachitic infants are especially liable. Indigestion, flatulence, and fermentative diarrhoea, common disorders of the rachitic, are perhaps, in some instances, the exciting causes of the eclampsia. Similar remarks may be made in reference to tetany, which, although it occurs in the adult, and is comparatively rare, appears to be more frequent in rachitic than in other children. Those physicians who attend in institutions in which children coming from tenement-houses are treated in a large city like New York have noticed the fact that the various tissues of the body, besides those that are con- spicuously affected in rachitis, are more liable to inflammatory diseases than are the same tissues in those who have sound constitutions. The frequency of the different forms of dermatitis, of nasal, post-nasal, faucial. and bronchial 180 CONSTITUTIONAL DISEASES. catarrhs, and of gastrointestinal maladies, we must attribute to the fact that rachitis diminishes the resisting power to noxious agents in the various soft tissues, and renders them more liable to disease. If the deformity in the thoracic wall — to wit, the lateral depression of the ribs and anterior projection of the sternum — be great, we would naturally expect that the two important organs underneath, the heart and lungs, would receive some detriment. Upon the surface of the heart, at the point where it supports the softened ribs, a white patch is often found, due to thickening of the pericardium and proliferation of the endothelial cells, just as thickening of the skin in the palm of the hand occurs from friction and pressure upon that part. It is probable that in ordinary cases this pressure does not seriously impair the function of the heart, but it may increase the weakness of its movements in supervening asthenic diseases, which may occur during the rachitic period. The injury sustained by the lungs is greater and more apparent. If the lateral depression of the ribs be considerable, full inflation of the lungs does not occur in those parts where the depression is greatest. The semi-collapse of certain lobules is likely to occur, and even complete collapse of the distant thin edges of the lungs. The stress of respiration falls unequally upon different parts of the lung. The anterior portion, which ascends with the sternum as that is propelled forward, is more fully dilated than the lateral and posterior parts, and it may in consequence become emphysematous. If in this state of the thorax and lungs severe bronchitis or broncho-pneumonia occurs, the muco-pus, being expectorated with diffi- culty, clogs the tubes, produces dyspnoea, and imperils the safety of the child. Even in comparatively mild forms of inflammation the result may be unfavor- able, owing to the lack of full expansion in the lateral and depending portions of the lung — a condition required to expel the mucus. Severe bronchitis and broncho-pneumonia are the causes of death in not a few cases of rickets attended by marked deformity of the thorax. Rachitic Paralysis. — In not a few instances in the course of rachitis the use of the limbs is greatly impaired, so as to resemble paralysis, and be desig- nated by this name, though the term " paralysis " is probably a misnomer. Cases like the following, related by Dr. H. W. Berg in the New York Medical Record, which closely resemble paralysis, occasionally occur : J. S , aged two years and eight months, was admitted into the Orthopaedic Dispensary Sept. 23, 1885. The parents stated that the child had never walked or stood alone. The legs were wasted, apparently from disease ; the patellar reflex was good ; there seemed to be some rigidity of the muscles about the knee ; and the patient was admitted with the diagnosis of " spastic paralysis.'' A closer examination disclosed the fact that the disease was one of typical rachitis, and by the use of the proper diet, with iron and phosphorus the patient was able to walk in November, and in a few months was entirely cured. The British Medical Journal, Jan. 4, 1890, contains the account of a case of rickets discussed by the Edinburgh Medical Society, Dec. 4, 1889. The patient, a boy of three years, had the waddling gait and straddling pose of pseudo-hypertrophic paralysis. The rachitic nature of the malady was made apparent by the symptoms of the case and its history. I have recently in private practice observed two similar cases of pseudo-paralysis of the lower extremities from the same cause. Acute Rickets. — Occasionally rachitis occurs with the sudden develop- ment of severe symptoms, so that the term " acute " is applied to it. Dr. Fiirst relates such a case in the Jahrb. fiir Kinderh., Band xviii. p. 192 : The patient, aged two years and one month, had been largely fed upon starchy food, and at six months had dyspeptic symptoms and sweating. Dentition began in the thirteenth month, and ability to walk several months later. RACHITIS. 181 Spasmodic croup and swelling of the epiphyses appeared at this time. At the above-mentioned age the child suddenly fell ill with acute febrile symptoms. It had an open anterior fontanelle, craniotabes, and a rachitic chest ; upper extremities free from pain and not swollen. The left femur and both tibiae showed diffuse cylindrical swelling. The appearance and feel of the limbs were suggestive of diffuse cellular infiltration proceeding from the periosteum in an attack of osteo-myelitis. The skin covering the limb was tightly drawn and of a reddish hue. In a few days the right forearm was affected, and soon after the right arm and left forearm, and the parts first attacked began to improve. In four weeks the fever and pain had abated, but swelling of the epiphyses and deformities of various bones continued. Cases like the above establish the fact that although rachitis is ordinarily a chronic disease, insidi- ous in its commencement, gradual and progressive in its development, occu- pying months, there is an acute form which is attended by more marked febrile movement and tenderness than occurs in the usual type, and in which the articular swelling appears more quickly. Treatment. — Hygiene. — We recall the recent statement of Prof. Henoch of Berlin that the spread of rachitis has been enormous in the cities of Cen- tral and Northern Europe. The poor of these cities, among whom this disease largely prevails, are emigrating in large numbers to the United States, but, as I have observed in the asylums and dispensaries of New York, the severest forms of imported rachitis come from Southern Europe (Italy). Evidently, as long as the influx of this class of foreigners continues, and the present insanitary conditions exist in our cities, causing rachitis in the native born, this will continue an important disease, impairing the health and vigor of coming generations. It is evident from the nature of rachitis that success in preventing it and in curing those who unfortunately exhibit its characteristic signs requires beyond anything else the employment of proper hygienic measures. The details of the hygienic requirements may seem prolix and tedious, but we cannot expect any marked diminution of rachitis until they are better known and heeded by the masses. The fact that inheritance is one of the recognized causes of rickets renders it very important that the parents be in good health. The mother especially should avoid all agencies or influences which impair the general health during the procreative period. She should, so far as possible, encour- age good appetite, take plain, easily-digested, and nutritious food, and lead a quiet, regular life, with sufficient out-door exercise to promote, so far as prac- ticable, a state of perfect health. Country residence, with quiet exercise in the open air, a diet consisting of fresh vegetables, meats, fresh and abundant milk, early retirement to bed and sufficient sleep, are much more conducive to the health of the mother and her child than are the excitement and irreg- ularities of city life. We have seen that there is sufficient clinical and experimental evidence that the common and predominating factor in causing rachitis is the use of a faulty diet, but general insanitary conditions are also potent agents. The foul air and noxious effluvia of the crowded tenement-house, so conducive to disease and fatal to infants in New York, should, if possible, be avoided. Even if poverty compels a residence in the small and dark apartments o\" a tenement-house, crowded by families, many of them entirely neglectful of sanitary measures, yet parents solicitous for the welfare of their children can do much to diminish the insanitary influences which surround them. Out- door air is everywhere available, and every child after the age of two or three months, unless suffering from acute disease, should in ordinary weather be in the open air one or more hours each day, as a means of improving its digestion and of producing a more vigorous state of the system. Any mother 182 CONSTITUTIONAL DISEASES. or nurse capable of the care of a child should be able to employ such meas- ures as will prevent its taking cold while in the open air. The room occupied by a child, whether rachitic or not, should be at a uniform temperature of about 70° to 73° F., and it should receive the sun- light or the full daylight, which is often excluded by faulty construction. The undergarments worn during infancy and childhood should be of wool, thin and light during the summer, thicker and heavier in the winter. No intelligent mother need be told of the need of personal cleanliness of her child as a means of promoting its health as well as comfort. This is a hygienic measure, and we need not repeat that the more complete the sanitary condi- tions the less the liability to contract rachitis or any disease dependent on cachexia. Bathing of children should always be before the fire or in a warm room. The bath for an infant under the age of six months should be at about 90°. As the age increases the temperature of the bath should be gradually reduced to 80° in the second year, to 75° in the third year, and to 70° sub- sequently. The bath should be short, only long enough to ensure cleanliness. For weakly infants it is sometimes best to dispense with the general bath, and employ the sponge instead. I see no advantage in the use of saline or medicated baths. After the bath the extremities should be warm, and to ensure a better peripheral circulation friction of the surface by warm flannel or otherwise, or the application of warmth to the limbs, is often useful. The extremities of a child should always be warm, for the normal warmth of the surface not only promotes nutrition of superficial parts, but it tends to pre- vent internal congestions and inflammations, to which the rachitic are espe- cially liable. A child that habitually has cool extremities cannot be at the maximum of health, and this is often the state of the poorly-fed and poorly- clad children of the tenement-houses. The measures to promote their normal circulation and warmth, such as exercise as far as practicable, artificial heat, exclusion of cold by woollen garments, friction of the limbs, either dry or by the use of mildly stimulating lotions, should be employed. But while the hygienic measures which we have detailed are important as a means of invig- orating the system and rendering it less liable to rachitis as well as other cachectic diseases, we repeat that the most common and potent cause of the malady which we are considering is a faulty diet, so that in the endeavor to prevent and to cure rachitis special attention must be given to the feeding. Clinical experience abundantly demonstrates the fact that in order to pro- mote healthy nutrition the food of the infant should be breast-milk until the age of ten or twelve months ; and subsequently, until childhood is well advanced, its food should consist largely of cow's milk, properly preserved and prepared. We need not state that human milk varies in its composition according to the health, diet, mode of life, and temperament of the individual who fur- nishes it. Many mothers possess the requisite moral traits to be good wet- nurses, and do all in their power for the welfare of their infants, but have an inadequate lacteal secretion. Many mothers, not only in the tenement-houses, but in the well-to-do class, are unable to furnish sufficient breast-milk, and their infants, unless they receive supplementary food, suffer from malnutri- tion and are liable to become rachitic. I have seen during the last year infants wet-nursed by their mothers, fretful, wasted, and at the verge of starv- ation, applied every half hour to the breast during the hours of wakefulness. Mothers, deprived of the needed sleep and sacrificing their own health in the constant endeavor to provide for the wants of their infants, usually have insufficient milk, as in the cases alluded to. Under such circumstances a medicine designated nutrolactis, which consists largely of the Galega offici- nalis, has been employed in the New York Infant Asylum with apparent bene- RACHITIS. 183 fit as a stimulator of the lacteal secretion. But if suckling by the mother continue inadequate and her infant be under the age of six months, a wet- nurse should be employed. If this be impossible, supplementary feeding will be needed. We refer the reader to the article on the artificial feeding of infants treated of in the first part of this book. The prevention and the cure of rachitis require strict enforcement of the details of hygiene. Hence the facts detailed in the foregoing pages relating to the mode of life and diet of children should be observed in order to pre- vent cachexia and promote a healthy growth. Medicinal Treatment. — Medicines which aid the digestion and assimilation of properly-selected foods are sometimes useful. Irritability of the stomach, imperfectly-digested stools, flatulence, colicky pains, etc. indicate faulty diges- tion, which may be improved by pepsin given with each feeding. Tonic reme- dies designed to improve the appetite and digestion, of a kind suitable for the age and condition of the patient, are often useful. In anaemia one of the readily-assimilated preparations of iron should be given. The complications which are so common require special management. The laryngismus stridu- lus, eclampsia, and tetany should be promptly treated. The bronchial catarrh to which rachitic infants are liable may be best treated by remedies like the following : R • Ammonii chloridi, £j ; Syr. tolutan., fjij. — Misce. Sig. Dose fifteen drops every hour or two hours for an infant of six to ten months. R. Ammonii chloridi, Ferri et ammonii citratis, ad. £ss. ; Syrupi, fgj ; A quae, f§ iij . — Misce. Sig. Give one teaspoonful every two to four hours to a child of one year. Some of the rachitic cases with protracted bronchial catarrh, especially those which also exhibit scrofulous symptoms, may be most relieved by the syrup of the iodide of iron and cod-liver oil administered three times daily, with the inhalation of moist air containing turpentine vapor. In the protracted intestinal catarrh of rachitic infants I have observed the best results, so far as medicine is concerned, from the following prescription : R. Subnitrate of bismuth, ^ij-iij ; Elix. of digestive ferments or essence of pepsin, f^j ; Distilled water, f§iij. — Misce. Sig. Shake bottle ; give half to one teaspoonful, according to the age, every two hours. But a remedy is needed which will act promptly in the cure of rachitis so as to prevent the evil consequences which its continuance is sure to produce. It is the opinion of many of the best clinical observers who have had ample experience that this has been discovered in the daily use of minute doses oi' phosphorus. Wegner fed young and growing animals (rabbits and fowls) for months with small, non-poisonous, and easily-assimilated doses of phosphorus, with the result, he believes, of expediting ossification and producing firmer bone. He states that under the influence of phosphorus the large marrow spaces diminish, by the formation of true bone, to the size of the Haversian canals in normal bone. According to Wegner, the administration of finely-divided, non-poisonous doses of phosphorus for a prolonged period to older fowls pro- duced to a considerable extent the conversion of cancellous into compact bone 184 CONSTITUTIONAL DISEASES. of normal chemical composition. Kassowitz has recently promulgated his views at some length on the pathology and treatment of rachitis. He states that the lime salts are not needed, since the ordinary food contains sufficient lime ; nor should the farinaceous foods be restricted. He adds that phosphorus in small doses restricts the formation of vessels in the growing bones of small animals. Hence it is useful as a means of overcoming the hyperemia, Kassowitz administers about y-|-g of a grain in a teaspoonful of cod-liver oil, the dose, of course, varying according to the age of the infant. The distinguished psediatrist of Vienna, Dr. Widerhofer, says of this remedy that its employ- ment " impresses him with the belief that it is not without benefit in the second year of life and upward." He thinks that it may be useful in the hardening of long bones, but he has not been able to obtain good results in craniotabes. Starker gives an analysis of 23 rachitic cases treated by Prof. Thomas of Freiberg in his clinic. He used the following formula : R. Phosphori, 1 centigramme (about \ grain); 01. morrhuse, 100 grammes (about 3 ounces). — Misce. A coffee-spoonful was administered twice daily, but variations in the dose according to the age are not stated in the report, the patients being between the ages of a few months and four years. Improvement in the general con- dition in 18 cases ; in the cranial development in 15 cases; in dentition in 14 cases ; in the shapes of the epiphyses in 21 cases ; in locomotion in 17 cases ; but strict attention was bestowed upon the hygiene, and especially upon the diet. Soltmann states that good results occurred from the use of phosphorus in 70 cases which he had under observation, and in no instance were unfavor- able results noticed. W. Meyer obtained similar results in 42 cases. He regards phosphorus as a specific for rachitis. When properly given it always, says he, produces positive results. Petersen has treated 200 cases with phos- phorus, and regards it as a specific. Sigel concludes, from the observation of 40 cases in private practice, that constitutional treatment is of the greatest importance, but instead of the administration of iron, lime, etc., phosphorus should be prescribed. Unruh also made many observations in the treatment of rachitic cases by phosphorus in the Dresden Hospital in 1885 and 1886, and considers it more efficacious than other remedies. Toplitz of Breslau treated 518 cases with phosphorus combined with cod- liver oil. No ill effects were observed, and in all the cases improvement occurred in the general condition. Of 208 cases of craniotabes, 176 were cured in eight weeks. In 58 cases of laryngismus stridulus the attacks ceased in eight to fourteen days, after having continued for months under other forms of treatment. Dentition was also promoted. In America, Dr. A. Jacobi, who has had a large clinical experience, also highly recommends phosphorus in the treatment of rachitis. The dose should be small, even minute, not more than ^io to yi-g- of a grain, according to the age, three times daily. As regards my own observations, I am not able to express a positive opinion as to the value of the phosphorus treatment, for reasons which I think also apply to many of the cases embraced in the favorable statistics of the distinguished observers mentioned above — to wit, the simultaneous use of cod-liver oil and improvement in the diet and general hygiene. The following prescriptions may be employed — first, the oleum phospho- ratum, made according to the following formula : R. Phosphorus, 1 part. Ether, 9 parts. Almond oil, 90 " — Misce. i RACHITIS. 185 Or. secondly, the following, known as Thompson's mixture : R. Phosphori, gr. j. Alcoholis (absolut.), tt\, cccl. Spts. menth. piperit., tt^x. Glycerini, f^ij.— Misce. Sig. Six drops, increased to ten, three times daily, to a child of two or four years. Ten minims contain T ^ of a grain, and thirteen minims contain jfa of a grain. Phosphorus should, I think, be given after the meals, in order to prevent irritation of the stomach. Dr. H. H. Purdy, physician to the large class of children's diseases in the Out-door Department at Bellevue, has preserved statistics of the treatment of rachitis during the last year. The cases which furnish the statistics num- bered about 80, and he gives a resume of the results of treatment as follows : •• Some were given cod-liver oil alone, some, cod-liver oil with phosphorus, and others, phosphorus alone, and of course all the mothers were given instruction in feeding and hygiene. Those infants that received only phos- phorus were the slowest to improve. Indeed, in several cases this method of treatment was abandoned because of the absence of the signs of improvement. The group treated with cod-liver oil did the best. In fact, all of the infants that could tolerate the oil apparently derived benefit from it. The group that were given cod-liver oil with phosphorus did very well, but seemingly no better than those that were given only cod-liver oil. The preparation that seems to be most beneficial is one that is used at the Church Hospital and Dispensary. It is an emulsion of cod-liver oil made with the yolk of eggs. The formula for the emulsion is R. Yolks of ten eggs, Cod-liver oil, Oij. Syrup of wild cherry, Oj. Sherry wine, Oj. — Misce. Sig. One or more teaspoonfuls administered three or more times daily." In my opinion, the treatment by phosphorus is still tentative, notwith- standing its recommendation by so many distinguished physicians ; and the old remedies, cod-liver oil and iron, should not be abandoned, although trial may be made of phosphorus at the same time. Care should be taken to prevent deformities while the bones are soft and yielding. The patient should not be encouraged to stand or use the limbs until they become firmer. He should lie upon a soft and even mattress. Uni- form support of body and limbs is requisite in order to prevent curvature. In craniotabes the pillows should be soft, and care should be taken that the yielding parts of the cranium be not unduly pressed upon. Profuse per- spiration may be relieved by sponging with vinegar and water. The patient may be bathed in water a little cooler than the body, and rock salt may be added to the bath. The attacks of laryngismus stridulus, eclampsia, and tetany which so frequently complicate rachitis should be promptly treated by the remedies which are appropriate when they occur under other circumstances. Consti- pation may be treated by enemata of glycerin and water if not relieved by change of diet. The surgical treatment of rachitic deformities is sometimes important, but Prof. Ogston of the University of Aberdeen and other surgeons who have given special attention to this subject state that in young patients these deformities frequently diminish during growth, so as to cause little incon- venience in adult life. The measures employed by surgeons in order to cure or minimize the deformities are treated of in another section. 186 CONSTITUTIONAL DISEASES. CHAPTER II. SCKOFULA. The term scrofula (scrofa, a pig, from the resemblance which the enlarged cervical glands of a scrofulous individual cause to a swine's neck) is applied to a diathesis which is characterized by increased vulnerability of the tissues. The nutritive process of the tissues is readily disturbed even by trifling irri- tants or agencies in those who have this diathesis, and therefore the scrofulous are prone to inflammations of various parts. Inflammations which can prop- erly be considered as dependent upon this diathesis or as occurring under its influence are for the most part subacute or chronic, and they diiFer from ordinary inflammations in the fact of a greater cell-formation and greater liability to cheesy degeneration of inflammatory products, so that return to the healthy state by absorption is slow or impossible. Moreover, this diath- esis, while it gives rise to certain inflammations which do not occur or are rare in other states of the system, and which all physicians at once recognize as scrofulous, often modifies those common inflammations to which all per- sons, whether scrofulous or non-scrofulous, are liable, as coryza and bron- chitis, rendering them more protracted and less amenable to ordinary treat- ment. Scrofula is a disease chiefly of infancy and childhood. Manhood, espe- Fig. 35. cially the first years of it, is not entirely exempt, but scrofulous manifesta- tions after the age of twenty years are feeble and infrequent, disappearing SCROFULA. 187 entirely as the individual advances toward middle life. The diathesis is most active prior to the age of ten years. Causes. — Scrofula is congenital or acquired. Parents who had scrofulous symptoms in early life or who are in a state of decided cachexia, as from can- cer, syphilis, intermittent fever, or tuberculosis, are likely to beget scrofulous children. Insufficient nourishment of the mother during a considerable part of her gestation, and advanced age, and therefore feebleness, of the father, are occasional causes. Near blood-relationship of the parents is also a recog- nized cause, and to this has been attributed the scrofula of royal families. Children whose father and mother are first cousins are, according to my observations, likely to be scrofulous. Again, those born with sound constitutions may acquire scrofula through antihygienic influences in the first years of life. Among the poor of New York we often observe one child in a family who presents scrofulous symp- toms, while the rest of the children are well, and in many cases we are able to trace back the diathesis to some depressing cause or causes which were sufficient to effect the peculiar change in the molecular condition of the tissues which constitutes this disease. Obviously, the causes of acquired scrofula are quite numerous. In the infant it is sometimes produced by insufficiency or poor quality of the breast-milk, or the use of artificial food during the period when breast-milk is required. Too protracted nursing at the breast also, espe- cially if artificial food be almost wholly withheld, may cause it ; as may also, in those who have been weaned, the continued use of a diet which is deficient in nutritive properties. Residence in damp, dark, and filthy apartments or streets may also pro- duce it. Hence one reason of its frequent occurrence among the city poor. Residence in a small, crowded, and imperfectly ventilated apartment has been known to cause it, even with personal cleanliness and a diet sufficiently nutritive. Scrofula may also be caused, in those previously robust and of sound con- stitution, by disease of an exhausting nature. The eruptive fevers, as small- pox, measles, and scarlet fever, if severe, occasionally produce this result, or they render active the diathesis which had hitherto been latent. In this city, where chronic entero-colitis of infancy is common, I have sometimes been able to trace the diathesis to the cachectic state and the impaired nutrition which it causes. The theory has recently been promulgated that scrofula has a specific principle, and that this is a modified form of the tubercle bacillus. This theory receives some support from the fact that scrofulous glands sometimes contain the tubercle bacillus, and scrofula in many instances precedes tuber- culosis. Van Merris considers the scrofulous inflammation as a local tubercu- losis, and Grrancher describes scrofula as a local curable tuberculosis. On the other hand, Dr. Jacobi regards the tubercle bacillus in a scrofulous disease as an " accidental invasion,' 1 and Lartigues calls attention to the fact that the tubercle bacillus cannot be discovered in most instances in the lesions of scrofula. Alexander also states that wherever we can trace the cause of scrofula, it seems to be distinct from any probable microbic agency (Annual of the Univer. Med. JSci., vol. iv., 1889). Noeldechen states that the close relationship of tuberculosis to scrofula arises from the fact that scrofulous ailments afford the most favorable soil for the development of the tubercle bacillus (Deutsche med. Zeit., 1887). Rabl also mentions the fact that the tubercle bacillus is often not present in scrofulous glands. He tabulates 1000 cases of scrofula, as regards their causation, as follows : 79 had scrofu- lous parents, 446 had tuberculous parents, 356 lived in damp dwellings. 25 were subjected to other bad hygienic surroundings, 69 could be ascribed to 188 CONSTITUTIONAL DISEASES. acute infectious diseases, 14 to vaccination, 7 to decrepitude, and 4 to con- sanguinity of parents ( Wien. med. Zeit., 1887). Scrofula, as we have seen, results from a variety of depressing agencies affecting the system in different ways, with the general result of impairing its vigor and lowering its tone. The theory seems improbable that these many and distinct agencies cause the phenomena of scrofula through the action of a microbe peculiar to this disease. The primary scrofulous ailments by which the diathesis is manifested occur for the most part upon one of the free surfaces — namely, upon some part of the skin or mucous membrane. Certain writers attribute this to the fact that these parts are most exposed to the action of noxious agencies. The lymphatics lying in the inflamed area take up the altered lymph and carry it to the adjacent lymphatic glands, which become irritated and un- dergo hyperplasia, and perhaps ultimately suppuration. This is, in a large proportion of cases, the beginning of scrofulous ailments. Nevertheless, in not a few instances the first manifestations are in deep-seated and covered parts, as when scrofulous periostitis or osteitis occurs without any peripheral lesion. Rabl expresses the opinion that in certain cases scrofula results from syphilis in the parent or grandparent. He believes that syphilis in the parent causes scrofula in the child by diminishing the power of resistance to the causes which produce the latter affection. He thinks that in this manner parental syphilis gives rise in some children to symptoms identical with those of scrofula, while in other children it gives rise to syphilitic symptoms. The author's observations in this particular correspond with those of Rabl. Anatomical Characters. — There are no ascertained anatomical changes in the blood which are peculiar to scrofula. As long as the appetite and gen- eral health remain good and the local affections have not occurred, the com- position of this fluid is, so far as known, unaltered. In the cachexia which is present when the general health is impaired the blood becomes impoverished, the red corpuscles lose a portion of their coloring matter, and the watery ele- ment predominates. The question arises whether the glandular hyperplasia of scrofula pro- duces an excess of white corpuscles in the blood. Virchow says : " During the progress of an attack of scrofula, in which, if the disease run a somewhat unfavorable course, the glands are destroyed by ulceration or cheesy thicken- ing, calcification, etc., an increased introduction of corpuscles into the blood can only take place as long as the irritated gland is still, in some degree, capable of performing its functions or still continues to exist ; as soon, how- ever, as the glands are withered or destroyed the formation of lymph-cells likewise ceases, and with it the leucocytosis. In all cases, on the other hand, in which a more acute form of disturbance prevails, connected with inflamma- tory tumefaction of the gland, an increase of the colorless corpuscles always takes place in the blood." (CeHid. Pathol). Although the glandular hyper- plasia occurring in scrofula increases the number of white corpuscles in the blood, scrofula cannot be regarded as sustaining any causal relation to that great and constant increase of white corpuscles which characterizes the disease leukaemia ; for this disease, as remarked by Niemeyer, does not occur in child- hood, when the scrofulous diathesis is active, but in manhood, when it has ceased to exist or has become latent. Strumous inflammations of the cutaneous and mucous surfaces, which we have seen are the initial lesions in a large proportion of scrofulous cases, do not present any peculiar anatomical elements. Some of them are attended by an abundant formation of cells and by dense infiltration of the inflamed tissues ; but inflammations which do not depend on the strumous diathesis SCROFULA. 189 have the same anatomical elements. The most marked differences between the strumous and non-strumous inflammations are found in their origin, amount of cell-formation and inflammatory exudate, and duration. The swelling of the lymphatic glands which is so common in the neigh- borhood of scrofulous inflammations, and is produced by the lodgement in the glands of irritating or noxious products of the inflammation taken up by the lymphatics and conveyed to the glands, is due to hyperplasia of the lymph- cells, with comparatively little or no increase of the stroma. Thus, hyper- plasia of the cervical glands is common, resulting from eczema of the scalp or face, or from otitis or any of the forms of stomatitis ; and so pharyngitis often gives rise to hyperplasia of the tonsils, which are lymphatic glands. The scrofulous nature of the glandular enlargement is apparent from the fact that it continues long after the primary inflammation which gave rise to it has abated. Lymphatic glands sometimes enlarge in those who are not scrofu- lous, but the tumefaction is commonly less in degree, and in most instances it soon abates when the exciting cause is removed. The glands which commonly undergo scrofulous enlargement are the cer- vical, inguinal, bronchial, and mesenteric ; but in those who are decidedly scrofulous the glands in the vicinity of any protracted inflammation are very prone to hyperplasia. Thus I have seen enlarged and cheesy glands in the vicinity of scrofulous osteitis or periostitis. Under favorable circumstances the glandular enlargement abates after a short time by liquefaction and absorption of the redundant cells. But the products of hyperplastic or inflammatory action in the scrofulous individual are very liable to undergo cheesy degeneration, and the close causal relation of this cheesy substance with tubercles is now admitted. If resolution does not soon occur in a gland, it begins to undergo cheesy degeneration. It becomes firm and inelastic, its nutrient vessels narrowed and compressed, so that cir- culation through it ceases, and its cells, losing their liquid and vitality, shrivel away. This necrobiotic process appears in points in the gland which enlarge and unite, till finally the whole gland becomes a dead mass, with shrivelled elements of a whitish appearance, like cheese, the resemblance to which has suggested the name by which the degeneration is known. In certain patients cheesy glands act as an irritant like inorganic matter, producing suppurative inflammation, and their subsequent history is that of an abscess. Purulent matter mixed with the cheesy debris escapes by ulcera- tion upon the nearest surface, and scrofulous ulcers result which slowly heal, leaving permanent cicatrices ; calcification of a cheesy gland occurs in excep- tional instances. The cervical lymphatic glands in the scrofulous child, having undergone hyperplasia of their cellular elements, not infrequently continue painless and indolent for a considerable time, producing, according to their size, an unsightly appearance without undergoing cheesy degeneration. Finally, one or more become inflamed, and the broken-down gland substance softens and is expelled, mixed with pus, through an ulcerated opening in the skin. In order to complete the description of the anatomical character of scrofula, it would be necessary to describe the various inflammations to which the diath- esis gives rise. Those which are most common and important occur in the skin, mucous membrane, connective tissue, the joints, the bones with their periosteal covering, and the eye and ear. Eczema and coryza are also very common scrofulous ailments. Phlyctenular keratitis with great intolerance of light, otitis externa, causing protracted otorrheea, or media and interna, causing deep-seated pain, with impairment or loss of hearing, offensive puru- lent discharge, and, in the gravest cases, caries of the mastoid cells or caries extending along the petrous portion of the temporal bone even to the brain. 190 CONSTITUTIONAL DISEASES. causing meningitis and death, are not uncommon manifestations of scrofula in the families of the city poor. Strumous cellulitis, occurring independently of the glandular affection and quickly ending in suppuration, is also common. The term cold is applied to the abscess when the local symptoms are slight and there is but little heat of the parts. In young children the common seat of these abscesses is directly under the skin, so that if subcutaneous cellulitis running into an abscess occur in a young child, he probably has the strumous diathesis. The osseous system is very prone to inflammation in the scrofulous. Peri- ostitis, osteitis, and arthritis, rare in those with healthy constitutions, are common in the scrofulous, in whom they result even from very slight injuries, and sometimes without the recollection of an injury, and apparently from the direct influence of the diathesis. These inflammations are more common in the lower extremities than in the upper. Periostitis often occurs in scrofulous children without osteitis when its usual seat is upon the shafts of the long bones, and it also accompanies inflammations of the bone, as pleurisy accom- panies pneumonia. The osseous inflammations of strumous patients are of two kinds : first, the destructive, producing caries with suppuration or necrosis ; and secondly, the so-called fungous, in which there is proliferation of tissue, as in white swelling. Often both these processes coexist, granulations and new tissue springing up while the carious or necrotic process is extending. Dactylitis is in most instances, when occurring in young infants, a syphil- itic affection, but in children of one year or more, in whom no marked syphilitic symptoms have previously occurred, it originates from the strumous cachexia, Fig. 36. as in the following case : Charles R , aged twenty months, was admitted into the New York Infant Asylum in 1876. He had always been pallid and had a strumous aspect. A physician acquainted with his parentage states positively that he is free from syphilitic taint, but when a few months old he had a mild form of coryza, which gradually abated under antistrumous SCROFULA. 191 treatment. At the age of five months he had purpura haemorrhagiea of a severe form, but apparently not accompanied by hemorrhage from any of the mucous surfaces. The patches of extravasated blood were quite numerous and large over the trunk and limbs, and it was nearly three months before they entirely disappeared. A few months subsequently he began to have offensive otorrhoea on one side, which did not entirely cease. In December, 1S76, at the age of eighteen months, well-marked dactylitis was first observed, involving the first phalanx of the left middle finger. The swelling was some- what tender, and the skin which covered it had a slightly reddish or pinkish tinge, indicating the inflammatory nature of the malady. Neither joint at the extremity of the phalanx was involved, so that the movements were unim- paired. The dactylitis increased somewhat after it was first discovered, and then began to decline under treatment with cod-liver oil and syrup of iodide of iron. The accompanying woodcut represents the outlines, obtained by tracing the hand of the infant when pressed on paper. Symptoms. — The scrofulous diathesis is exhibited by certain physical signs which are present in infancy, but are more manifest in childhood. In one class of strumous children they are as follows : Form tall and slender ; quickness of movement and perception ; intelligence good ; skin thin and semi-transparent, through which the superficial veins are distinctly seen; features delicate ; cheeks habitually pallid or florid, and flushed by slight excitement ; eyes bright, with bluish conjunctiva ; muscles and bones slender in proportion to their length. Those children who present these peculiarities are said to have the erethitic form of the diathesis. Others have what has been designated the torpid scrofulous habit, which is characterized by softness and flabbiness of the flesh, distended abdomen, large head, broad face, slow, languid movements, and an over-production of fat in the subcutaneous connective tissue in certain situations, especially the nose and upper lip. Though typical cases can be readily referred to one or the other of these forms, there are many which are intermediate. One of the earliest of scrofulous manifestations is subcutaneous cellulitis, alluded to above, giving rise to abscesses, commonly not large, with little sur- rounding induration, little pain, tenderness, and heat, and slow in discharging ; in a word, indolent. The most frequent seat of these abscesses is upon the extremities, but they may occur upon the scalp or elsewhere. They gradu- ally heal when the pus escapes, their site being indicated for a considerable time by the depression and reddish discoloration of the skin. Ordinarily, these abscesses do no harm apart from the reduction of the general health which they effect, but, when occurring in localities where the connective tissue lies upon the periosteum, as upon the fingers, periostitis may result, with destruction of the surface of the bone. Again, thrombi may occur in the vessels of the inflamed part, giving rise to emboli, embolismal pneumonia, and death. Specimens from such a case were presented by me to the New York Pathological Society in 1868. The scrofulous affections of the skin often also occur at an early age, even before dentition. They are more frequent in infancy than in childhood. The most common are eczema and impetigo, and, of rare occurrence, ecthyma and lupus. But all these may occur in those who are not strumous or who do not present the characteristics of the strumous diathesis. Scrofulous affections of the mucous surfaces are scarcely less frequent than those of the skin. They present the ordinary features of mucous inflammations of a subacute and chronic character. Sometimes they occur without obvious exciting cause; in other cases there is a cause of this kind, such as exposure to cold : but the inflamma- tion, once established, continues on account of the diathesis. It is often 192 CONSTITUTIONAL DISEASES. doubtful whether inflammations in strumous subjects be of such a character that it is proper to designate them strumous, especially if they occur upon such surfaces as are frequently the seat of ordinary inflammation. If the child have heretofore presented symptoms of scrofula, if the inflammation be subacute, and there be no apparent cause to originate or sustain it apart from the diathesis, it is probably of a strumous character. The diagnosis is rendered more certain by observing the effect of antistrumous remedies. The most frequent of these scrofulous inflammations of mucous surfaces are coryza, tracheo-bronchitis, and conjunctivitis. More rarely, stomatitis, pharyngitis, vaginitis, and, according to some, entero-colitis, are of a stru- mous character. Coryza gives rise to snuffling respiration, the formation of crusts around and within the nares, and excoriation of the upper lip. The tracheo-bronchitis is attended by thickening of the mucous membrane, increased production of mucous and epithelial cells, and a loud tracheal rale accompanying each inspiration. Strumous inflammation of the mucous membrane of the trachea and bronchial tubes is a not very infrequent disease in this city. It sometimes originates in a simple inflammation from cold or the tracheo-bronchitis of measles or pertussis, and it may continue, with its rales, cough, and scanty expectoration, for months, unless relieved by a proper course of treatment. Among the most common of the strumous affections are inflammation of the eyelid, designated psorophthalmia, and that of the eye itself. The former is characterized by redness and thickening of the lids, detachment of the eyelashes, and inflammation and altered secretion of the " Meibomian glands ;" the latter — to wit, strumous ophthalmia — by pain, lachrymation, photophobia, and a moderate degree of hypersemia of the affected organ. One of the most common serious results of strumous conjunctivitis and keratitis is the formation of phlyctenules and ulcers on the margin of the conjunctiva and upon the cornea, fed by newly-formed vessels. If not con- trolled by proper treatment they may result in opacities more or less perma- nent, or possibly, worse still, in perforation, with its consequent ill effects. Inflammations of the external and middle ear have their origin very gen- erally in the strumous diathesis. Occasionally there is an exciting cause of the otitis, as an injury or severe constitutional disease, like scarlet fever. Protracted otitis, whether external or internal, and especially that form of it which leads to ulceration, destruction of the ossicles, and caries of the petrous portion of the temporal bone, it is proper in a large proportion of cases to regard and treat as strumous. The stubbornness and frequent disastrous consequences of scrofulous inflammation of the bones are well known. Nearly every bone, as well as its periosteum, is liable to this form of inflammation, but some are more fre- quently affected than others. Inflammation of the bone may terminate by resolution, by the formation of an abscess, or (and frequently) by carious or necrotic destruction of the bone itself. Necrosis most frequently occurs in the shafts of the long bones ; caries in the spongy extremities of these bones and in the spongy portions of the short bones. If abscesses form, the pus may finally escape from the system by a tedious ulcerative process, or, retained, may undergo cheesy degeneration. Scrofulous arthritis, if early detected and properly treated, may resolve, leaving no ill effect ; if other- wise, suppuration, ulceration, cartilaginous and osseous, and ankylosis often occur. Scrofulous children are perhaps no more liable to inflammation of the internal organs than other children, but the inflammatory products are more liable to cheesy degeneration, and the prognosis is therefore less favorable. The most frequent of these inflammations and the one of chief interest is SCROFULA. 193 pneumonia. Catarrhal pneumonia, so frequent in early life, whether primary or secondary, in connection with measles, pertussis, etc., is a disease often involving grave consequences in those who are decidedly scrofulous, since, instead of resolving, the affected lung-tissue presents a strong tendency to caseous degeneration, ending in tuberculosis of the lungs and death. I have most frequently noticed cheesy pneumonia during extensive epidemics of measles as a complication or sequel of this disease. It may occur in those who are not scrofulous if the vital powers be greatly reduced, but it is so much more common in the scrofulous that some recent writers have desig- nated this form of inflammation by the term of scrofulous instead of cheesy pneumonia. From the fact, however, of its sometimes occurring in the non- scrofulous, the term cheesy or caseous — especially, too, as it expresses the anatomical state — seems more appropriate. The caseous substance which results from degeneration of the products of scrofulous inflammations affords a nidus in which the tubercle bacillus frequently obtains lodgement and conditions favorable for its propagation. Hence the close etiological relations of scrofula or scrofulous inflammations to tuberculosis. Prognosis. — As scrofula may be acquired through antihygienic influ- ences, so it may disappear or become latent through influences of an opposite character. Therefore the manifestations of scrofula may be limited to a brief period, or they may occur at intervals through the whole of childhood and the first years of youth. When the diathesis is inherited and fostered by unfavorable circumstances, the scrofulous affections appear earliest, are most varied and severe, and continue longest. In most cases, with proper treatment, the prognosis is good, but the dan- ger to life depends on the nature and extent of the scrofulous inflammation. The most common unfavorable result is the occurrence of pulmonary or gen- eral tuberculosis, the caseous substance, as we have said, affording a favorable nidus for the development and propagation of the tubercle bacillus. This is the usual result in cheesy pneumonia. The next most common cause of death, either directly or indirectly, is inflammation of the osseous system. Many deaths occur from inflammation of the vertebrae or of the hip or knee- joint when it has been allowed to continue a considerable time without proper treatment. Protracted suppurative inflammation of the bones is liable to produce amyloid degeneration of organs, which is permanent and likely to prove fatal, or death may occur from exhaustion, with or without tubercu- losis. Among the city poor meningitis is not very uncommon, consequent on long-continued otitis media and caries of the petrous portion of the tem- poral bone. Permanent impairment of sight and hearing often results from neglected strumous ophthalmia and otitis. At puberty the strumous affections gradually become less frequent, and they finally disappear in advancing age. Among the most robust adults are some who in early life presented indubitable symptoms of the strumous diathesis. Treatment. — Prophylactic. — Measures designed to prevent scrofula are impossible without the co-operation of willing and intelligent parents. It is evident that the prevention of congenital scrofula requires the treatment of disease or impaired health in the parent. If parents should be taught or should remember that good health in themselves is the necessary condition of the inheritance of a sound constitution in the child, and would adopt such therapeutic and regimenal measures as would procure this, the number of cases of inherited scrofula would be materially reduced. As the first years of life are very important, both for correcting the diathesis when inherited and for preventing its development in those of sound 13 194 CONSTITUTIONAL DISEASES. constitution, care should be taken that the regimen of the child be such that it does not cause deterioration of the general health. The nursing infant, if the mother be in poor health, should be provided with a healthy wet-nurse, for in young children the diathesis may be acquired solely by the use of food that is scanty or of poor quality. Those old enough to be weaned should have plain and nutritious diet, with a proper admixture of animal food. More or less outdoor exercise and residence in a salubrious locality, with sufficient air and sunlight, are also requisite. Curative. — Since scrofula originates in a state of weakness existing in the parent in the congenital, and in the child in the acquired, form of the disease, and is characterized by feeble resistance of the tissues to irritating agents, the inference is reasonable that all tonics have, to a certain extent, an anti- scrofulous effect upon the system. The ordinary vegetable tonics, and some- times the ferruginous, are indeed useful in the treatment of scrofula. Employed in connection with proper regimenal measures, they are sufficient, in many cases, to remove the diathesis after a time or render it latent. Besides the medicinal agents, which tend to correct the scrofulous diathesis by their general tonic effect, there are certain others which experience has shown to be beneficial in the treatment of scrofulous affections, and which are therefore largely used. One of these is cod-liver oil, which contains iodine among its many ingredients. Cod-liver oil is useless or nearly so in the torpid form of the diathesis, which is characterized by an increased deposit of fat in the subcutaneous connective tissue, slow circulation, and sluggish muscular movements. On the other hand, in the treatment of the erethitic form it possesses real value. Its protracted use in such cases does so modify the molecular condition of the tissues that they are less liable to inflammation, and the diathesis is there- fore rendered milder or removed. From one to three teaspoonfuls, according to the age, should be given three times daily. While we frequently expe- rience so much difficulty in administering it to adults affected with tubercu- losis, and sometimes find it necessary to discontinue its use on account of its nauseating effect, scrofulous children rarely refuse to take it, and it does not seem to diminish their appetite. Iodine is justly celebrated as a remedy in the treatment of scrofulous maladies, but it is a question whether it has not been overrated as a remedy for the diathesis itself. Iodine employed internally is especially serviceable in glandular hyperplasia and in scrofulous thickening and induration of the connective tissue and periosteum. In general, it should not be administered to children in its isolated state, on account of its irritating properties, but one of its compounds should be employed. The compounds which are chiefly prescribed in the treatment of scrofula are the iodides of starch, iron, potas- sium, and sodium. If, as is frequently the case, the patient be pallid and his appetite poor, the iodide of iron should be preferred ; if not in this cachectic state, the iodide of starch may be used. Pharmaceutists prepare syrups of both these iodides, so that the}^ can be readily administered to the youngest child. The iodide of starch may be administered by dropping from one to five drops of the officinal tincture of iodine on a little powdered starch and giving it in syrup. These iodides are preferable to the iodides of potassium and sodium for internal administration to children, since they are not irritat- ing to the mucous membrane and the iodine is readily set free. Prof. Dalton has, indeed, demonstrated that the iodide of starch is decomposed in most of the liquids of the body and the iodine liberated. In New York City a large proportion of the scrofulous children are cachec- tic and need iron, and the iodide of iron is more frequently employed, and with good results, than any other iodine compound. The syrup of the iodide SCROFULA. 195 of iron, which is readily absorbed, should be given in one- to two-drop doses three times daily to a child of six months, and one additional drop be added for each additional year. Among the vaunted remedies of scrofula are phos- phoric acid and the phosphate of lime. I have not employed these agents without at the same time using other remedies, and cannot say, therefore, to what extent they have been curative in my practice. Probably there is no better combination of remedies for the strumous diathesis than the following, which is now used in some of the institutions of New York, and which we have already recommended in the treatment of rachitis : R. 01. morrhua?, 2 parts ; Syr. calcis lactophosphat. , 1 part ; Aquae calcis, 1 part. — Misce. Dose : One teaspoonful to a dessertspoonful three or four times daily. The syrup of the iodide of iron should be given at the same time in three daily doses, but not mixed with the above preparation of oil and lime, as a double decomposition occurs from the admixture. The internal use of mercury as an antidote for scrofula is now generally discarded. Unless, perhaps, in those cases in which the diathesis is imme- diately dependent on syphilis, its use for this purpase, from what we know of its therapeutic effects, would probably be more injurious than beneficial. Among the medicines which have from time to time been employed for the cure of scrofula, some of which have had considerable reputation, but have nearly fallen into disuse, are walnut-leaves, sarsaparilla, elecampane, conium, digitalis, horseradish, compounds of silver, gold, arsenic, baryta, and bromine. It is probable that none of these has any effect on scrofula or scrofulous ail- ments except such as improve the appetite and general health, as horseradish. The same hygienic measures are required in the treatment of scrofula as are employed in the prophylaxis of it. The nursing infant should have healthy breast-milk, and if its mother belong to a tubercular or scrofulous family or be feeble, a healthy wet-nurse should be employed, or it should be sent to the country, where suitable cow's milk as well as pure air can be obtained. The expressed juice of beef slightly boiled, the peptonized beef or beef tea prepared as recommended for rachitic infants, given several times daily in small quantity to infants, aid materially in restoring a better nutri- tion of the tissues. Obviously, similar care is necessary in the selection and preparation of the food of children who have passed beyond the period of infancy. While the diet should be highly nutritious, it should be plain and easily digested, and given at sufficient intervals, so as not to overtax diges- tion. The cow's milk employed should be of the best quality, and for young children it may be best to peptonize it. Fresh air, outdoor exercise, daily bathing, personal and domiciliary clean- liness, are very necessary for the successful treatment of the diathesis. Since scrofula is comparatively infrequent in farming sections, scrofulous families are greatly benefited by farm-life, with all the accessories to health which pertain to it. The use of sea-air and sea-bathing has, according to the testi- mony of several observers, been very efficacious. Dr. F. P. Henry states that no other remedial measure is so efficacious as these (Annual of Uhiver. Med. Sci., 1889). Dr. Valcourt, who is in charge of the Maritime Hospital at Cannes, where scrofulous children receive daily sea-baths during a consider- able part of the year, read an interesting paper in commendation of its use before the Pediatric Section of the Ninth International Medical Congress in 1887. Alexander quotes the statistics prepared by Cazin. which show that the mortality of scrofulous children is much less in the hospital at Barek, 196 CONSTITUTIONAL DISEASES. where sea-bathing is employed, than in two Parisian hospitals (I/iverp. Medico- Chir. Journ., 1888). The local scrofulous ailments require additional and special treatment. Those located on the cutaneous and mucous surfaces are less dangerous, as a rule, than the deeper-seated inflammations ; still, they should be promptly treated, not only for the inconvenience and annoyance which they cause, but because they may give rise to hyperplasia of the neighboring glands, as we have stated elsewhere. Thus, pharyngitis may cause a peripharyngeal ade- nitis and abscess, and a bronchitis may cause adenitis of the bronchial glands, with the probability of their cheesy degeneration. The so-called bronchial phthisis is believed to result, in a large proportion of cases, from a strumous bronchitis which has been allowed to continue uncontrolled by medicine, and a similar state of the mesenteric glands may result from intestinal catarrh. Inflammation of the skin or mucous surface occurring in the strumous requires the continued use of antistrumous remedies, conjoined with such treatment, designed to act locally, as is appropriate for the case. It is the common practice to treat the enlarged glands of struma by daily applications over them of the stronger iodine preparations. This treatment does not cause absorption of the redundant gland-substance. It causes pro- liferation of the epidermic cells, and quickens the cell-change in the adjacent gland and accelerates suppurative inflammation. I once produced accident- ally such an amount of vesication over an enlarged, hard, and apparently indolent gland in an infant of fourteen months that I was very anxious lest a sore should result which would heal with difficulty, and yet, instead of dis- persion of the glandular swelling, the pathological processes were so promoted that suppuration and discharge of pus occurred by the time that the cuticle had re-formed. When scrofulous glands have undergone degeneration they should be removed with the knife. It is necessary to completely extirpate the gland by a dissection which includes the entire gland-structure. Merely opening the gland, removing its contents, and curetting its cavity, as are sometimes practised, is not sufficient. It is well also to cut away all cicatricial tissues in order to secure union with as little deformity as possible. We know no better substance for the local treatment of strumous adenitis than iodine, and it should be applied, in my opinion, in such a manner that it is absorbed with the least possible irritation of the gland. The following will be found useful ointments and solutions for the treatment of these cases : R. Potas. iodidi, 3j ; Ung. stramonii, ^j. To be rubbed over the gland several times daily. It should not be applied as a plaster, since it is too irritating and will vesicate. I have known a glandular swelling which had continued about three months to disappear in three weeks under its use in connection with internal remedies. Lanolin may be employed in place of the stramonium ointment, inasmuch as it is believed to be more readily absorbed than most oleaginous substances. Another useful iodine mixture for these cases is the following : R. Liq. iodinii composita, Glycerini, equal parts. To be applied as an inunction. Glycerin renders the skin soft and in a state favorable for absorption. In The Medical Press and Circular for August 3, 1870, J. Waring Curran states that he has used with great success what he designates a new iodine paint, consisting of half an ounce of iodine, the same quantity of iodide of ammonium, twenty ounces of rectified spirits, and four ounces of glycerin. SCROFULA. 197 Mercurial ointments have been recommended by writers of reputation for the treatment of these glands. I have employed them and know them to be employed, but cannot say that I have ever observed any benefit whatever from their use. In the children's class at the Out-door Department at Belle- vue we have discarded them entirely for this purpose, although both the citrine and white precipitate ointments, diluted with an equal quantity of lard, have been used with apparent benefit for chronic coryza of a strumous nature, and also occasionally for external otitis of the same nature. The application of cold over an inflamed lymphatic gland and the adjacent inflamed connective tissue is a useful adjuvant to the treatment in many cases at an early stage. A small India-rubber bag containing ice, or muslin fre- quently wrung out of ice-water and applied over the inflamed parts, contracts the vessels, diminishes the activity of the morbid process going on underneath, and aids materially in the resolution. When the gland becomes so actively inflamed or the inflammation so advanced that redness of the skin occurs, applications of iodine are no longer proper. They increase the local disease. There is no longer any probability of resolution of the gland, and poultices should be applied. It is important that the diseases of the osseous system should receive early treatment, but, unfortunately, it is in reference to these inflammations that error of diagnosis is frequently made. Thus I have known periostitis, with the diffused redness of the skin and heat which it produces, to be mistaken for erysipelas, until the diagnosis was corrected from its persistence and non- extension. It is remarkable that strumous arthritis sometimes appears in two or more joints at once, as in the case related below. I have known it to occur nearly simultaneously in three joints, though only for a brief time in two of the joints, while it was chronic in the other. Hence, the fact that this inflammation is often mistaken for inflammatory rheumatism, and treated as such for some days till its nature becomes apparent, and in like manner the febrile movement, lassitude, abdominal pain, etc. of vertebral caries are in a large proportion of cases attributed to something else, and the true disease not suspected till irreparable damage has occurred, or much longer con- finement and treatment required than would have been necessary with an earlier diagnosis. The common strumous inflammations of the osseous system which involve the joints, as Pott's disease, hip disease, and white swelling, are usually quite amenable to treatment, early applied, which ensures complete rest ; but, as a rule, cases neglected or wrongly treated go from bad to worse. There are exceptions, for a case may do well or terminate with moderate deformity without treatment, as in the following interesting in- stance, which also shows the difficulty which often attends diagnosis : Anna D , aged six years, came to the children's class in the Out-door Department at Bellevue in February, 1877, with the following history : Her health was good till two years ago, when she complained of pain of a mild form in both knees. Her parents attributed it to her rapid growth, and she was always able to walk with little suffer- ing. Slowly but steadily these joints began to swell. She has had no pain in other joints, and no member of the family has had rheumatism except a grandparent. She walks without complaint to the rooms ol' the Bureau. Fig. 37. 198 CONSTITUTIONAL DISEASES. The affected joints are about equally swollen, and it is evident on examination that they contain some serous effusion. Direct pressure is not painful, but pressing the bones together with a twisting or rotating movement gives some pain. She is pale and has a strumous aspect. A sister of fifteen years has a similar swelling of one knee which began at the age of seven or eight years, but which has received no regular treatment, has not prevented the free use of the limb, and has given her little inconvenience. The ph}*sicians who have examined this child, one of whom is an expert in orthopaedic surgery, agree that the disease is strumous and not rheumatic, and that it did not, during two years of neglect and unrestrained motion, go on to suppura- tion and destruction of the joints was probably due to her good general health. Though the result in the above case was good, since there was little impairment in the use of the joints and no suffering, yet delay and neglect in the treatment of those strumous inflammations which involve the joints are exceedingly dangerous, for if left to themselves they most frequently end in suppurative inflammation and ulceration, with all the sad conse- quences which these entail. Strumous inflammations of the osseous system now receive more early and correct treatment than formerly, and orthopsedia, almost unknown till within the last twenty years, has become an important branch of surgery. Formerly in New York, especially in the tenement- houses, we often met emaciated bed-ridden children with strumous osteitis and arthritis, their limbs swollen and painful in motion, and offensive from the discharge, for the most part shunned by physicians, and with no prospect of relief except by amputation, Now this spectacle is comparatively infre- quent. The early symptoms of these diseases being better understood and sooner recognized, the plaster-of-Paris or starch dressing to ensure immo- bility, or ingeniously devised steel splints which produce extension and allow motion of the limb without friction of the inflamed surfaces, coming into general use, a large proportion of cases do not go beyond the first stage and are cured. Strumous Ophthalmia. [Written by Dr. O. D. Pomeroy, Surgeon to the Manhattan Eye and Ear Hospital.] Strumous ophthalmia in young children, as described by the older writers, is simply a keratitis or inflammation of the cornea, and is usually of the fol- lowing varieties : phlyctenular or herpetic keratitis and diffuse or paren- chymatous keratitis. Perhaps it is a misnomer to designate these affections strumous. This general principle governs most cases of these inflamma- tions — to wit, depressed vital energy, which is a prominent characteristic of the strumous diathesis. As is well known, the cornea is a tissue of low vitality, and any constitutional state accompanied by depression predisposes to an attack of keratitis. One of the commonest hospital experiences is to see a mild case of catarrhal conjunctivitis which should be self-limiting gradually extend to the cornea, causing an ulcerative keratitis. I believe all ophthalmic surgeons hold that the presence of corneal disease, not dependent on an obvious or specific cause, points to diminished vitality on the part of the patient. Herpetic or Phlyctenular Keratitis is the most frequent variety of corneal disease in children. It is a question whether it commences with a vesicle on the cornea or a papula ; but in either case it soon becomes an ulcer. Ciliary injection probably precedes it, although this can by no means be always observed. In some patients the characteristic symptom— to wit, photophobia — may exist for a long time without injection of the eyeball or any corneal changes whatever, but sooner or later it is probable that other characteristic signs of the disease will make their appearance. The photo- SCROFULA. 199 phobia is frequently accompanied by blepharospasm, making it wellnigh impossible to separate the eyelids. When, however, this is accomplished, abundant tears gush forth, the child exhibiting signs of extreme distress. When the vesicle or papula is in a state of ulceration in the earlier stage, there may only be seen a minute loss of corneal tissue, without any opacity whatever. Soon, however, the ulcer becomes more or less opaque, perhaps seeming to be only a minute whitish spot on the cornea. This usually shows the commencement of reparative action. If the disease continue long, a general conjunctivitis sets in, more especially of the ocular conjunctiva. Frequently there will be only one or not more than two or three ulcers, but in exceptional cases the cornea may have the periphery studded with phlyc- tenule, which, instead of promptly healing, proliferate so as to form elevated nodules, the so-called " scrofulous nodular bands." If the ulcers in any case continue long, a number of blood-vessels shoot out from the conjunctival border of the cornea, quite up to the ulcer, producing what may be termed a vascular keratitis. The discharge from the eye is often very acrid, causing catarrh of the lachrymal canals, and even of the nares. Herpetic or ec- zematous eruptions on the cheeks or the lip near the nostrils are often seen, and may sometimes appear to be the cause of the disease rather than the effect. In this condition the upper lip may swell considerably, giving the patient a very " strumous " appearance. The duration of phlyctenular keratitis is exceedingly variable ; two or three weeks may bring it to a close or it may continue many months. The patient's general condition probably determines its duration as much as any other factor. If an ulcer perforate the cornea, staphyloma and anterior synechia may result, rendering recovery more tedious and incomplete. The diagnosis of this malady is not difficult. The photophobia so characteristic of keratitis is present in no other disease except iritis, and this disease chil- dren rarely have ; the little speck, spot, or abrasion on the cornea, together with the intolerance of light, is wellnigh diagnostic. Photophobia is present in most forms of corneal disease, though not in all. The causes of phlyc- tenular keratitis are as follows : Any condition of the system known as strumous, or whatever tends to lower the vital powers of the patient, affords a, predisposing cause. Exposure to cold or sudden change of temperature is the common exciting cause, leaving out of the question any cutaneous dis- eases. Naturally, any cause which produces a conjunctivitis may also pro- duce this disease secondarily. The process of dentition may have something to do with the eye disturbance, or any disorder of the intestinal canal ; the latter, however, being rather predisposing than exciting causes. This dis- ease also frequently occurs in patients affected with aural or nasal catarrh, but the condition of such children approximates closely the state designated " strumous." The prognosis in a large number of cases is very favorable. The opacities of the cornea left after the healing of the ulcerations are the principal difficulties in the way of a good recovery. If the opacities are in the proper substance of the cornea, we are not certain that they will dis- appear by absorption, though they may. Nothing is more difficult than to determine this point. In the epithelial and Bowman's layers, as well as the posterior layer, opacities readily disappear. When the ulcer perforates the cornea we have an anterior synechia and the appearance known as myo~ cephalon, which usually disfigures the eye more or less for life. One discouraging point about these opacities is that, although they dis- appear, the cornea is left with a somewhat distorted curvature, causing irreg- ular astigmatism, and if they chance to be near the centre oi' the cornea great disturbance to vision results. I have often, in fitting spectacles, 200 CONSTITUTIONAL DISEASES. noticed that the patient's vision was less than normal, and on investigation have found a history of an infantile keratitis which had done all the mis- chief. In those cases described as having " scrofulous nodular bands " the proliferative nodules are very likely to undergo a variety of degenerations which do not end in a properly restored cornea. One great difficulty in mak- ing an exact statement here is the tendency of the keratitis to recur, and it. cannot be determined where the process will cease after a number of recurrences. Treatment. — As the fifth nerve presides over the ciliary vaso-motory system of the corneal nutritive supply, it is obvious that treatment calcu- lated to correct any of its morbid manifestations would be rational. Such is found to be the fact. Sulphate of atropia, in solution of one to two grains to the ounce, dropped into the eye three times daily, is probably superior to any other treatment. It inclines to break up the orbicular spasms, relieving the photophobia and ciliary neuralgia, diminishes vascularity, and contributes more to the relief of the patient than any other one remedy. If the pain be severe, the atropine may be used six or eight times daily, or it may be even instilled every fifteen or twenty minutes until pain is relieved. If an over-effect be reached, the patient complains of dryness in the throat, possi- bly pain in the head, or he may have other cerebral disturbances, when the drops may be discontinued for a time. Muriate of pilocarpine in two-grain solutions may be used in a similar manner and for the same purpose ; but it contracts the pupil and renders the accommodation tense, the very opposite to the atropine effect. I have not as much confidence in this remedy. A 2 per cent, solution of cocaine, instilled, will sometimes relieve the spasm and pain temporarily. Powdered calomel may be dusted into the eye every second day. A small quantity only should be used, since it is apt to col- lect in masses which act as foreign bodies (we desire to produce irritation for a few minutes only). A drachm of table-salt to a pint of water may be used to bathe the eyes freely four or five times a day, used warm or cold accord- ing to the patient's pleasure, although warm applications are more likely to be well received. Red precipitate ointment (R. Vaseline, £j ; hyd. ox. rub. in very fine powder, gr. j to ij. — Misce.) placed under the eyelids every day or two, is often very beneficial ; also the yellow precipitate ointment, made in the same manner, has a similar effect. Occasionally the ulcers show a disin- clination to heal, when they may be touched with Arg. nit. gr. x to xxx ; aquae dest., ^j. — Misce. Wind a bit of absorbent cotton on a probe, dip this into the solution, and touch the ulcer, but no other point. Cupri sulph., in solution of the same strength, may be used for the same purpose. A platinum probe, heated to a red heat in a spirit lamp, is much used at present. A few drops of a 2 per cent, solution of cocaine, previously instilled, will prevent pain from these applications. A protective bandage exerting moderate pres- sure on the eye sometimes does good, but it should not cause discomfort. If there be much spasm of the orbicularis, however, it is not indicated. If the pain in the eye continue and the orbicularis be in a state of spasm, can- tholysis may be performed ; that is, divide the external canthus so as to cause the lid no longer to press hard upon the eyeball, and close the wound thus made by stitching the skin to the conjunctiva above and below the incision, placing one stitch in the extreme outer canthus. The result of the ope- ration is temporarily to break the power of the orbicularis, so as to arrest the spasm. This measure accomplishes in some cases what nothing else will. If the eye be painful, without spasm of the lid, and there be great pho- tophobia, whether the eyeball be too hard or not, paracentesis may be done. The mode of performance is described in the treatment of ophthalmia neonati in another place in this book. After a while the accompanying conjunctivitis SCROFULA. 201 may need treatment in the ordinary way. Indeed, astringents may often be used quite early to obviate the irritating effects which occasionally result from the use of atropine. If an ulcer refuse to heal after the treatment already laid down, iridectomy may be performed, although this is not often resorted to. Occasionally an ulcer may be cut across by passing a narrow Graefe's knife through it, making a puncture on one side and a counter-punc- ture on the opposite side, and then cutting out quite through the ulcer, divid- ing it into two equal parts. All needful treatment for the constitutional condition of the patient should be attended to. So necessary are fresh air and sunlight that I would never shut the patient in a dark room. Blue or smoke-colored glasses may be worn to protect the eyes from a strong light, and in some cases the eyes may be protected by a bandage of some dark material, so that the patient may be taken for an airing without suffering. I would, however, advise that the eyes be accustomed to the light as much as is possible without causing pain. In Parenchymatous or Diffuse Keratitis we have quite a different array of symptoms. The margin of the cornea near the limbus may show a decided zone of injection of the conjunctival and episcleral vessels. It may be so excessive as to consist apparently of a rosy ring surrounding the cornea. These vessels after a time shoot inward, and may involve a large part or even the whole of the cornea. In other cases, designated non-vascular diffuse keratitis, the injection is very slight indeed, and sometimes apparently want- ing altogether. In either case, however, the same consequences result : the cornea becomes diffusely clouded, the process generally, but not always, com- mencing at the limbus. This cloudiness may be quite without lines or dots of opacity, like ground glass. Again it may appear composed of innumer- able minute opaque points or lines running in various directions. At first, the corneal epithelium escapes, presenting a regular and uniform polish, but afterward it becomes opaque. Again, if the process involve the whole of the cornea, minute opaque spots may be seen in Descemet's membrane, giving it some of the characteristics of keratitis punctata. In the earlier stages there may be some pain and intolerance of light, but as a rule the disease, for a corneal affection, is comparatively painless. The duration of this disease is never short ; it may continue for many months, and it shows a strong tend- ency to relapse. The most frequent causes are hereditary syphilis and struma. Mr. Hutchinson of London always examines the teeth of these patients to see if there be anything characteristic of hereditary syphilis. As similar teeth are often noticed in strongly-marked strumous subjects, it becomes doubly interesting to make the observation. One point is apparent in most of these cases : that there are in almost every patient some signs of badly-developed physique — that is faulty tissue-elaboration. As a rule, both eyes sooner or later become affected, pointing to a constitutional origin of the affection. In treatment we are often disappointed in our efforts. At the first, if there be pain or photophobia, atropine may be instilled and the eyes bathed with warm or tepid water several times a day. Tonics or alteratives are always indicated. One of the most useful prescriptions is the following : R . Hydrarg. chlor. corros., gr. j. ad jss ; Tine, cinchon. comp., Syr. aurantii, da. £iv. — Misce. Dose : One teaspoonful three times daily after eating. Iodide of potassium is frequently given, and may very properly alternate with the mercurial treatment ; children will bear very large doses of the iodide. and indeed they are often necessary in order to obtain the curative effects of 202 CONSTITUTIONAL DISEASES. the drug ; I would suggest from three to twenty grains three times daily, well diluted with water. Both these remedies may be continued for months, but ptyalism should always be avoided. Cod-liver oil with extract of malt may be administered. Whatever tends to improve the patient's general condition is indicated. Exercise in the fresh air is good, but the pernicious effects of cold must be avoided. Paracentesis of the cornea rarely does good, but occa- sionally iridectomy may be of benefit. The complication of iritis or irido- choroiditis is not common, though it does occur. When the disease becomes very chronic there will be hardly vascularity enough for the purposes of repair. This being the case, stimulating collyria may be used, similar to those indicated in conjunctivitis. Olive oil and spirits of turpentine, in equal parts, may be applied to the eye every second day. Bathing with warm water sufficiently to congest the eye will sometimes be serviceable. An attack of acute conjunctivitis has been known to do good. But, do what we may, this affection sometimes runs on unchecked for a very long time. It rarely destroys the sight, but I recently treated a case from the beginning, and in spite of treatment there was only perception of light remaining. I have heard of only one other similar case. From some recent experiences I am inclined to believe that bichloride of mercury internally and atropine as a collyrium are of as much value as any other agents in the treatment of this obstinate malady. CHAPTEE III. TUBEKCULOSIS. The term " tuberculosis " is applied to a disease which is characterized by the formation of small tubercles or nodules in one or more organs. Though more prevalent in some countries or localities than in others, it occurs in all or nearly all parts of the globe from which we have exact information, and it has been more destructive to human life than any other one disease. Etiology. — One of the most important discoveries of recent years relat- ing to the etiology of diseases is that of the specific principle of tuberculosis. It has long been suspected by observing physicians that a specific cause did exist, and that this disease is to a certain extent infectious, but it is only recently that patient microscopic investigations have triumphed over the difficulties which surround this subject, and have detected the micro-organ- ism which has been so fatal to the human race. The honor of its discovery belongs mainly to Dr. Koch of Berlin. In his investigations Koch invariably found a certain bacillus in all recent tubercles, proving beyond a doubt that they always accompany the development of the tubercular nodule. By inoculating guinea-pigs, rabbits, and cats with tubercular material he com- municated tuberculosis, reproducing the tubercular nodule, in which he always found the same bacillus. But it still remained to determine the rela- tion of the bacillus to the tubercle, whether it was merely an accidental accompaniment, or whether it sustained a causal relation, producing the nodule by its irritating action on the cellular elements of the part where it happened to lodge. After many trials Koch succeeded in preparing a pabu- lum in which the bacilli grew and reproduced their kind. By adding a little of the first cultivation to the pabulum, he produced a second cultivation, and TUBERCULOSIS. 203 after a series of cultivations he produced a bacillus which was evidently freed from all other substances. With the bacillus of the last cultivation he was able to produce the tubercular nodule, having all the characteristics which are observed when it is developed in the usual way in man. Different micro- organisms take coloration differently, and Koch was enabled to discriminate the tubercular bacillus under all circumstances from other microbes by the peculiar color imparted to it. The tubercle bacilli have the form of " delicate rods from a quarter to half the diameter of a blood-corpuscle in length." The more severe the tuberculosis, the greater the number of bacilli. They occur not only in the recent tubercle, but also in immense numbers in the periphery of the caseous masses of a tubercular patient. They are found not only elsewhere, but also in the interior of the giant-cells, as many as twenty even in some cells. They do not seem to have the power of movement, and oval spores are found in some of them. They grow in a temperature of 86° to 104° F., and not in a temperature outside these limits. As might be expected, these microscopical researches of Koch have attracted wide attention, and have led to a repetition of his experiments by many pathologists, and to new experiments relating to the etiology of tuber- culosis. The result has been to establish more firmly the views of Koch, and the doctrine that tuberculosis is a specific disease, and that the bacillus is the specific principle. Among the most thorough and convincing researches bearing on the causal relation of micro-organisms to tuberculosis, growing out of Koch's discovery, were those contained in a report to the London Association for the Advance- ment of Medicine by Research (Practitioner ; London Lancet, March 17, 1883). Experiments were made with the cultivated bacilli obtained from Koch. 11 Twelve animals were inoculated with these organisms, chiefly into the anterior chamber of the eye, and all of them became tuberculous. The tubercles produced in these cases were infective and caused tuberculosis in animals. On examination of tuberculous material Koch's tubercle bacilli are always found, though in varying numbers About eighty organs of tuberculous animals and thirty-six cases of human tuberculosis were examined, and in all of these, without exception, tubercle bacilli were found." The discovery of Koch has already proved of great importance as an aid in diagnosis, for the sputum of tubercular patients contains the bacillus. Tubercular sputum affords a soil in which the bacillus thrives and multiplies, as it does in the tissues of a tubercular patient, and by careful microscopic examination we are able to discover it in this sputum, while it is absent from non-tubercular sputum. According to Frisch ( Wiener med. Woch., No. 46, 1883), the bacilli were found without an exception in the sputum of 140 patients with confirmed tuberculosis, while the sputum of 150 non-tubercular patients was in every instance free from them. Heitler ( Wiener med. Woch., No. 43, 1883) examined the sputum of 140 tubercular patients, 1 of whom had miliary tubercles, and 1 other caseous pneumonia. All the other cases were chronic and were grouped by the author as follows: 1st, 6 cases of old infiltration of the apices of the lungs, cured, with the persistence of dulnesa on percussion, without rales; no bacilli observed. 2d, 12 cases of tuberculo- sis with slight dulness and dry rales. In 2 of these, notwithstanding marked physical signs, fever was absent and the tubercular process was arrested apparently ; no bacilli. In the sputum of the remaining 10 cases bacilli were present in all the examinations except 2. The third group contained eases of advanced and progressive tuberculosis, and the fourth group eases oi' advanced chronic phthisis, but with remissions. In the sputum of these two 204 CONSTITUTIONAL DISEASES. groups bacilli were always observed. That Heitler in 6 instances witnessed the disappearance of bacilli when the tubercular process was arrested is an interesting fact, as showing the relation of the bacilli to tuberculosis. He examined the sputum of 29 non-tubercular patients, patients with pneumonia, bronchitis, bronchial dilatation, and putrid bronchitis with gangrene, and in no instance found the bacilli of tuberculosis. As usually happens when a great discovery is announced, there are dis- sentients ; there are those apparently competent to express an opinion, as Spina and Formad, who do not accept or only partly accept the views of Koch. But the testimony of many observers, constantly accumulating, tends to establish more securely the doctrine of the microbic origin of tuberculosis, and it is now apparently as securely established as any doctrine in pathology. Koch's discovery necessitated revision of the teachings long accepted relating to tuberculosis. The tubercle nodule is, as we will see, an aggre- gation of cells produced from the cellular elements of the part where the nodule appears through a proliferating process caused by an irritant, and in the light of our present knowledge we consider the bacillus to be the irritant. A local corpusculation and a cellular nodule may be produced in the lungs or elsewhere by the lodgement of a non-specific irritant, whether organic or inor- ganic, as putrid cheese, particles of dust, or metallic particles, and thus far no cells have been discovered in nodules thus produced which are characteristic of tuberculosis. The giant-cells which at one time were thought to be pecu- liar to the tubercular nodule have been found in growths of another nature, as in gummata. The characteristic and peculiar element in the tubercular nodule is the bacillus. It has long been the belief from clinical observations in Southern Europe, and of certain observing physicians in the temperate regions of Europe and America, that phthisis is contagious, and the acceptance of the parasitic theory will probably soon render this belief an established principle in pathol- ogy. Already many instances have been published in the journals which show the infectiousness of tuberculosis, as the following : In an inland town in Europe a midwife with advanced phthisis had been in the habit of blowing into the mouths of new-born infants, and so many of them perished of tuber- cular disease as to excite attention and cause alarm, while those attended by a healthy midwife remained well. Dr. E. I. Kempf relates the following striking example in the Louisville Medical News for March 22, 1884 : In the fall of 1880 a girl of eighteen years, whose brother had died of consumption, was found to have tubercles at the apices of both lungs. She belonged to a sisterhood, and slept in the general dormitory with the other sisters. In four months nine of her companions began to cough and were found to have tubercles. No one of the sisterhood had previously had disease of this kind. Dr. A. Ollivier, physician to l'Hopital des Enfants-malades, Paris, states that a family having uniform robust health occupied two small rooms opening into a narrow court. The parents, a young son, and the baby slept in one of the rooms. An older son, who had been living elsewhere, contracted phthisis, returned home, and slept in the same apartment. He died January 16, 1883. His mother, who was constantly at his bedside, began to cough, emaciated, and died of the same disease in the following May. Seven days after the death of the mother the infant had tubercular meningitis, of which it per- ished ; and the older child, who occupied the same apartment, sickened and died like the ^mother. The father only survived of those who occupied the small room {Etudes d' Hygiene publique, 1886). The fact that wives devoted in their attendance on consumptive husbands frequently perish of the same disease has been long known to physicians, but it has usually been attributed to the depressed state of system incident to long watching and grief, and not TUBERCULOSIS. 205 to any contagious property. But now that a clearer insight has been obtained into the nature of tuberculosis, and both microscopical researches and clinical facts show its communicability, more caution will be exercised in the inter- course with patients. The recent experiments of Cornet ( Wiener med. Wochen., June 2, 1888) have shown that the walls and furniture of a room occupied by a phthisical patient may be infected by the lodgement of the tubercle bacillus upon them, so that any one occupying this apartment subsequently is in danger of con- tracting the disease. He rubbed the walls and bedsteads in the ward occu- pied by phthisical patients with disinfected sponges, avoiding such surfaces as might be infected by the hands and sputum of patients ; 9-1 animals were inoculated with these sponges, and 52 of them died, apparently of causes different from tuberculosis ; the remaining 44 were killed after forty days, and 20 of them had tubercles. 168 animals were inoculated with the dust from the walls of rooms occupied by phthisical patients in family practice. Of these animals 90 died soon afterward. Of the remaining 78, 34 contracted tuberculosis. In control-experiments, the dust being used from surgical wards, operating-rooms, and from crowded thoroughfares, the result was neg- ative as regards the production of tuberculosis. " It has been abundantly demonstrated by numerous experiments that the milk from tuberculous cows is capable, when ingested, of causing tuberculosis. How serious is this dan- ger may be seen from the statistics of Bollinger, who found the milk from cows affected with extensive tuberculosis infectious in 80 per cent, of the cases, and that from cows with moderate tuberculosis infectious in 33 per cent, of the cases Bollinger estimates that at least 5 per cent, of the cows in dairies are tuberculous. From statistics furnished me by Mr. A. W. Clement, V. 8., the number of tuberculous cows in Baltimore which are slaughtered is not less than 3 to 4 per cent." 1 It has been shown by tests with tuberculin that the proportion of milch cows having tuberculosis in dairies supplying New York City is large, and physicians aware of this fact advise their families to Pasteurize milk designed for the nursery : that is, subject it to a heat of 167° for twenty minutes. The sterilization of milk we have treated of elsewhere. I may repeat that tuber- cles are found in the milk of tuberculous cows even when the udders and teats or lacteal tract is healthy. The frequency of tubercular milch cows in America is apparent when I state that more than fifty cows have been con- demned and slaughtered in a single dairy supplying New York City. The causal relation of scrofula to tuberculosis we have considered elsewhere, but we may here repeat that scrofulous ailments, especially the caseous prod- ucts, afford the soil which is favorable to the growth and multiplication of the bacilli. Hence these microbes are not infrequently found in scrofulous products, showing that the tubercular has supervened on the scrofulous dis- ease. Kanzler treats of the relation of scrofula to tuberculosis in the Berlin klin. Woch., January 14, 1884. He believes that the two diseases are distinct, but that, as expressed by the French reviewer, la scrofule of re un terrain de predilection pour le developpement de la tuberculosa He has discovered bacilli only in a minority of the local manifestations of scrofula, never in glands which had not undergone suppuration or caseation, never in eczema, impetigo. suppurative otitis media, and never in the nasal, conjunctival, pharyngeal, and vaginal catarrhs of the scrofulous. It is not till degenerative changes have occurred in the inflammatory products of scrofula that the bacilli oi' tuberculosis appear, indicating the supervention of the latter disease. Anatomical Characters of the Tubercle. — As Virchow pointed out, the tubercular nodule when recent is semi-translucent and small, attaining about 1 Prof. W. H. Welch's Address be/ore the Amer. Med. Asso. } 1889. 206 CONSTITUTIONAL DISEASES. the size of a millet-seed and consisting mainly of cells. The cells of which it is chiefly composed resemble the white corpuscles of the blood in appear- ance and size, but some are smaller and others larger than those corpuscles. They have been designated the lymphoid cells. Each cell when fully developed has a bright homogeneous nucleus, small and spherical or large and oval, and nucleoli. A large cell sometimes contains two or more nuclei. The lymphoid cells appear to be developed from the cellular element of the connective tissue. This is Virchow's belief. In addition to these cells, which constitute the greater part of the tubercle, large uninuclear cells are also observed, designated epithelioid cells. They resemble large and swollen endothelial or epithelial cells, and they are believed by pathologists to be pro- duced from these cells, which lie within the area of the nodule. A third cell also occurs, known as the giant-cell from its size. It has many nuclei, and occupies chiefly the central part of the nodule. All these cells, as has been recently shown, occur in other pathological products besides the tubercular nodule, and no one of them is therefore characteristic of it. But the element which is of greatest importance, since it sustains a causal relation to the disease, was, as we have seen, the last discovered. The bacillus is always found in the recent tubercle lying without the cells, as we have stated, but also in the interior of the giant-cells, for which it appears to have an affinity. A fibrous network with more or fewer blood-vessels surrounds the cells and holds them together. The blood-vessels belong to the normal tissues, and are not a new growth, the tubercle having developed around them. The nodules are single or in clusters, forming masses of considerable size. When the nodule has attained a certain age, caseation always occurs in its centre and extends outward, causing an opaque and yellowish-white dead mass, in which fragmentary cells can be observed under the microscope. Caseation is now known to be a form of decay which is common to path- ological products of different kinds, and is not peculiar to tuberculosis, as was supposed before the time of Virchow. It occurs in consequence of abundant exudation or cell-formation and the compression and obliteration of vessels. It is therefore more common in scrofula than in any other disease, since scrofulous inflammations afford the conditions in which it is especially liable to occur. The yellow tubercle is only an advanced stage of the semi-transparent miliary tubercle. In the cheesy metamorphosis granules of fat are deposited within and around the cells, and the cells shrivel and disintegrate. The shrunken granular and fragmentary cells were believed to be the true tubercular cells until Virchow pointed out their character. When the nodule or nodular mass becomes yellow or caseous, and circulation ceases in it, it is surrounded by a vascular zone in which circulation still continues. It is very seldom, perhaps never, absorbed, although particles of it may enter the lymphatics or blood-vessels and be carried elsewhere with the bacilli. It is an irritant, producing inflammation in the surrounding tissues, with thick- ening, induration, and abundant production of pus-cells, which mingle with the elements of the nodule. Its history henceforth is that of an abscess, and ulceration and discharge of the liquefied substance upon one of the free sur- faces is the common result. In rare instances the tubercular nodule, instead of cheesy degeneration, undergoes fibroid degeneration or cretefaction. Various pathological conditions furnish the soil in which the bacillus obtains lodgement and grows, and in this way becomes a cause of tubercu- losis. Cheesy pneumonia and exhausting suppurating surfaces often afford a nidus favorable for the development of the tubercle bacillus. During epidemics of measles many cases occur of cheesy pneumonia ending in tuberculosis. Cheesy and disintegrating lymphatic glands, as the bronchial, TUBERCULOSIS. 207 often become tubercular, as do the inflammatory products of the grippe or influenza. Inheritance. — Csoker states that a cow advanced in pregnancy died of tuberculosis. In the hepato-duodenal ligament of the foetus were six enlarged lymphatic glands partly caseous and partly cretefied, but containing numerous bacilli and tubercles (Deutsche med. Zeitg., Jan. 29, 1891). Birch-Hirschfeld states that a woman seven months pregnant died of general tuberculosis. Twenty months before her death the foetus which she carried was alive. A Cesarean section was performed, but both mother and child died soon after. The mother had acute general tuberculosis ; the placenta contained numerous tubercles, and portions of the liver, spleen and kidneys, inoculated in the guinea-pig and rabbit, communicated phthisis. Baumgarten from his obser- vation expresses the opinion that infection of the foetus occurs in three ways — by a diseased ovum or fructifying sperm and by a diseased placenta. Prausnitz inoculated guinea-pigs with scrapings obtained from railway- coaches running from Berlin to Meran, in which consumptives are accustomed to travel. The scrapings of five coaches contained virulent tubercle bacilli, and Prausnitz urges the disinfection of railway-carriages. Schnirer found similarly infected dust, which communicated tuberculosis, lodged upon grapes. Inhalation. — The observations of Cornet have disclosed the fact that the inhalation of the dried sputum of phthisical patients is probably the most frequent mode in which this disease is contracted through the respiratory organs ; but the inhalation of the moist breath of the consumptive has in numberless instances conveyed the disease. Anatomical Characters in Infancy and Childhood. — The anatomical cha- racters of tuberculosis in the first years of life vary in certain particulars from the form which they present in the adult, but after the age of three years the differences are fewer and less pronounced than previously. Tubercular laryngitis, so common in the adult, is absent in a large pro- portion of cases under the age of three years, and when present it has little intensity. Ulceration of the larynx very seldom occurs. This has been attributed to the fact that there is so little expectoration in young children, the sputum being an irritant. Niemeyer, however, does not consider the sputum of tuberculosis sufficiently irritating to cause laryngitis and laryn- geal ulceration ; but the arguments in favor of this mode of causation, in my opinion, more than counterbalance those which have been presented against it. I have never met a case of tubercular ulceration of the larynx or trachea in the post-mortem examination of young children, nor do I recollect ever treating a case in which there was that degree of dysphonia which indicated ulceration. Rilliet and Barthez, in more than 300 necropsies of tubercular cases, found no ulcers in the larynx or trachea under the age of three years, but met 8 cases between the ages of three and ten years, and 8 between ten and fourteen years. The ulcers, whether seated in the larynx or in the trachea — and they are in most cases in the former, since the inequalities upon the surface of the larynx favor the retention of the sputum — are com- monly small, superficial, round or elongated, and with little thickening or infiltration of their borders. Occurring in the folds of the mucous mem- brane — as, for example, around the vocal cords — their form is usually elongated. Bronchitis is not infrequent. This inflammation is due to. and dependent on, the pulmonary tubercles, and is therefore most intense in the part o\ % the lung where the tubercles are most abundant and farthest advanced. Conse- quently, it is more intense on one side than on the other, and it may be unilateral. It differs in this respect from idiopathic bronchitis, which is 208 CONSTITUTIONAL DISEASES. commonly nearly uniform on the two sides. It differs also in the fact that it is sometimes accompanied by ulcerations. The ulcers are round or elon- gated in the direction of the axes of the tubes, and, like those of the larynx or trachea, are superficial. Circumscribed inflammation may attack a bron- chial tube, as, indeed, the trachea, and give rise to ulceration and perforation from the pressure of a diseased lymphatic gland external to the tube. This subject will be treated of hereafter. Lungs. — It is well known that in the adult tubercles are always present in the lungs if they occur in any part of the system. I have met 2 cases in which the lungs were free from tubercles in 36 post-mortem examinations of children who died of tuberculosis. One of the two was an infant, but its exact age is not stated in the records. It had cheesy degeneration of the thymus and bronchial glands, enlargement of the mesenteric glands, but without cheesy degeneration, and disseminated tubercles in liver and spleen. The other, fifteen months old at death, had tubercular meningitis, with numerous granulations upon the convexity of the brain, and the other usual lesions of meningeal inflammation, with bronchial and mesenteric glands slightly enlarged and cheesy, and one of the former softened. In 1 case, then, in 18, the lungs had escaped the disease. Rilliet and Barthez in their statistics of the state of the lungs in infancy and childhood found these organs non-tubercular in 47 cases in 312. and Hillier in 25 cases in 160. Therefore, the lungs were exempt from tubercles in about 1 case in 7. But it is to be recollected that the observations of these physicians were made at a time when all cheesy degenerations were thought to be tubercular, so that their published statistics may not have been strictly accurate. Pulmonary tubercles in children under the age of three years are, as a rule, discrete and disseminated through the lungs. In cases at this age which have advanced to a fatal termination we find yellow tubercles from the size of a pin's head to that of a shot in the different lobes ; many still semi-trans- parent if the disease have been of short duration, but if protracted most of them yellow, and here and there one softened and surrounded by condensed fibrous tissue. Around the semi-transparent or gray tubercles, many of which were growing, and therefore were in a state of active cell-proliferation at the time of death, vascular zones can often be detected by the naked eye. Under the age of three years tuberculosis exhibits but little tendency, perhaps none, to affect the upper lobes sooner or in greater degree than the lower. The following are the statistics relating to the site of the tubercles in the lungs in the cases which I have examined ; all, it is to be remembered, were under the age of three years : Tubercles disseminated throughout the lungs 26 Tubercles disseminated throughout the two upper lobes 3 Tubercles disseminated through right middle lobe and left lower lobe only 1 Tubercles disseminated through left upper lobe only 2 Tubercles disseminated (few and semi-transparent) in left lung only . 1 Tubercles disseminated in three points in right and two in left lung . 1 No tubercles in lungs 2 ~36 Between the ages of three and fifteen years statistics show that the upper lobes are more liable to tubercles than the lower ; but the difference in liabil- ity is not great. In many cases occurring in this period the different lobes are affected nearly simultaneously, and not very infrequently the upper lobe is the last which is involved. In October, 1866, I made the post-mortem TUBERCULOSIS. 209 examination of a boy who died in the Children's Service of Charity Hospital at the age of fifteen years, and small scattered tubercles were found in the lower lobe of the left lung, while all other portions of these organs were healthy. Rilliet and Barthez, who include in the same statistics all cases from birth to the age of fifteen years, found gray semi-transparent tubercles — • Cases. In the right superior lobe in 63 In the right middle lobe in 43 In the right lower lobe in 55 In the left superior lobe in 65 In the left inferior lobe in 54 The same observers found yellow tubercles in the Eight superior lobe in 40 Eight middle lobe in 28 Eight inferior lobe in 39 Left superior lobe in 35 Left inferior lobe in 31 Tubercular nodules, especially when softening commences, act as an irri- tant, exciting inflammation around themselves. Inflammation occurring from this cause is obviously likely to be protracted, continuing for weeks or months unless the tubercular matter be eliminated by ulceration. The highly vas- cular and delicate lungs of the young child are very liable to inflammation when they are the seat of tubercles, and as the tubercles are disseminated, the pneumonia is commonly more extensive than when it occurs from ordi- nary cases. In fifteen, or nearly one-half, of my cases there was pneumonia affecting portions of one or more lobes or an entire lobe. From the extent and position of the solidified portions it was obvious that in most instances the inflammation originated from the irritating effect of the tubercular matter, while in others it was due to hypostatic congestion, occurring in consequence of the long-continued recumbent position and feebleness of circulation. In these 15 cases the seat and extent of the pneumonia were as follows: Cases. Nearly entire right lung 2 Nearly entire middle and lower lobe of right lung 1 Entire left upper lobe 2 A considerable part of both lungs • • • • 1 Posterior parts of both lower lobes 4 Posterior part of left lung 1 Left lower lobe, and right middle and lower lobes ........ 1 Left upper lobe (contained a large cavity) and posterior part of left lower lobe 1 Nodules of inflamed lung around tubercles 2 The inflammation in about one-third of the cases was due to hypostasis, since it occurred in depending portions, extended but little into the lungs, and sus- tained no relation to the amount of tubercle. It was in the stage of red — or, more rarely, of gray — hepatization. In 7 of the cases there were pulmonary cavities as large in proportion as we ordinarily find in tuberculosis of the adult. The seat oi' 1 was in the right lower lobe ; of 2, the left upper lobe ; of 1, the right upper lobe; oi' another, the right lung, its exact seat not stated ; and in the remaining ease the cavity, which was the largest of all, occupied the interior of all three lobes on the right side. Some idea of the size of these cavities may be •learned by the following extracts from the records: 1st Case. "A small 14 210 CONSTITUTIONAL DISEASES. superficial cavity communicating on one side with a bronchial tube, and on the other side with a small circumscribed collection of pus in the pleural cavity." 2d Case. " Cavity of the size of a hickory-nut." 3d Case. " Cavity of the size of a large hickory-nut." 4th Case. " Cavity three-fourths of an inch in diameter." 5th Case. " A large abscess." 6th Case. " The cavity occupied nearly the whole of the interior of the left upper lobe." 7th Case. " About half the right lung excavated into a cavity which extended through the three lobes." Circumscribed pleuritis, produced by tubercles underneath the pleura, was observed in 7 cases. It was ordinarily attended by little exudation except the fibrin, but in one case a sufficient amount of serum had been exuded to compress considerably the lung. Pus was not observed in any notable quantity. Emphysema was present in several cases, chiefly in the upper lobes, some- times vesicular, with fulness or bulging of the lung, an anaemic appearance of it, and doughy, inelastic feel. In other cases emphysema was interstitial, producing little bladders of air under the pleura, especially toward the root of the lung, or separating the lobules by wedge-shaped or irregular inter- spaces filled with air. In one case air had escaped from an emphysematous bladder into the right pleural cavity, causing pneumothorax and collapse of the lung. Next to the lungs, the bronchial glands are more frequently diseased than any other organs in the tuberculosis of infancy and childhood. They undergo the successive structural changes which characterize glandular inflammations — to wit, hyperplasia — and more or fewer of them cheesy degeneration and softening. In the state of hyperplasia their firmness is diminished and they have a pale flesh-color. Cheesy degeneration commences in one or more points in the gland, sometimes in the peripheral, sometimes in the central portion, and it extends till the whole gland presents the well-known cheesy appearance. When the gland softens the thick liquid has a puriform appear- ance, consisting of amorphous matter, fatty particles, and the shrivelled and disintegrated cells of the gland. Soon pus-cells occur, and their number increases. The cheesy gland may or may not be tubercular. If it be tuber- cular, the tubercle bacillus will be found in it. Rilliet and Barthez state that the bronchial glands were tubercular (caseous) in 249 cases in children, while the lungs were tubercular in 265. All cheesy glands, it is to be recollected, are considered tubercular. In 4 of the 36 cases which I have examined no record was preserved of the state of the bronchial glands ; in 1 case there was no perceptible hyperplasia and no cheesy degeneration ; in 2 there was hyperplasia, but no cheesy degenera- tion, while in the remaining 29 cases cheesy degeneration had occurred in some of the glands or in parts of them, with occasional softening. The enlarged and caseous bronchial glands afford an explanation in part of the fact that the symptoms in the tuberculosis of young children differ from those in the adult, since Louis found the bronchial glands involved in only 28 per cent, of the adult cases of tuberculosis which he examined, and Lombard in only 9 per cent. A gland pressing upon the recurrent laryngeal or pneu- mogastric nerve or the trachea may give rise to dyspnoea and a cough ; or on the descending vena cava or one of the venae innominatae to congestion of the brain and meninges, intracranial serous effusion, and even thrombosis in the cranial sinuses. That a softened bronchial gland is not infrequently eliminated from the system by ulceration into a bronchial tube or into the trachea is well known. In one case which I observed the ulceration had destroyed portions of three of the cartilaginous rings of a bronchus, and the aperture was plugged by a cheesy fragment of a softened gland which pro- TUBERCULOSIS. 211 Fig. 38. truded. Occasionally, it is stated by authors, the ulceration is into one of the large vessels of the mediastinum, or even into the oesophagus. The following is an example of bronchial phthisis as it commonly occurs : This case, -which is not included in the foregoing statistics, was seen almost daily by me during its entire progress : On September 3, 1874, 1 examined an infant in the New York Infant Asylum who had wheezing respiration during the last eight days. The wheezing occurred both in inspiration and expiration, and also, though less pro- nounced, during sleep ; pulse 96, respiration 40, temperature normal. Its mother, who had charge of it, and had till recently wet-nursed it, had unequivocal symp- toms of tuberculosis for several months. The child was pallid and its flesh was soft and flabby. The fauces were perhaps a little redder than usual, but were other- wise normal, and a careful exploration of the chest revealed no cause of the embar- rassed respiration. Auscultation and percussion gave a negative result. In the latter part of September a troublesome diarrhoea occurred, which continued more or less till near death. The temperature on September 28th, October 8th, 10th, and 11th, was 100J°, 100°, 99|°, and 100°. The pulse on October 10th and 11th was 120 and 126. On October 8th the percussion-sound over the upper part of the right lung seemed somewhat duller than onj the other side, though the respiration was not observed to be notably changed in the area of the dulness. There was but little cough during the entire sickness. Death occurred on October 20th. At the autopsy the bronchial glands were found enlarged and cheesy, and underneath the right bronchus, near the bifurcation, was a softened, almost diffluent gland, as large as a small hickory nut and compress- ing the bronchus. This, no doubt, had pro- duced the wheezing respiration, which had been the chief local symptom. The lungs, spleen, and in less degree the liver, con- tained numerous small miliary tubercles. Certain of the mesenteric glands were also cheesy, but to a less extent than the bron- chial. The disease of the bronchial glands was evidently primary, the tubercles of the lungs and abdominal organs being appar- ently quite recent. The accompanying wood- cut, from a photograph by Mr. Mason, the photographer at Bellevue Hospital, repre- sents a posterior view of the lungs and air-passages. In no case have I found tubercles in the heart or pericardium, though they have been observed in rare instances in the latter. The mesenteric glands were enlarged by hyperplasia and more or less cheesy in 30 cases, were apparently normal in 2 cases, while in the remaining 4 cases their condition was not stated. In most of the patients the mesenteric glands were smaller and less cheesy than the bronchial, but in a few instances they were larger than the bronchial and more cheesy. It is a noteworthy fact, as bearing on the causal relation of these glands to tubercles, that not infrequently the amount of hyperplasia and cheesy degeneration occurring in the former was very considerable, while the tuber- cles in the lungs or elsewhere were small, even minute, semi-transparent, and apparently of recent formation. It was evident in such cases that the gland- ular hyperplasia and degeneration, bronchial or mesenteric, or both, preceded the tubercular disease, and furnished the conditions favorable for the lodge- ment and propagation of the tubercle bacillus. Since the cases which fur- nished the above statistics occurred my clinical experience with tubercu- losis has greatly increased, but nothing new or different has been observed at autopsies. Abdominal Viscera — Bollinger says : " The upper half of the alimentary 212 CONSTITUTIONAL DISEASES. tract (mouth, throat, oesophagus, stomach, duodenum, and jejunum) offers an unfavorable site for tuberculosis. The lymph-follicles of the ileum and large intestine are the organs usually infected when the disease has its origin in the alimentary tract. However, primary tuberculosis of the cervical lymph- atics in children occurs through infection of the throat. Primary tubercu- losis of the intestine, combined with tuberculosis of the peritoneal lymphatic glands, occurs oftener in children than in adults, the cause of which is prob- ably to be sought for in the feeding of young children with the milk from tubercular cows." In children tubercles in the solid organs of the abdomen rarely give rise to appreciable symptoms, since they are small and dissemi- nated, not impairing materially the function of the part in which they are located. On the other hand, peritoneal and intestinal tubercles and the enlarged and cheesy mesenteric glands give rise to symptoms which require description. The most frequent seat of peritoneal tubercles is upon the attached surface of the peritoneum, where they are formed in the connective tissue. They are distinctly seen through the peritoneum, and cause some prominence of it. Exceptionally their seat is upon its free surface. Every portion of the peritoneum, whether visceral, parietal, or omental, is liable to tubercles, but general tuberculization of so extensive a surface seldom occurs in any one case. The tubercles are spherical or lenticular, and most of them small. Sometimes they are very numerous, but so minute as to be scarcely visible. They are gray or yellow according to their age. Peritoneal tuber- cles often produce circumscribed peritonitis, causing adhesion of opposite sur- faces. The tubercles in themselves cannot be detected by external palpation ; but masses composed of tubercles and inflammatory products are sometimes so large that they can be felt through the abdominal walls. The symptoms of peritoneal tuberculosis are attributable, for the most part, to the peritonitis. Among them may be enumerated abdominal tender- ness or pain, meteorism, ascites — usually slight — and derangement of the bowels, commonly diarrhoea. Since tubercles in this situation occur, in most cases, subsequently to tubercles elsewhere, the symptoms which have been described are associated with and are subordinate to others. Stomach and Intestines. — The most common seat of gastro-intestinal tuber- cles is the small intestine, and more frequently its lower portion, near the ileo-caecal valve, than its upper or central. They are rare in the duodenum or contiguous part of the jejunum. They are developed ordinarily in the connective tissue, either that lying under the mucous or the serous surface. Gastro-intestinal tubercles are often accompanied by ulceration of the adjacent mucous membrane. But in a certain proportion of cases, probably, the tubercles do not cause the ulcers, for ulceration of this membrane is not infrequent in the tuberculosis of children, when there are no tubercles in the walls of the stomach or intestines. The following statistics of Rilliet and Barthez relating to this point will aid to an understanding of the symptoms : rr.ii- 11 ^x x. n f with ulcers, 6 cases. Tubercles m walls of stomach, 7 cases, ^ j ^^ ^^ ± cage Ulcers of gastric mucous membrane, without gastric tubercles, 14 cases, rp i t • n • , ,• 00 f with ulcers, 70 cases. Tubercles m small intestine, 82 cases, { without ulc ' ers> 12 cases . Ulcers without tubercles in small intestine, 51 cases. m -, , . , .... n ^ f with ulcers, 10 cases. Tubercles in large intestine, lo cases, { without ulc ' ers> 5 cases . Ulcers in large intestine, without tubercles, 47 cases. The ulcers have vascular, thickened, and infiltrated borders. Their diam- eters vary from a line to half an inch or more, and their general form is TUBERCULOSIS. 213 circular, or. if two or more unite, irregular. Tubercular ulcers of the stomach are mostly in the great curvature, those in the small intestines in the ileum and lower part of the jejunum, and those of the large intestine in the caecum. The following table exhibits the state of the principal abdominal viscera in the 36 cases embraced in my statistics : Liver. Spleen. Kidneys. Tubercular 12 22 1 Non-tubercular 16 6 21 Not stated 8 8 14 Fatty 5 In no instance did I observe tubercular softening in the abdominal organs, and a large proportion of the tubercles in the liver, spleen, and kidneys were still in the first stage. In the 5 cases in which the liver was recorded fatty, this state of the organ was obvious to the sight, as it is in tuberculosis of the adult. A moderate excess of fat in the hepatic cells may have been present in some of the other cases, but it was not sufficient to be appreciable without the microscope. It is to be remarked that in the 5 cases in which the liver was recorded fatty this organ contained no tubercles. The spleen is seen to have been the most frequent seat of tubercles of all the viscera, except the lungs. In 14 cases the intestines were examined ; and in 5 tubercles discovered, developed in their connective tissue. The intestinal tubercles were small, and ulceration had occurred of the mucous membrane which covered them. The brain was examined in 15 cases. In 12 the amount of cerebro-spinal fluid varied from ^ss to gv by estimation. In 2 others the records state that there was a considerable amount of this fluid, the exact quantity not being given, while in the remaining case congestion of the brain and meninges was noticed, but nothing was recorded in regard to the amount of cerebro-spinal fluid. The increase of the cerebro-spinal fluid in tuberculosis is attributable to wasting of the brain, a hydrocephalus ex vacuo, and in some cases to passive congestion and serous transudation, due to feeble circulation, or obstructed flow from the pressure of bronchial glands on the vessels within the thorax, as already stated. Tubercles were present in the pia mater in 3 cases : in 2 with fibrinous exudation ; in the other without fibrin or other evidence of inflammation. Tubercular meningitis is described in another part of this book. Symptoms. — The symptoms in tuberculosis of children arise in part from the diathesis and in part from the tubercles. Before the period of tubercles there are signs of failing health, such as loss of appetite, flabbiness of the soft parts, or emaciation, lassitude, and loss of strength. These symptoms continue after the formation of tubercles, and increase. The features are ordinarily pallid, but during the paroxysms of fever, to which tubercular patients are subject, they may be flushed. Lividity of the features, due to imperfect decarbonization of the blood, occurs if there be enlarged bronchial glands which compress the vessels within the thorax, or if there be extensive pulmonary tuberculization or pulmonary tuberculiza- tion, whether extensive or not, which is complicated by capillary bronchitis or pneumonia. The skin is nearly natural, or it loses its flexibility and softness and becomes dry and rough. In some patients there is, at times, general or par- tial furfuraceous desquamation of the skin, due to- exaggerated development of the epidermis. Children, like adults, notwithstanding the general dryness of the surface, are liable to perspirations at night and in sleep. This symp- 214 CONSTITUTIONAL DISEASES. torn is less frequent at the commencement than at an advanced period, in acute than in chronic cases, and in those under three or four months than in older children. It is more abundant about the head and limbs than else- where, and is sometimes confined to these parts. Anasarca is not infrequent. It sometimes arises from obstructed circula- tion in consequence of compression of the thoracic vessels by enlarged lymphatic glands ; in other cases it is due to diminished plasticity of the blood, a result of the tubercular cachexia. The latter is the more common cause. It is not an important symptom, on account of the small amount of serous transudation and the character of the parts in which it occurs. Emaciation, already alluded to, is early, constant, and progressive. Under the age of six or eight months it is less marked than in older children, many preserving considerable rotundity of features and form even in advanced tuberculosis. The failure of the strength corresponds in amount and prog- ress with the emaciation. Slight at first, and exhibited only by a degree of lassitude, it gradually increases, till for weeks before death the little patient is fatigued by the ordinary muscular movements, and is inclined to be quiet. The nervous system is not ordinarily affected except in cases of intra- cranial tubercles. In acute tuberculosis or tuberculosis complicated by severe inflammation there may be agitation and delirium, especially at night. In most patients the mucous membrane of the buccal cavity presents its normal appearance, with the exception of a moist fur upon the tongue and a paler hue than normal of its surface generally. In acute tuberculosis and in cases complicated by inflammation the tongue is sometimes dry and brown. The appetite may be normal till the close of life or it is poor or changeable. Occasionally it is increased, although the disease is progressing. The bowels are regular or relaxed. Diarrhoea may be a prominent symptom, even when there are no intestinal tubercles or ulceration. Meteorism and fulness of the abdomen are common. Fever, constant, but usually with evening exacerbation, is rarely absent- It continues for weeks or months. During the exacerbation the pulse rises to 120, 140, or even to 180 beats per minute, and there is a corresponding exaltation of the temperature, which in the latter part of the day, without inflammatory complication, ranges from 100° to 102° or 103°. The febrile movement is a symptom of diagnostic value as regards the nature of the dis- ease, though it does not indicate the seat of the tubercles. In addition to the symptoms now described, there are special symptoms due to tuberculization of the different organs. In young children, on account of the fact already referred to — to wit, the tendency to a generalization of tubercles — there is often a blending of the symptoms which arise from dif- ferent organs, but with care it is not difficult in most instances to isolate and refer them to their proper source. The following are the symptoms which arise from tuberculization of the more important organs : Encephalon. — The symptoms produced by tubercles of the encephalon vary according to their seat and size and the structural changes in surround- ing parts to which they give rise. Meningeal tubercles, which are located for the most part in the meshes of the pia mater, and ordinarily along the course of the small arteries, are, as a rule, small, not more than a line in diameter, and they may remain latent for a considerable time. In the majority of cases, however, they sooner or later cause meningitis, the symptoms of which are well known and need not be described. But tubercles in this situation do sometimes give rise to symptoms when there is no meningeal inflammation. They occasion congestion of the sur- rounding vessels and serous transudation, and, if developed on the under TUBERCULOSIS. 215 surface of the pia mater, they may produce symptoms by encroaching upon and irritating the brain ; for they are sometimes so much imbedded in the convolutions that careful examination is required in order to determine that they are meningeal and not cerebral. Among these symptoms may be mentioned headache, frontal or occipital, sometimes intermittent, nausea, melancholy, and in certain cases the symptoms produced by serous trans- udation. The symptoms of cerebral are in part similar to those of meningeal tuberculosis, but in most cases others of a neuropathic character are present, which serve for differential diagnosis. The differences as regards the symptoms of different patients having cerebral tubercles are attribut- able in part to their size and rapidity of growth, but more to the differ- ence in their seat ; for any part of the brain may be the seat of tubercles, though certain portions, as the cerebellum, are more frequently affected than others. The child with cerebral tubercles is quiet, but irritable, and easily excited. Delirium is not common, but many before the close of life exhibit a degree of mental dulness. The headache, common in cases of cerebral as well as meningeal tubercles, may be nearly general, or it is frontal, parietal, or occip- ital according to the seat of the tubercles. It is often lancinating, often intermittent. Clonic convulsions occur toward the close of life. Exceptionally, they are among the earliest symptoms. Observations have failed to establish any relation between the seat of the tubercles and the localization of the convul- sions. The convulsions may be unilateral, while the tubercles are in both hemispheres ; or general, while the tubercles are on one side only. The severity and duration of the convulsive attacks, and the frequency of their occurrence in tuberculosis of the brain, vary greatly in different patients. They have been attributed to softening of the cerebral substance, which sometimes occurs immediately around the tubercles, to local conges- tions excited by them, and also to serous effusions in the ventricles. The convulsions sooner or later end in paralysis or coma. Contraction, or tonic spasm of certain muscles, is sometimes observed. Its most frequent seat is in the muscles of the back and of one or both of the lower extremities. It is a late symptom. It occurs in those cases in which there is softening around the tubercles, and usually in the muscles of the opposite side. Paralysis is also a late, but not an infrequent, symptom. It is preceded by headache, and sometimes, as already stated, by convulsions. Occurring as a symptom of tuberculosis of the brain, it is due either to pressure on a cranial nerve or to compression and perhaps softening of the cerebral sub- stance. The paralysis may be paraplegic, commencing as feebleness of the lower extremities, and increasing until it becomes complete, or more or less complete, hemiplegia. In paraplegia due to tubercles of the brain the cere- bellum is, as a rule, their seat ; while paralysis of one side or of certain mus- cles of one side indicates tubercles of the opposite cerebral hemisphere ; but there are exceptions. Paralysis of the third cranial nerve gives rise to ptosis — of the sixth, to paralysis of the external motor nerves of the eye. and therefore to internal strabismus. Feebleness or loss of vision, inequality, oscillation, and finally dilatation of the pupils, are not infrequent symptoms of tuberculosis of the brain, and they possess great diagnostic value. Atrophy of the optic nerve, causing amaurosis, sometimes results from tubercles as well as other tumors of the brain. Atrophy of this nerve occurs not only when the tubercles are so located as to press on the optic tract, in which case the explanation is appar- 216 CONSTITUTIONAL DISEASES. ent, but also, in certain patients, when the tubercles are in other parts of the brain. In these last cases it is thought by Brown-Sequard and others that the imperfect nutrition of the nerve is due to contraction of its nutrient vessels, produced by the tubercles through reflex action. In tuberculosis of the brain symptoms pertaining to the respiratory, cir- culatory, and digestive systems are either absent or are quite subordinate to those of a neuropathic character. Slowness of the pulse, with or without intermittence, has sometimes been observed, and it is therefore a symptom of some diagnostic value. Toward the close of life both pulse and respiration are usually accelerated. Vomiting, constipation, and retraction of the abdo- men, which are so common in meningitis, are only occasional symptoms. Bronchial Glands. — During the progress of tuberculosis, hyperplasia, cheesy degeneration, and softening of various lymphatic glands may occur throughout the body, but the bronchial and mesenteric are not only those which are most frequently affected, but they are the only glands, unless in exceptional instances, which materially increase the danger or give rise to special symptoms. These symptoms either have a mechanical cause — to wit, the pressure exerted by the enlarged glands on contiguous parts — or they are due to softening of the glands and consecutive inflammation and ulceration. The following are the principal symptoms due to compression ; some of them are not infrequent, others are rare : Compression of the pulmonary veins retards the flow of blood from the lungs to the left auricle, giving rise to congestion and, in extreme cases, oedema of the lungs, with sanguineous extravasation into the lung-substance, congestion of the right cavities of the heart, hepatic veins, and of the systemic capillaries generally. Compression of the pneumogastric nerve or of the recurrent laryngeal, which is the motor nerve of the laryngeal muscles, modifies the voice and produces a cough which is often spasmodic. The cough resembles that of pertussis, and has been mistaken for it, but it is not so violent or protracted. The voice, clear and natural at first, becomes by degrees hoarse or feeble from deficient in- nervation of the laryngeal muscles. An enlarged gland or mass of glands lying against the trachea or one of the bronchial tubes (this may occur with tubes up to the third or fourth division), and pressing its walls inward, obviously obstructs more or less the current of air. If there be considerable obstruction, a loud, sonorous rale is produced, which is heard distinctly at a distance from the chest, obscuring other rales. It is loudest when the patient is agitated, and it sometimes intermits. Feeble respiratory murmur, dyspnoea, and a cough are not infre- quent in bronchial phthisis. Diminished intensity of the respiratory murmur is general or partial, according to the seat of the compression. It has been most frequently observed at the summit of the lungs. In certain patients this symptom is not constant, the respiration being for a time feeble and then normal. The dyspnoea may be a prominent and distressing symptom, the alse nasi dilating, and the inframammary region sinking with each respira- tion. The cough which occurs when a gland presses on the trachea or bron- chial tube is due to the tracheitis or bronchitis to which the pressure gives rise. If ulceration occur at the point of pressure, the cough continues as long as the ulcer remains. Compression of the large veins within the thorax which return blood from the head and upper extremities causes more or less congestion of these parts, with, perhaps, transudation of serum in the sub- cutaneous connective tissue and within the cranium. Rarely, a softened gland by ulceration gives rise to other symptoms than those mentioned — to wit, hemorrhage by ulceration into a vessel or pleuritis or pneumonitis if the ulceration be toward the lungs. Improvement in the condition of the patient affected with bronchial TUBERCULOSIS. 217 phthisis is not unusual. It may be permanent, but in most patients it is temporary, so that in a few weeks or months the symptoms are as severe as before. The improvement is due to softening and elimination of a gland which had given rise to symptoms by its mechanical effect or by the inflam- mation which it had excited. Physical Signs. — From Tubercular Bronchial Glands. — These are absent or obscure in the incipient disease when the glands are small, and they are most marked in those cases in which the glands are so large as to press on the thoracic walls, since they then become the medium for the transmission of sounds to the ear. The part of the thorax against which they most fre- quently press is the dorsal vertebrae from the first to the sixth, and each side of the vertebrae, and less frequently the upper third of the sternum. The physical signs are dulness on percussion over the interscapular space, and perhaps, though to a less extent, over the upper part of the sternum, and bronchial respiration in the same situations. Occasionally a bruit can be detected, due to the pressure of a gland on one of the large vessels of the chest. Lungs. — A cough is one of the earliest and most persistent of the symp- toms of pulmonary tuberculosis. It is so rarely absent that those of large experience do not meet with more than one or two such cases. It varies in severity and frequency. If the tuberculosis be acute, and its course rapid, the cough, even from its commencement, is frequent, so as to weary the patient and deprive him of needed rest. But in ordinary cases — that is, when the disease is chronic — it commences gradually, attracting at first little attention by its infrequency, but becoming more frequent and painful as the malady advances. Ordinarily, the cough is dry in the first weeks or months, but it becomes looser in the course of the disease, from the greater amount of bronchial inflammation. In exceptional instances it has a spasmodic character, like that produced by pressure of an enlarged bronchial gland on the pneumo- gastric or recurrent laryngeal nerve. This occurs from the accumulation of viscid mucus in one or more of the bronchial tubes, usually in dilated portions of them, from which it is with difficulty expectorated. The respiration in pulmonary tuberculosis is accelerated in proportion to- the degree of tuberculization. Tuberculization of a considerable part of both lungs gives rise to dyspnoea, especially when, as is ordinarily the case, bron- chial, pulmonary, or pleuritic inflammation has supervened. Pneumonitis or pleuritis gives rise to the expiratory moan, and as these inflammations, when induced by tubercles, are protracted, the symptom may continue for weeks or months. Patients under the age of six years do not expectorate, or but rarely. After this age expectoration is not common in the commencement of pul- monary tuberculosis, but in the confirmed disease it is a pretty constant attendant of the cough. Haemoptysis is also rare under the age of six years, and less frequent subsequently than in the adult. It is most likely to occur in those cases in which there is already passive congestion of the lungs pro- duced by the pressure of enlarged bronchial glands in the manner already described. Patients old enough to express their sensations, sometimes com- plain of fugitive pains under the sternum or between the shoulders. In young children the physical signs of incipient pulmonary tuberculosis are wanting, or are so obscure as not to be readily recognized. This is due to the small size and dissemination of the tubercles. In older children the physical signs appear early, and are readily recognized, because, as a rule, the tubercles are aggregated, and are more frequently at the apices of the lungs, as in the adult, than elsewhere. In the advanced disease, whether in 218 CONSTITUTIONAL DISEASES. infancy or childhood, when inflammation and more or less destruction of the lung-substance have occurred, the physical signs, so far from being obscure, enable us, in most cases, in connection with the history, to make an immediate and positive diagnosis. In young children affected with pulmonary tuberculosis the irregular and imperfect expansion of the lungs produces by degrees changes in the shape of the thorax which are apparent on inspection. In some, the lungs being habitually imperfectly inflated, the obliquity of the ribs is increased, and the thorax consequently elongated, while its antero-posterior and transverse diam- eters are diminished. This obviously increases the convexity or arch of the diaphragm, so that this muscle sometimes lies against the thoracic walls as high as the ninth or even eighth rib. If the costal cartilages are yielding, there are anterior flattening of the chest and depression of the sternum ; if they are firm on account of the more advanced age, the chest remains circular. Another shape of the thorax is not infrequent in feeble tubercular chil- dren, especially infants, who have suffered from repeated attacks of bronchitis. It occurs also in the non-tubercular if the conditions which favor it are present. The conditions are, on the one hand, feebleness of the patient, with diminished force of respiration and impaired resiliency of the ribs, and, on the other, obstruction by mucus of one or more of the bronchial tubes. Occlusion, more or less complete, of a bronchial tube, and consequent obstruction to the current of air, produce a corresponding degree of collapse in the portion of lung to which the tube leads. The parts which collapse are, in most cases, the lower lobes and the thin anterior margins of the upper lobes. This causes lateral depression of the lower ribs, except such as are pressed outward by the abdominal viscera and an anterior projection of the lower part of the sternum. The shape of the thorax in these cases differs from that in rachitis in the fact that the lateral depression does not extend to the upper ribs, nor does the upper part of the sternum project. Certain precautions should be observed in examining the chest by percus- sion and auscultation. The child should sit or recline, with the arms and shoulders in the same position on the two sides, and the axis of the trunk straight. Inclination of the trunk to either side, raising or depressing a shoulder, may produce an appreciable difference in the two sides as regards the physical signs. Percussion of the two sides should be practised at the same stage of respiration. A slight difference in the degree of resonance does not afford proof of disease unless it be observed at different examina- tions ; for in feeble children it often happens that all portions of the lungs do not expand alike, so that where we have noticed slight dulness at one visit, it may by the next have disappeared, or even at the same visit, if forcible inspirations be excited. The physical signs ascertained by palpation, auscultation, and percussion are, as in the adult, vocal fremitus, bronchial respiration, bronchophony, and dulness on percussion. In those cases in which the tubercles are mainly at the apices of the lungs, diminished expansion of the infraclavicular region is observed during inspiration, and this part of the thoracic wall is permanently depressed, so that the clavicles are unusually prominent. If there be emphysema, this flattening does not occur or is slight. Dulness on percus- sion, though more frequently observed in the infraclavicular region than elsewhere, may be present in different isolated places. If pneumonia super- vene, the dulness not infrequently extends over a considerable part of one lung. The cracked-pot sound is often observed on percussion, but it pos- sesses little diagnostic value. It can be produced when there is no pul- monary disease by percussion over a bronchus. Bronchial respiration and bronchophony are important signs, as indicating TUBERCULOSIS. 219 solidification of the lung, but they do not show whether the solidification be tubercular or pneumonic or the two conjoined. This must be determined by the history of the case, the extent of surface over which these signs are heard, and their persistence. When the tubercles begin to soften and the lung-tissue breaks up, moist rales appear, often hoarse and gurgling, obscur- ing the bronchial respiration. A cavity in the lung, or pneumothorax, is attended by the same physical signs as in the adult. Pleura.. — Little need be said in reference to the symptoms and physical signs of tuberculosis of the pleura, since this affection is in most instances associated with tuberculosis of the lungs, and is not distinguishable from it. But now and then the pleural tubercles are numerous and large, giving rise to symptoms, while those of the lungs are small, few, and without symptoms or attended by symptoms which are quite subordinate. Either the costal or visceral portion of the pleura may be the seat of tubercles. They are developed directly under the pleura or upon its free surface. They may occur in the newly-formed connective tissue which results from pleuritis. Those located upon the free surface or under the costal pleura rarely soften, while those under the visceral pleura sometimes soften and cause ulceration. Occasionally numerous aggregated tubercles form a firm continuous layer upon the surface of the pleura, preventing, if upon the visceral pleura, full expansion of the lung. This may give rise to a degree of dulness on per- cussion and feebleness of the respiratory murmur. Ordinarily, however, in this form of tuberculosis the symptoms and physical signs, so far as any are observed, are due to the pleuritic inflammation which the tubercles excite. Stomach and Intestines. — The symptoms in tuberculosis of the stomach and intestines vary according to the seat and stage of the tubercles. Tubercles, whether gastric or intestinal, are not at first accompanied by symptoms, or the symptoms are obscure and ill-defined. Symptoms arise when inflammation occurs in the tissues in which the tubercles are imbedded or upon which they lie, and through their irritating action. Diarrhoea is one of the most common and persistent of the symptoms. The alvine discharges are brown and thin, and sometimes, in advanced cases, very offensive. They may be streaked with blood which has escaped from the ulcers. Intestinal tubercles, developed immediately underneath the peritoneal coat, sometimes cause local peritonitis, usually of little extent. This gives rise to circum- scribed pain, tenderness, and more or less meteorism. Diagnosis. — It is evident from the foregoing description of symptoms that the diagnosis of incipient tuberculosis is much more difficult in children than adults. Before commencing the examination it is best to learn the hereditary tendencies of the family and the history of the patient, especiallv as regards antecedent disease or debilitating agencies, and the duration of the symptoms. Early and accurate diagnosis of tuberculosis in the child, as well as in the adult, is now rendered possible by the discovery of the tubercle bacillus in 1882 by Koch. This bacillus, abounding in the sputum as well as in the affected organs of phthisical patients, having a slender rod-like form, with a length varying from one-fourth to the entire diameter of the red blood-cor- puscles, and susceptible of a peculiar staining by the aniline colors which differentiates it from all other bacilli, is, as we have stated above, believed to be uniformly present in tuberculosis and absent in other conditions. Children with tuberculosis of the lungs expectorate comparatively little. but sufficient sputum can be obtained in most instances for the purpose o\! diagnosis. The presence of the bacillus indicates clearly the tubercular nature of the disease. Tuberculosis of the encephalon is diagnosticated with more difficulty than 220 CONSTITUTIONAL DISEASES. that of the thoracic or abdominal organs ; but certain of these organs are in most patients tubercular at the same time, and the knowledge of the fact that they are affected aids in the diagnosis of the disease of the brain or its meninges. Among the symptoms of intracranial tuberculosis which possess diagnostic value may be mentioned cephalalgia and more or less fever, with exacerbations in the commencement of the disease, and, at a more advanced period, strabismus, inequality or irregular action of the pupils, impairment of vision, retraction of the head, and convulsive movements or paralysis. In certain cases careful observation and discrimination of symptoms are requisite in order to determine whether they arise from intracranial tubercles or from congestion of the brain caused by obstruction in the venous circu- lation by the pressure of enlarged bronchial glands. The diagnosis of bronchial phthisis, when the glands are still small, is necessarily uncertain, on account of the absence of symptoms. When they have increased in size and are so located as to press on the pneumogastric or recurrent laryngeal nerve, producing the spasmodic cough already described, the differential diagnosis between that disease and pertussis may be made by attention to the following facts : Bronchial phthisis occurs singly and is non- contagious, while pertussis occurs as an epidemic and with evidences of con- tagion. There are no successive stages — to wit, those of catarrh, paroxysmal cough, and decline — as in that disease, and the cough, though paroxysmal, is short and without whoop or vomiting. In feeble children with inherited tubercular diathesis, emaciation, sweats, a chronic cough, and the absence of pulmonary symptoms, should excite suspicions that the bronchial glands are involved. The evidence is almost conclusive if the cough become paroxysmal and there be a loud, persistent tracheal or bronchial rale. In certain patients affected with this form of tuberculosis we have seen that the prominent symptoms are due to compression of one or more of the large vessels in the chest. Compression of these vessels, and consequent retarded circulation, may be confidently referred to enlarged bronchial glands, since aneurism, carcinomatous or other tumors, which w T ould produce a sim- ilar result, are very rare before puberty. Sometimes the diagnosis is rendered certain by the physical signs observed by auscultation and percussion over the sternum and the interscapular space. The condition of the external glands should also be observed, as those of the axilla, neck, and groin. The diagnosis of pulmonary, though more readily made than that of intracranial and bronchial, tuberculosis is often difficult and uncertain. This is in part explained by the fact that the tubercles are so frequently dis- seminated, while emaciation and a chronic cough are not infrequent from other causes than tubercles. Rachitis, intestinal worms, dentition, simple tracheal or bronchial inflammation, may be attended both by a chronic cough and emaciation. Caution is therefore requisite in order to avoid a grave error in diagnosis. Precipitancy in the diagnosis of doubtful cases is worse than indecision, and it is often best to postpone an expression of opinion as to the nature of the disease till the case has been observed a few days. The significance and importance of the symptoms, physical signs, and other facts on which a diagnosis must be based have already been sufficiently pointed out. It is difficult — in fact, in certain cases impossible — to discrim- inate by the physical signs between simple cheesy pneumonia and cheesy pneu- monia which has ended in the formation of tubercles. The patient has an attack of catarrhal pneumonia, but instead of absorption of the inflammatory product, cheesy infiltration occurs, and the lung in places becomes infiltrated with pus, softens, and breaks down. The patient presents the symptoms and physical signs of phthisis. He may recover after a protracted sickness or TUBERCULOSIS. 221 Though Fig. 39. the differ- Bacilli of tubercle from sputum. X 500 (Bristowe). may die. But cheesy degeneration of the inflammatory product com- monly ends in the development of tubercles, and in a certain proportion of cases tubercles do form in the last weeks of life, ential diagnosis in such cases between cheesy pneumonia and tuberculosis supervening on pneumonia is impossible by the physical signs, practically the discrimination is unim- portant, as the same treatment is required. But it is obvious, from the facts now ascer- tained in reference to the tubercle bacillus, that in all cases of doubtful diagnosis the sputum, if it can be obtained, should be ex- amined microscopically. If the bacillus be present, the diagnosis of tubercular disease may be considered certain. Prognosis. — It has long been the belief in the profession, as well as among the laity, that tuberculosis is in the end, with few ex- ceptions, fatal, whatever remedial measures are employed, and that, therefore, remedies may ameliorate symptoms, but do not change the result. But since attention has been directed to this subject a sufficient number of observations have been made to show that tuberculosis at an early stage can in a considerable number of cases be cured or rendered latent. The late Professor Austin Flint, in his treatise on Phthisis, published in 1875, stated that of 670 phthisical cases which came under his observation, he ascertained by auscultation and percussion that the disease had been cured in 44 and was non-progressive in 31 others. But the most convincing proof of the curability of tuberculosis is furnished by the post-mortem examination of those who died of other dis- eases. A cretaceous or fibroid state of the apex of the lung, without tuber- cles elsewhere, may be regarded as certain evidence of arrested tuber- culosis. Now, two of the curators of large New York hospitals inform me that they frequently find cretaceous or fibroid degeneration at the apex of the lung, without tubercles elsewhere, in the autopsies in these institutions. One of these gentlemen, whose examinations are in the dead-house of Belle- vue Hospital, states that this evidence of arrested tuberculosis is present in at least one-fourth of the cadavers which he examines. The Bellevue Hospital patients come from the most crowded and insalubrious tenement- houses of the city, and have led a life of poverty and privation, and fre- quently of dissipation. H. P. Loomis (Med. Record, Jan. 9, 1892) gives the following results of post-mortem examinations made in the Bellevue dead- house. Of 769 dying of non-tubercular diseases, 71, or over 9 per cent., had the anatomical characters of a cured tuberculosis. The London Lancet (September 22, 1888) states that M. Vibert has examined the records of the necropsies in the Paris Morgue, and that in 131 subjects who had died suddenly from violence or acute diseases, the lesions of pulmonary tuber- culosis were present in 25, and in 17 of these the tubercles had undergone the cretaceous or fibroid change, and were practically cured, h is certain, therefore, that tuberculosis in its commencement, and when affecting only a small portion of the lung, is often cured or rendered permanently latent. It is now known that ordinary serum circulating in the blood-vessels possesses marked germicidal properties, and therefore measures which benefit the general health and improve the quality of this important constituent of the blood have a curative effect as regards tuberculosis. The tubercle bacillus 222 CONSTITUTIONAL DISEASES. is an irritant to the tissues, and in cases which are cured or rendered latent it becomes surrounded by dense tissue which in time undergoes the cretaceous or fibroid degeneration. The bacilli in the interior of the mass may retain their vitality for an indefinite time, but, being encapsulated, they do no harm. There can be no doubt that many adults have local tuberculosis, and are cured by improvement in their general health and in the quality of their blood, without suspecting that they have had this disease. In young children, especially in infants, tubercles are frequently disseminated in the organs, and recovery under such circumstances must be impossible or rare ; but local tuberculosis or tuberculosis limited to certain glands, as the bronchial, is not unusual in childhood, and this form of the tubercular disease may be cured by measures which improve the general health. Hospital statistics show that the average duration of the disease is from three to seven months. Under favorable circumstances it is more protracted,, even to two or three years. Those succumb soonest who inherit a strongly- marked tubercular diathesis, live in damp, dark, and ill-ventilated apartments, and whose diet is scanty or of poor quality. Therefore in the poor quarters of the city tuberculosis presents a worse form and pursues a more rapid course than among families in better circumstances. Favorable prognostic signs are absence of tubercular diathesis, good appetite and general health, with little emaciation, infrequency of cough, with respiration, pulse, and temperature nearly normal. Such symptoms may afford hope of recovery with judicious regiminal and therapeutic measures. On the other hand, if the symptoms be grave death is inevitable, unless in bronchial phthisis, in which, even when there is considerable urgency of symptoms, the offending gland is sometimes eliminated by softening and ulceration, and the patient improves temporarily, if he do not ultimately recover. Complete and permanent recovery is, however, quite exceptional in bronchial phthisis, as it is in other forms of the disease. As Liebermeister has said, recovery in any form of tuberculosis is impossible except in incipient and very limited forms of the disease. Death in tuberculosis of children may occur from exhaustion induced by the general disease or from the local effects of the tubercles. Thus, in intra- cranial tuberculosis it may result from meningitis ending in convulsions and coma ; in pulmonary tuberculosis, from dyspnoea, though more frequently from exhaustion ; in that of the bronchial glands, from dyspnoea or hemor- rhage ; in that of the abdominal organs, from peritonitis or protracted diar- rhoea. Prophylaxis. — Since tuberculosis originates in so many different ways, measures designed to prevent this disease have a wide range. Precau- tionary measures are especially required in the nursing of the tuberculous patient. His sputum should always be received in a cup or spittoon contain- ing a disinfectant liquid, and this vessel when emptied should be cleansed with boiling water or a disinfectant. Sputum should never be received upon a handkerchief or cloth and allowed to dry. Towels and handkerchiefs should be moist when used, and immediately afterward placed in boiling water or a disinfectant. We have seen what disastrous results occur from the dried sputum. Whatever may be said of the innocuousness of the breath of the phthisical patient, based on the supposition that the tubercle bacillus has so great a specific gravity in its moist state that it is not exhaled in ordinary respiration, nevertheless the sad experience of the midwife related in a fore- going page should teach us to avoid the breath of a consumptive so far as is compatible with proper ministrations to him. The floors and walls of his apartment should occasionally be washed with a disinfectant fluid, and the bedding, clothing, rugs, and mats should never be shaken in the apartment, TUBERCULOSIS. 223 but outside the house. Ventilation of the apartment should be allowed to the full extent compatible with the safety of the patient. The remedies which we will hereafter recommend in the treatment of the patient are destructive to the bacillus, and therefore whenever employed have also a prophylactic action. No physician who has read in the medical journals of the last decade the many reports of cases in which milk has been the vehicle of pathogenic organisms has failed to see the urgent need of obtaining this indispensable article from healthy dairies. Families should insist on the inspection at regular intervals of the dairies that furnish them milk, and the exclusion of such animals as exhibit the least sickness. Moreover, no one with a chronic cough should be employed in milking or in the subsequent handling of the milk. To this matter we have already called attention. But with the utmost endeavor, on the part of families living at a distance, to obtain milk free from impurities, no one can state positively that it will not sooner or later contain pathogenic organisms, as those of diphtheria, scarlet fever, typhoid fever, or tuberculosis, so many and unsuspected are the modes of infection. Fortu- nately, heat at or near the boiling-point is an effectual sterilizing agent, and it can be employed without diminishing the nutritive properties of milk or rendering it more indigestible. I do not forget the interesting experiments which have been made to determine the tenacity of life of the tubercle bacillus when subjected to heat and cold. In experiments made it is said to outlive most of the microbes associated with it. Schill and Fischer state that dried and pulverized tubercular matter not subjected to treatment retains its virulence six months, and Pietro states that tubercular sputum well dried and maintained at 77° retains its virulence nine or ten months. But what concerns us most at present is the remarkable statement made by Max Voelsch (Centralb. fur Min. Med., June 30, 1888), that twice boiling- does not entirely destroy the virulence of the tubercle bacillus. I habitually direct that the morning supply of milk designed for children shall be imme- diately placed in a steamer and subjected for fifteen minutes to a temperature of 167°, the temperature which, according to Pasteur, is sufficient to destroy the pathogenic germs. No pathogenic microbe can probably survive if sub- jected so long a time to this degree of heat. The flesh of the tubercular animal, which it is believed is often purchased by unsuspecting families, evidently requires similar treatment — that is, thorough cooking — in order to be rendered innocuous. A competent meat inspector should be employed at each slaughter-house, and all diseased meats be rejected ; but in the present management of the meat market the only sure method of preventing the presence of living and active bacilli in the meat foods appears to be by thorough cooking. Outdoor life, residence in elevated localities, where the air is not only pure but rarefied, the occupancy of sunlit and well-ventilated rooms, the avoidance of rooms or localities where the air is contaminated by the pres- ence of others, as in crowded schools or factories, or by unwholesome occu- pations, and all measures which promote the appetite and general health, are prophylactic, as they are also to a certain extent curative, of tuberculosis. It is evident, from what has been stated above, that caseous substance occur- ring in any part of the system, inasmuch as it sustains a close causal relation to tuberculosis, should, if practicable, be removed by surgical measures. Moreover, since cheesy degeneration results for the most part from inflam- mations occurring in the scrofulous, measures designed to prevent or cure such inflammations or to cure scrofula have a prophylactic effect as regards tuberculosis. The strumous child should be watched with great care, and such measures be employed as are calculated to invigorate his system, lie 224 CONSTITUTIONAL DISEASES. should receive antistrumous treatment, both hygienic and medicinal. Espe- ciall} T should glandular hyperplasia and the products of inflammation, whether occurring in the lungs or elsewhere, be, if possible, removed before caseation occurs. For this purpose the old remedies, like cod-liver oil and syrup of the iodide of iron, given internally, and for hyperplasia of the subcutaneous glands ointments like iodide of potassium in lanolin, may be advantageously employed. Finally, one having an abrasion or sore of the cutaneous or mucous surface, or catarrh of the air-passages, as indicated by discharge from the nostrils, sore throat, or a cough, should not attend as nurse or otherwise a phthisical patient until his local ailment is cured, since the tuber- cle bacillus is believed to enter the system more readily through a diseased than a healthy surface. Treatment. — The indications of treatment are twofold : first, to invigorate the system in every possible way, so that the organs and tissues are in a better condition to resist the bacillus and the serum to antagonize and destroy it ; and, secondly, the employment of medicinal agents, if such can be found, which are destructive to the bacillus and safe to the patient. Measures designed to improve the general health must be chiefly hygienic, and are described in the text-books. The diet should consist of sterilized milk, the meat preparations, and farinaceous substances, prepared in such a way that they afford the maximum amount of nutriment and are easily digested. If the digestion be poor, peptonized food may be advantageously employed, and pepsin may be taken with the food. In 1881-82, Debove recommended gavage or forced feeding of consumptives through a flexible rubber tube having a funnel attachment, the tube being introduced into the stomach. He employed meat preparations, with pepsin. In the Medical Neics, October 1, 1887, Dr. S. Solis-Cohen of Philadelphia also recommended gavage in the treatment of phthisis. A quart of milk, two tablespoonfuls of beef powder, three eggs, fifteen grains of scale pepsin, and thirty drops of dilute muriatic acid were warmed and administered twice daily through a stomach-tube, a patient eating what he wished in the interval. Gavage has been employed by certain European physicians in the treatment of chil- dren suffering from various forms of innutrition, and it seems probable that tubercular patients may be benefited by it in some instances. In the ordi- nary mode of feeding, the predigested foods can often be used with benefit by consumptives, inasmuch as they have, for the most part, feeble digestion. As regards the hygienic measures designed to arrest tuberculosis, the most important, next to the use of proper food and the employment of such aids to nutrition as cod-liver oil and the alcoholic preparations, is outdoor life, and, if possible, in localities having a high altitude. The late Professor Flint, in examining the records of 62 cases of arrested phthisis which came under his observation, ascertained that the principal agent in effecting this result was exercise in the open air. He therefore strongly recommended this mode of life to consumptives, and also constant ventilation of their sleeping apart- ments, even in the winter season, the danger of taking cold being averted by maintaining sufficient warmth of air by a fire. Dr. James Blake has also reported instances of recovery of phthisical patients who lived during the five or six months of the dry season in the open air upon the Coast Range of mountains in California at an altitude of 3000 to 5000 feet. These patients were in the open air night and day, without even the protection of tents. Residence at a High Altitude. — The London Lancet, May 26, 1888, contains the abstract of a paper read before the Medico-Chirurgical Society of London by Dr. Williams, recommending residence at a high altitude as an efficient means of checking the progress of tuberculosis. He states that of 141 TUBERCULOSIS. 225 patients who had employed the high-altitude treatment, 14.13 per cent, were completely cured, 29.78 per cent, were much benefited, 11.34 per cent, were more or less benefited, and 17.02 per cent., including 13.47 per cent, who died, continued to grow worse. Drs. Quain and Pollock, in discussing this paper, expressed the opinion that consumptives who improve at a high altitude improve equally with the same treatment at lower elevations ; in other words, that residence at a high altitude does not influence the result. Brehmer, on the other hand, believes that the inhabitants have immunity from tuberculosis at an altitude of 1500 feet in Germany, of 4500 to 5000 feet in Switzerland, and 10,000 to 15,000 feet at the equator {Die Therapie Chronische Lungenbesclucerden, Wiesb., 1887). The most apparent and notable peculiarity in the air at high elevations, apart from its purity, is its rarefac- tion. At an altitude of 9000 feet above the level of the sea it is said, from observations made, that the air is so rarefied that three times the usual exercise of the lungs is required to meet the demands of the system. Dr. Mays states in a paper published in the Medical News, November 27, 1886, that the Quichua Indians, on the lofty plateaus of Peru, constantly breath- ing a rarefied air, " acquire enormous dimensions " of the chest, due to an increase in the size, and perhaps number, of the air-cells. More numerous and more exact observations are required in order to determine whether or to what extent residence at a high altitude is beneficial to consumptives, and, if it exerts a controlling effect on the disease, whether this result is due to the increased pulmonary expansion and activity or to other causes. Certainly, from observations already made, we are justified in recommending outdoor life in a mild and equable climate, and also residence at high elevations if the cold is not too severe. Residence in the Evergreen Forests and the Use of Turpentine. — In a paper read before one of the societies, and subsequently published, the late Dr. A. L. Loomis stated his belief that the terebinthinate vapors in the evergreen forests possess healing properties for consumptives. He quotes the state- ment of Ringer, that turpentine employed as a medicine enters the blood, and may be detected in the breath, the perspiration, and in an altered form in the urine of the patient. The presence of the vapor of turpentine in the pine forest, Dr. Loomis remarks, cannot be doubted, and its " local and con- stitutional effects," he adds, " are those of a powerful germicide as well as stimulant." Dr. Loomis quotes the opinion of Mr. Kingsett that turpentine, during its oxidation, evolves the peroxide of hydrogen, and therefore by the " oxidation of the terebinthinates there is produced in extensive pine forests an almost illimitable amount of peroxide of hydrogen, which renders the atmospheres of such forests antiseptic." He believes that the peroxide of hydrogen so abundantly produced in pine forests " successfully arrests putre- factive processes and septic poisoning," and therefore he recommends resi- dence in the pine forests as one of the most efficient means of relieving the symptoms of tuberculosis and retarding the progress of this fatal malady. At high altitudes the coniferous or evergreen trees usually predominate, and if the views of Professor Loomis be substantiated by future investigations. it. may be that the benefit believed to be obtained by consumptives at high elevations is partly due to the exhalations from these trees. , The bacteriologists who have cultivated the tubercle bacillus, and observed the action upon it of the various agents which have been employed and extolled by clinical observers, state that most oi' these agents do not penetrate the tubercular mass — that while they may destroy the superficial bacilli, they do not affect those more deeply seated, and therefore fail to arrest the disease. But turpentine and its derivatives appear to penetrate the tissues as deeply as almost any other agent, and therefore, it' they are 15 226 CONSTITUTIONAL DISEASES. sufficiently antiseptic and not too irritating, we may expect good results from their judicious use. But it is probable that they are less efficient as germicides than some of the other agents which can be safely employed, and therefore should be recommended only as adjuvants, or as remedies which may give some relief to the catarrhal and other symptoms without exerting any marked antiseptic action. Hohnfeld states that he applied oil of turpen- tine to fresh colonies of the micrococcus prodigiosus and staphylococcus aureus, and that it exerted little destructive or retarding effect on these micro-organisms. 1 These experiments would lead us to distrust the germi- cide action of turpentine and the terebinthinate preparations in tuberculosis, for the tubercle bacillus is tenacious of life beyond most other microbes. Dr. Trudeau of Saranac Lake prescribed the hot-air treatment in four cases four hours each day, the temperature of the inhaled air being 392° F. The first and second patients improved slightly at first, but refused the treatment, the one after one month, and the other after six weeks. The third patient was treated three months without the least appreciable effect. The fourth patient was treated four months, with manifest improvement in her physical signs and general health, but no more improvement than frequently occurs from any new mode of treatment. In all the cases the sputum was examined before, during, and after the treatment, and in every examination the tuber- cle bacillus was present. The result claimed for the hot-air treatment had not been obtained — that is, the destruction of the bacilli ; and if they are not destroyed in the sputum, certainly they are not in the tissue of the lung. Therefore there can be little doubt that the hot-air inhalations, so far from coming into general use, will be discarded, not only because they are unpleasant to the patient, but are inefficient. There is always a large amount of residual air in the alveoli, and there can be little doubt that in the hot-air inhalations the air in the alveoli and terminal bronchial tubes never attains the elevation of temperature of the air that is inhaled, nor of that which is exhaled. Moreover, as we have seen, the tubercle bacillus resists the destructive action of high temperature. It is said to retain its vitality in liquids which have been twice heated to the boiling-point. Creasote. — Of the many medicines which have been recently employed in the treatment of tuberculosis, creasote appears to have given more general satisfaction than any other. It has to a great extent taken the place of cod- liver oil, which was formerly employed in the treatment of tuberculosis in want of a better agent. I am informed that the late Dr. Cammann, the in- ventor of the binaural stethoscope, employed it twenty years ago in the treat- ment of tuberculosis, but it was seldom prescribed for this disease until within the last decade. In the Berliner Mimsche Wochenschrift, July 20, 1886, Von Brunn stated that he had treated 1700 phthisical patients in the preceding eight years with creasote, giving to adults not less than six to eight drops in twenty-four hours. He employed it in solution with tincture of gentian and wine, and believed that he obtained good results, especially in acute unilateral cases. Professor Sommerbrodt stated in 1887 that he em- ployed creasote in about 5000 phthisical cases during the preceding nine years. At first he used Bouchard's solution of creasote, and afterward gel- atin capsules, each containing three-fourths of a grain of creasote and three minims of the balsam of Tolu. The amount of creasote administered daily to the patients who were adults was increased gradually from one capsule to not less than nine. As many as 600 to 2000 capsules were given to each patient without a break. In many cases the improvement was marked, not only in the symptoms and in the general health, but also in the physical signs. He believes that he has cured cases by insisting on a continuance of 1 Fortschritte der 3Iedicin, October 1, 1887. TUBERCULOSIS. 227 the treatment. To show the good effect of creasote, he cites the case of a student of sixteen years, with tuberculosis of the right lung, who took three capsules three times daily, or about seven and a half grains per diem. His cough abated, his weight increased six pounds in two months, his expectora- tion had ceased. Instead of the dull percussion sound over the apex of the right lung, only a slight rhonchus was observed, and his general health had greatly improved. Many others who have employed creasote during the last two or three years, both in this country and in Europe, report favorable results. Strum- pell says that it produces no ill effects, and in large doses it frequently causes improvement in such symptoms as the cough, expectoration, and appetite, but he doubts whether it exerts any marked curative effect upon the disease. It has been employed largely in the New York Hospitals and in family practice in various combinations, and the general opinion expressed is very favorable to its use. I have prescribed creasote for internal use in the following formula : R. Creasoti (Morson's), Spiriti chloroformi, Alcoholis, da. 3SS. — M. Dose for an adult, nine drops three times daily in half a teacupful of water con- taining a tablespoonful of brandy or two tablespoonfuls of wine. The nine drops of the mixture, containing three of the creasote, have been increased to twelve drops, or four of creasote, and thus far in my practice patients believe that they have been benefited by this remedy, and have desired to continue it. At the same time, in some instances I have recom- mended the inhalation of ten or fifteen drops of the same mixture from Robinson's inhaler. This dose of creasote, three or four drops, may seem large, but it is tolerated when sufficiently diluted, though it may be best to commence with a smaller quantity. Children should of course take doses proportionate to the age, the fractional part of a drop being sufficient for in- fants. Creasote has also been injected into the tubercular lung through the chest-walls by several physicians, a syringe provided with a long and delicate needle being used. Rosenbusch injected eight drops of a 3 per cent, solu- tion of creasote in almond oil in two places at the seat of the disease, or six- teen drops in all. The result was a marked diminution of the cough, the sweats, the amount of sputum, and, in recent cases, an increase in weight. The beech creasote was used, and the skin and apparatus were first sterilized by an antiseptic lotion. When the instrument was not introduced deeply enough, a sharp, pleuritic pain sometimes occurred, but it soon abated. Creasote appears to be the most valuable of the recent remedies recommended for tuberculosis, but in order to determine its exact value, the proper mode of employing it, and the size and frequency of the dose, more extended observations are required. Frantzel says that experiments have shown that this substance is inimical to the growth of the bacillus when mingled in minute quantity with a gelatin culture-medium, and on this fact is based its internal administration. When it is injected into the lungs through the chest-walls, Dr. E. G. Janeway of New York believes that it is very import- ant that the almond oil or other vehicle employed should be first sterilized. In the present state of our knowledge of the use of antiseptics in the treatment of tuberculosis, creasote is the one which is most deserving o'l con- fidence and employment. In New York City, in cases of protracted broncho- pneumonia with emaciation, the symptoms indicating the probability of cheesy degeneration and commencing tuberculosis, I am prescribing the hourly inhalation of the vapor of creasote, one part to ten of fifteen of tere- 228 CONSTITUTIONAL DISEASES. bene, fifteen to twenty-five minims, or more of the mixture being dropped on the sponge in Robinson's perforated zinc inhaler. Children willingly in- hale this vapor five or ten minutes at a time, with some apparent relief of symptoms. Dr. Robinson (Amer. Journ. of Med. Sci.) writes : " I am convinced from what I have seen .... that we have in beechwood creasote a remedy of great value in the treatment of pulmonary phthisis, particularly during the first stage. Not only does it lessen or cure cough, diminish, favorably change, and occasionally stop sputa, and relieve dyspnoea in very many instances, but it also often increases appetite, promotes nutrition, and arrests night-sweats." Von Brunn obtained favorable results from the use of creasote in 1700 cases. The gastric digestion, and later the respiratory symptoms, were improved. A diminution, and even disappearance, of bacilli occurred. The creasote was given in wine and by inhalation. The experiments of Guttmann show that the tubercular bacillus will not grow in solutions of the strength of 1 : 2000, and only feebly in solutions of the strength of 1 : 4000. The medical journals during the last five years contain numerous communications recommending creasote as the most effi- cient remedy in tuberculosis and chronic catarrhs. For such maladies it has to a great extent taken the place of the old remedy, cod-liver oil. Seitz pre- scribes it for these affections with cod-liver oil, in the following formula : R. Creasoti, 38 grains (2.5 grammes); Olei morrhuse 6 \ ounces (200 " ); Sacchari, 2 grains (0.13 gramme). Dose : One to four teaspoonfuls two or three times daily. For children smaller doses. Creasote has also been given in two or three teaspoonfuls of orange juice, to which the same quantity of Tokay or Malaga wine is added, and it should, in my opinion, always be given, especially to children, in smaller and more frequent doses than most formulae state, and after the feeding, so as not to irritate the stomach. It is the common and, I believe, correct practice to pre- scribe the minimum dose at first and gradually increase the quantity given if tolerance is manifested. A half-drop to one drop after taking food would be considered a proper dose for a child of five years. But the dose can be doubled if sufficiently diluted so as not to be irritating, and given more times daily. Every year since the introduction into practice of creasote as a remedy for tuberculosis its use has extended and it has been more and more extolled. It is commonly stated by those who have most employed it, that creasote properly administered does no harm, but improves the digestion and general health ; therefore it has been useful when its vapor is employed in protracted catarrhal affections and tuberculosis, of the lungs and air-passages. By my own experience I can highly recommend the following formula : Creasoti (Morson's beechwood), £ij ; Terebene, *^iv. — Misce. Add one teaspoonful to three or four tablespoonfuls of boiling water, and inhale the vapor from three to five minutes, or employ the same upon the sponge of Robinson's perforated zinc inhaler. It may be used once in three or four hours or oftener. Guaiacol. — This is described in the books as a liquid compound consisting of 60 to 90 per cent, of creasote. In 1891-92 a carbonate of guaiacol was produced, which promises to be a medicine of great value, and in some TUBERCULOSIS. 229 instances a substitute for creasote. It occurs in the form of neutral crystals without taste or odor, insoluble in water, but dissolving at 86° to 90°. The combination with the carbonate appears to remove all irritating properties from the medicine, and I have several times allowed five grains of the guaia- col carbonate to dissolve in my mouth and be swallowed without experiencing the least irritation from it. I look for a favorable reception of this agent in chronic catarrhs and in incipient as well as in advanced tuberculosis. As is the case with all common and fatal diseases, many new drugs for phthisis have been recommended each year since the appearance of the last edition of this book. Most of them, after a few trials, have fallen into disuse. The one that has attracted the most attention, originating from a high scien- tific authority, is tuberculin. Tuberculin. — Koch published the experiments which led to the preparation of tuberculin in the Deutsch. med. WocJien., No. 46, 1890. If a healthy guinea- pig be inoculated with a pure culture of the tubercle bacillus, the wound closes and for a few days appears to be healing. In about two weeks, how- ever, a hard nodule forms, which soon breaks down, leaving an ulcer until the death of the animal. But if the animal, successfully inoculated four to six weeks previously, be reinoculated, no nodule is formed, but on the second day the point of inoculation becomes hard and darker to the extent of .5 to 1 centimetre. This dark necrotic substance is cast off and the wound soon heals. If the injection of a proper quantity be repeated in one to two days, the health of the animal improves and the wound becomes smaller, cicatrizes, and the lymphatic nodules diminish in size. Koch found, however, that " the objection to the use of the sterilized cultures lay in the fact that the dead bacilli were not absorbed, but remained at the point of injection, and caused more or less suppuration. The material which had a curative effect was something which was soluble and which entered the fluid of the tissue about the bacilli.'' Koch then endeavored to extract from the cultures of the bacillus this soluble substance. Clinical results are the test of the value of a medicine given to check or cure disease, and the result of the use of tuberculin, whatever will be its future, has been less efficient than that of creasote. Still, already one im- portant benefit has resulted from its use. If tuberculin be injected under the skin of an animal having tuberculosis, it causes fever, but none if the animal is healthy. It is therefore very useful as the means of excluding diseased cows from a dairy. I have described in the foregoing pages the most important of the remedies which have been recently recommended by apparently competent observers. There are others which, from their nature and the limited trial which they have received, I have not thought of sufficient importance to require notice. Most of them will probably soon be discarded by those who now recommend them. The hygienic measures — as outdoor life, residence at a high altitude. free ventilation of sleeping apartment, and the use of the most nutritious and easily-digested food — still maintain a most important place in the treatment of tuberculosis. Of the medicines, creasote, used internally and by inhala- tion, appears to be the most deserving of recommendation. 230 CONSTITUTIONAL DISEASES. CHAPTER IY. SYPHILIS. Syphilis in infancy and childhood occurs under two forms — to wit, the congenital and acquired. The former is the more frequent. Etiology. — Congenital syphilis may be derived from either father or mother. Either parent, having syphilis in its first or second stage, may transmit it to the offspring, although at the time free from syphilitic symp- toms. The mother, healthy at the time of conception and contracting syph- ilis prior to the eighth month of gestation, may communicate the disease to the foetus. Syphilis contracted by the mother in the eighth or ninth month of gestation is less likely to be communicated to the foetus. Writers mention the case reported by Zeissl, in which the wife, previously well, contracted syphilis from her husband between the fifth and seventh months of gestation, and the infant, born at term, soon exhibited the characteristic syphilitic lesions. If both parents have syphilis at the time of conception, the infant is almost necessarily syphilitic ; on the other hand, if only one parent be syphilitic, the infant may or may not be contaminated. Sometimes with such parentage a part of the children are syphilitic and a part healthy. All syphilographers agree that syphilis in its third stage is not transmis- sible from parent to child, but parents in this stage of the disease are likely to beget scrofulous children. Hutchinson of London regards syphilis as an exanthem, with its periods of efflorescence and decline, and the symptoms and .ailments which characterize the so-called third state he regards as sequelae. That syphilis is no longer transmissible after the close of the second stage is shown by many observations. Thus, M. Mireur relates the history of a man and wife who were syphilitic and were never treated, but their children were without syphilitic symptoms. Acquired syphilis in infancy and childhood may be received through primary lesions — that is, by reception of the virus from a chancre or bubo — or it may be derived from certain of the secondary lesions. Inoculation by primary lesions may occur at the birth of the infant from a syphilitic sore in the vagina or upon the vulva of the mother ; inoculation in this manner is, however, rare. Children may also receive the virus from primary lesions on the persons of nurses or companions. Infection in this manner is sometimes accidental and sometimes the result of criminal conduct. A chancre on the breast of the wet-nurse not very infrequently communicates syphilis to the nursling. The contagiousness of " secondary manifestations," for a long time doubted, is now fully established. Syphilis may be communicated by the secretion or exudation of a mucous patch or a secondary sore. Hence the danger of suckling by infected wet-nurses, though they present no symptoms of recent syphilis. Excoriations or sores upon the nipple or breast of a syphilitic wet- nurse may communicate the disease to the nursling ; and, on the other hand, mucous tubercles or fissures upon the lips or tongue of the infected infant may be the means of contaminating a healthy wet-nurse. Many such cases are now contained in the records of medicine. Vaccination by means of the scab is also a mode by which syphilis has been communicated. (For further particulars in reference to this subject the reader is referred to our remarks on vaccination.) Syphilis is believed to be a microbic disease, but further investigations SYPHILIS. 231 are required in order to determine positively which microbe is the causal agent. Klebs obtained by cultivation bacilli which he found in indurated chancres. With these bacilli he produced a local affection by inoculation of the monkey which resembled, in some respects, that of syphilis and in other respects that of tuberculosis. Ziegler and Von Rinecker obtained negative results from similar experiments (Ziegler's Path. Anatomy). Lustgarten has described a bacillus which occurs in syphilitic lesions, and which he dis- tinguishes from that of tuberculosis by colorations which the latter receives and this does not, Alvarez and Tavel in 1885, and later Cornil, describe a bacillus found in the desquamation of the genitals which closely resembles Lustgarten's bacillus of syphilis, but which Cornil states can be distin- guished from it by certain differences in the coloration (Cyclop, of Diseases of Children, vol. i. 168, Phila., 1889). Dr. "W. H. Welch, the distinguished professor of pathology in Johns Hop- kins University, has favored me with the following note relating to the micro- organism which causes syphilis : Baltimore, Aug. 14. There has hitherto been no satisfactory demonstration of this organism, although there have been many claims to its discovery. The only organism yet demonstrated which has any claims to being considered the cause of this disease is, in my opinion, the bacillus of Lustgarten There is much to be said in favor of the bacillus discovered by Lustgarten, and first described by him in November, 1884, and I think this is the only micro-organism hitherto observed in syphilitic lesions which possesses much interest. His work from the first attracted attention, as it was done under the direction of Prof. Weigert, one of the greatest living experts in this line of study. The organism is described by Lustgarten as a bacillus three to seven micro-millimetres long, often slightly wavy in shape, and found usually within the protoplasm of cells in syphilitic products. It was found by Lustgarten in all of the syphilitic products, including gummata, which he examined. Next to Lustgarten's, the most important studies of this bacillus have been made prob- ably by Doutrelepont of Bonn, in co-operation with Schutz ; by Matterstock of Wiirzburg ; by Markase ; and by Fordyce. The significance of Lustgarten's dis- covery for a time seemed to be overthrown by the detection by Matterstock and by Alvarez and Tavel of a bacillus in smegma, which these observers believed to be identical with Lustgarten's syphilitic bacillus ; but, although strikingly similar, these two species of organism have now, I believe, been shown to be entirely differ- ent species, and the smegma bacillus has nothing to do with the syphilis bacillus. Lustgarten's bacillus has not been cultivated, notwithstanding repeated attempts to find a medium suitable for its growth. It is certainly often, and probably con- stantly, present in syphilitic lesions. Still, several observers have reported negative results in searching for it. The reason of this is probably the extraordinary diffi- culty in demonstrating this organism. There is nothing in all histological technique which requires such an outlay of time and patience as the demonstration of the syphilis bacillus, so that so skilled an histologist as Weigert says that he simply has not the patience to work at this subject : and this is probably the conclusion of others who have tackled it. It is clear, however, that the discovery of a peculiar bacillus with remarkable staining properties, enclosed within cells in syphilitic products, is something of great significance — far greater than finding, as did Aufrect, ordinary cocci in juice squeezed out of a flat condyloma, or in mistaking plasma-cells for clumps of cocci. as Birch-Hirschfeld is known to have done. When, in addition to this, the lew good observers, who, like Lustgarten, have had the patience and skill to make a satisfactory study of the question, claim to find this peculiar bacillus so frequently in the lesions of syphilis, I think it must be admitted that this bacillus has special claims upon our consideration. It must be admitted, however, that a complete demonstration that Lustgarten's bacillus is the specific cause of syphilis has not as yet been furnished. It may interest you to know that within the last year or two some interest has attached to the observation first made by Kassowitz and Hochsinger. that strepto- cocci are often present in congenital syphilis ; but I do not think that there can be 232 CONSTITUTIONAL DISEASES. any doubt that these streptococci have nothing to do with the specific contagium of syphilis (and, indeed, Doutrelepont has found Lustgarten's bacillus in combi- nation with streptococci in congenital syphilis), but they are evidence of mixed infection. They are probably the ordinary streptococci of suppuration. It is, how- ever, of some interest to have this bacteriological evidence of a clinical fact, that many cases of congenital syphilis are examples of mixed infection. It is probable that some lesions of congenital syphilis which have been regarded as specific, particularly those of a suppurative character, are due to the secondary invasion of these streptococci, for which the soil has been prepared by the specific organism of syphilis. Yours very truly, W. H. Welch. It is evident, in consequence of the risk of begetting syphilitic children, that one who has contracted syphilis should not niarry or sustain conjugal relations until four years have elapsed from the time of infection and the disease has passed through its first and second stages, and eighteen months of treatment have been employed. We have seen that hereditary syphilis may be inherited from either parent, although the parent do not exhibit at the time any syphilitic symptoms, and that the mother, contracting syphilis during gestation even as late as the seventh month, may transmit it to her infant. Clinical History. — The effects of the syphilitic poison upon the devel- opment of the foetus and the development and health of the infant are differ- ent in different cases. The foetus, under the influence of the poison, often ceases to grow, shrivels, dies, and is expelled long before term ; or it may be born alive, but prematurely, and showing clear evidences of the disease as soon as it comes into the world ; or, again, it may be born at term, but dead. So frequently is syphilis a cause of non-viability that, as Trousseau has remarked, this disease should be suspected as the cause whenever a woman repeatedly aborts. Abortion from syphilis commonly occurs at or about the sixth month of gestation. In those cases in which the foetus dies from syph- ilis there is often placental syphilitic disease — to wit, an undue growth of cells in the villi, which, compressing the vessels, gives rise to fatty degenera- tion and prevents the requisite interchange between the maternal and foetal blood (Harring, Frankel). Frankel designated the change " granulation-cell hypertrophy of the placental villi." Yirchow in one case found a gummy tumor in the maternal portion of the placenta. When a foetus destroyed by syphilis is expelled, it frequently presents a macerated appearance, the cuticle being detached over large patches of sur- face, and in other parts raised in blebs, with a thin, puriform, and offensive fluid underneath ; the liver is occasionally indurated, and abscesses with spots of inflammation are sometimes observed in the thymus gland ; the amniotic fluid is offensive, turbid, and of a greenish or greenish-brown appearance. If the foetus in which syphilitic manifestations have begun to occur have reached a viable age and be born alive, it is small and imperfectly developed, often shrivelled and senile in appearance. The skin looks unhealthy, and it may exhibit a distinct rash. Bouchut saw a seven and a half months' infant born alive, with an eruption of a copper color upon the legs and arms and onychia upon the fingers and toes. The bullae of pemphigus are also not infre- quent upon the skin at birth, or they appear within a few days (two or three) after birth. The smallest are about the size of a split pea, but many are considerably larger ; the largest consist of two or more which have coalesced. They contain a thin, greenish, purulent matter, and appear most frequently upon the palms of the hands and soles of the feet, but also in severe cases upon the face and over the surface of the body. Eecently I was able to diagnosticate syphilis in an infant within a day after birth by its small size and feebleness and the appearance of large blebs of pemphigus upon its SYPHILIS. 233 hands, feet, fingers, and toes, over which the skin soon broke leaving trouble- some and bleeding sores ; coryza commenced about the twelfth day. The parents seemed healthy, but I was enabled to trace the syphilitic taint to the mother. Non-syphilitic pemphigus, the result of cachexia, sometimes appears soon after birth, but its primary and usual seat is around the neck and upon the body. I have known it to appear within the first week of life, and end fatally by the close of the second week. I have not found it difficult to dis- tinguish it from syphilitic pemphigus by the history of the family and its absence from the palmar and plantar surfaces of the hands and feet. Con- dylomata, mucous patches, and stains of a copper color are the principal syphilitic affections, besides pemphigus, which have been observed at birth on the bodies of contaminated infants. It is stated that M. Cullerier in ten years' attendance at the Hopital de Lorraine met only two cases of syphilitic manifestations at birth, and Victor de Meric only two cases in forty-six infants, who were affected with congenital syphilis (Bumstead) ; but in the practice of others a larger proportion have exhibited symptoms at birth. Ordinarily, the period in which congenital syphilis is first revealed by symp- toms is between the fifteenth and fortieth days. Rarely the manifestations of the disease are delayed several months. M. Diday ascertained the time of the commencement of symptoms in 158 cases, as follows : Before the completion of one month after birth, in 86 Before the completion of two months after birth, in 45 Before the completion of three months after birth, in 15 At four months 7 At five months 1 At six months 1 At eight months 1 At one year 1 At two years 1 When the symptoms do not occur until several weeks have elapsed, it is probable that the poison has been partially eradicated from the affected parents by appropriate treatment. The nutrition of the infant who has inherited the syphilitic taint, but does not exhibit it at birth, is for a time good, but it begins to be impaired when the local manifestations of syphilis appear or soon after. The system gradually wastes ; the skin loses its fresh and healthy appearance and becomes sallow, and after a time more or less wrinkled ; the features become pinched and contracted and wear a sad expression. M. Diday says : " Next to this look of little old men, so common in new-born children doomed to syphilis, the most characteristic sign is the color of the skin." Trousseau thus described this discoloration of the surface : " Before the health becomes affected the child has already a peculiar appearance ; the skin, especially that of the face, loses its transparency ; it becomes dull, even when there is neither puffiness nor emaciation ; its rosy color disappears, and is replaced by a sooty tint. which resembles that of Asiatics. It is yellow or like coffee mixed with milk, or looks as if it had been exposed to smoke ; it has an empyreumatie color, similar to that which exists on the fingers of persons who are in the habit of smoking cigarettes. It appears as if a layer of coloring had been laid on unequally ; it sometimes occupies the whole of the skin, but is more marked in certain favorite spots, as the forehead, eyebrows, chin, nose, eye- lids — in short, the most prominent parts of the face; the deeper parts, such as the internal angle of the orbit, the hollow of the cheek, and that which separates the lower lip from the chin, almost always remain free from it. Although the face is commonly the part most affected, the rest of the body 234 CONSTITUTIONAL DISEASES. always participates more or less in this tint. The infant becomes pale and wan." The infant whose system is profoundly affected by syphilis rarely smiles and its voice is feeble and plaintive ; its frequent, whimpering cry is quite characteristic. Coryza is one of the earliest and most constant of the local affections in infantile syphilis. It is slight at first, attracting little attention on the part of the parents, who are not aware of its significance and usually attribute it to a slight cold ; but it gradually increases. It gives rise to a secretion from the Schneiderian membrane, at first thin, but which becomes more consistent and is attended by the formation of scabs. The thickening of the mucous membrane in consequence of the inflammation and the presence of crusts narrows the passage through the nostrils, so as to produce snuffling respira- tion and sometimes render nursing difficult. In severe cases respiration through the nostrils is almost wholly prevented, so that death may occur from inanition, unless the breast be milked into the infant's mouth or it be fed with a spoon ; but ordinarily, even in grave coryza, it continues to nurse, though obliged often to release its hold of the nipple to obtain breath. It is when the coryza interferes with drawing the nipple that it first alarms the parents. The inflammation at the same time may affect the throat and larynx, causing hoarseness of the voice. Ulceration of the Schneiderian mem- brane and the adjacent cartilage or bone is rare in infancy or childhood, although cases occur which are even attended with more or less flattening of the nose. Diday believes that the discharge which accompanies coryza is in great part due to mucous patches developed on the Schneiderian mem- brane. The upper lip, over which the discharge flows, becomes red, excoriated, and more or less incrusted. The coryza in most cases coexists with other local syphilitic affections. Occasionally it occurs alone, and is the only evi- dence of the presence of the specific taint, except such as is afforded by the malnutrition and general appearance of the patient. Mucous patches occur in most patients. They are developed either upon the mucous surfaces or upon parts of the skin which are thin and exposed to friction, and such as are moistened by secretion or transudation from the vessels underneath. The most common seat of mucous patches is at the ter- mination of mucous canals ; but in infancy, on account of the peculiar deli- cacy of the skin, they may occur upon almost any part of the cutaneous surface. They are most common, however, around the anus, upon the vulva, scrotum, umbilicus, labial commissures, in the axillae, and behind the ears. Mucous patches upon the skin present a rounded border and are slightly elevated. Their color has been compared to that of skin which has been softened by the prolonged application of a poultice. Erosions and cracks sometimes occur in the patches, from which a thin liquid exudes. Upon mucous surfaces they are less elevated than upon the skin, and are prone to ulcerate. These ulcerations, commencing at the centre, extend, and soon the mucous patch disappears and its site is occupied by an ulcer. The ulcer may be circular, oval, elliptical, crescentic, or irregular. The arches of the fauces are a common seat of mucous patches. Roseola is an occasional symptom of infantile syphilis. "It is distin- guished," says Diday, " by patches of a bright rose color, circumscribed, irregularly rounded, of various sizes (most frequently about as large as one of the nails) ; appearing by preference on the belly, lower part of the chest, neck, and inner surface of the extremities." The spots do not readily and fully disappear by pressure. Pemphigus, appearing soon after birth, has already been alluded to. Its- most frequent seat, whether occurring at birth or as a subsequent manifesta- SYPHILIS. 235 tion, is as we have stated, the palms of the hands, soles of the feet, the fingers, and the toes. This eruption commences by a violet tint of the skin, and in the course of twenty-four to forty-eight hours a watery fluid collects under- neath, which soon becomes turbid. The skin peels off, and sometimes an angry sore results, which bleeds readily when rubbed or pressed. In other and more favorable cases new skin takes the place of that which is lost. Pemphigus at birth is a precursor of death, but when it appears for the first time some weeks after birth, it is a less unfavorable prognostic sign. In cases of recovery it disappears, with proper treatment, in two or three weeks. Acne, Impetigo, and Ecthyma are occasionally observed in children afflicted with syphilis. The indurated pustules of acne occur most frequently upon the shoulders, back, chest, and buttocks. The pus is sometimes absorbed and in other cases discharged, leaving a small cicatrix, which after a time dis- appears. Impetigo appears most frequently upon the face, and occasionally upon the chest, neck, axillae, and groin. Unlike simple impetigo, the syphi- litic impetiginous eruption is surrounded by a copper-colored areola. Ecthyma occurs upon the legs and buttocks chiefly. It commences as violet-colored spots, which are soon transformed into pustules. Ulcers succeed, which in reduced states of the system sometimes enlarge and endanger the safety of the child. Of the three pustular eruptions, acne, according to Diday, is the least serious, indicating a " less confirmed diathesis." Ecthyma is the most serious, on account of the reduced state of the system with which it is usually associated. Syphilitic papulae and squamae are rare in infants, but cases have been observed. Onychia occasionally occurs, though less frequently than in syphilis of the adult. In an interesting lecture on hereditary syphilis Dr. Miller remarks that polymorphism of its cutaneous eruptions characterizes hereditary syphilis. In 1000 cases of the inherited disease the local affections referable to syphilis, and seated upon or in immediate relation with the cutaneous and mucous surfaces, were as follows : x Papules 74 per cent, of the cases. Khagades of the lips and anus 70 " " " Khinitis 58 " " Ulcers of hard palate 52 " " Erythematous eruptions .45 " " " " Lymphadenitis chronica 20 " " " Ulcers of tongue (glossitis ulcerosa) 27 " " " Bullous eruptions (pemphigus) 25 " " " Onychia and paronychia 23 " " " Laryngitis 17 " " " Pseudo-paralvsis of extremities 7 " " " Ulcers 4 " " Ulcerative gingivitis 4 " " " Visceral Lesions. — The visceral lesions which result from the syphilis of infancy and childhood are suppuration in the thymus gland; gummy tumors in certain organs, most frequently the lungs and liver ; increase of the con- nective tissue of the liver, known as syphilitic cirrhosis; partial perihepatitis. with depressions resembling cicatrices on the surface of the liver; periostitis. with thicking of the bone ; and exostosis. Suppurative inflammation in the thymus gland is not common or has not been frequently observed. When it is present the gland sometimes presents its normal appearance externally, and the abscess is only discovered by incis- ions. Gummy tumors are white and spheroidal ; some arc as small or smaller than a pin's head, while others are as large as a pea or even a hazel-nut. T 1 Pacific Med. Surg. Jouni., 1888. 236 CONSTITUTIONAL DISEASES. have seen a considerable number of them not as large as a pin's head in the liver of an infant. Gummy tumors, according to Lebert, consist " of loose fibrous tissue made up of pale, elastic fibres, enclosing in their large inter- spaces a homogeneous granular substance, the elements of which are less adhe- rent to each other than in deposits of true tubercle." Lebert also, with other microscopists, discovered round granular cells in these tumors. According to Robin, gummy tumors " are made up of rounded nuclei belonging to fibro- plastic cells, or cytoblastions ; of a finely granular, semi-transparent, and amor- phous substance ; and, finally, of isolated fibres of cellular tissue, a small number of elastic fibres, and a few capillary blood-vessels." Constitutional syphilis is one of the principal causes of waxy degenera- tion, and the spleen and liver of infants may be enlarged from this cause. Dr. Samuel Gee has expressed the opinion that in half the cases of hereditary syphilis the spleen is enlarged {London Lancet, April 13, 1867). Infiltration of the liver by fibrous substance was first noticed by Gubler. It is not common in the infant. A specimen, showing this lesion, was pre- sented to the London Pathological Society in' 1866 by Dr. Samuel Wilks. The following remarks by Dr. Wilks convey a good idea of the appearance and state of the liver in syphilitic cirrhosis : " Having dissected the bodies of several infants who have died of congenital syphilis, I have found fatty livers and an inflammation of the capsule, but in only two have I discovered adventitious products of a fibrous character. The present example, however, corresponds in every particular with the disease described by Gubler. It must be distinguished (at least as far as the naked-eye appearance reaches) from syphilitic disease of adults, of which many specimens have been before the society. In these the organ is cicatrized on the surface and contains dis- tinct nodules of fibrous tissue ; while in the disease of children, as in the present specimen, the whole organ is infiltrated by a new material, and it consequently becomes, as described by Gubler, hypertrophied, globular, and hard, resistant to pressure, and even when torn by the fingers its surface receives no indentation from them ; it is also elastic, and when cut creaks slightly under the scalpel. This was the form of disease in the present specimen. It came from a syphilitic child a month old, in whom the liver could be felt enlarged during life, and when removed weighed a pound and a half. It was smooth on the surface, and so hard that it resembled rather a fibrous tumor than a liver. It is seen that the liver in the syphilitic child is liable to three distinct pathological processes — namely, gummy tumors, cir- rhosis or fibroid degeneration, and waxy degeneration." Syphilitic perihepatitis and periostitis are more rare in infancy and child- hood than in adult life, but they occasionally occur. The late Sir James Y. Simpson considered peritonitis in the foetus one of the results of syphilis, and a cause of its death. Osseous Lesions. — Within the last few years important discoveries have been made in regard to the effect of syphilis upon the nutrition of the bones in children. In 1870, Dr. Wegner of Berlin published his observations of the state of the skeleton in twelve syphilitic children who were either stillborn or who died within a few days or weeks after birth. He found clear proof that the syphilitic dyscrasia frequently disturbs the nutrition and produces anatomical changes in the skeleton of the foetus. The following are the lesions clearly referable to syphilis which he observed : Periostitis of long bones, including the ribs ; softening', separation, and sometimes crepitation at the point of union of diaphysis and epiphysis ; chalky concretions and infil- trations along the line of ossification ; fatty degeneration of marrow ; irreg- ular formation and distribution of spongy substance in the epiphysis. These lesions were not all observed in each case, but they occurred with such fre- SYPHILIS. 237 quency that tliere could be no doubt that they were due to the syphilitic taint of system. Confirmatory observations also in twelve cases have since been made by Waldeyer and Kobner. 1 Again, there is a syphilitic lesion of the bone in children which is not usually present or has not usually been observed at birth, but is developed in the first weeks or months of infancy. The lesion alluded to is a circum- scribed enlargement of one or more bones. This has been most frequently observed upon the long bones, including the clavicle and ribs, but in certain children it occurs upon other bones in addition. In some cases it is one of the first manifestations of hereditary syphilis, occurring even sooner than the coryza, while in others several months elapse before it appears. In one case reported by Dr. Bulkley 2 of this city it was first seen only a few days after birth, being perhaps congenital ; while in another case, in which the enlarge- ment was upon certain phalanges, and which is represented in the accompany- ing figure, it appeared at the age of twelve months. When it occurs upon a phalangeal bone it is designated dactylitis syphilitica. The enlargement, if upon a long bone, ordinarily begins at or near the point of union of the diaphysis with the epiphysis. It is located upon the extremity of the shaft, which it encircles, and it extends over a part or nearly the whole of the epiphysis. It has an elevation of perhaps one-half or three- quarters of an inch in typical cases : its surface is smooth or slightly undu- lating, and the skin over it, though distended, has its normal appearance and is easily movable, unless ulcerations have occurred. These enlargements, which result from the specific inflammation occurring in the periosteum and the bone, may resolve under proper treatment : but if neglected and the antihygienic conditions are bad, degenerative changes may occur, ending in ulceration and destruction of the diseased part to a greater or less extent. 1 See paper by K. W. Taylor, M. D., New York Journal of Obstetrics, etc, July. 1874. 2 "Bare Cases of Congenital Syphilis," New York Med. Journal, May, IS, 4. 238 CONSTITUTIONAL DISEASES. Though these bone-enlargements, whenever observed, should excite suspi- cions of syphilis as the cause, enlargements which present the same general appearance do occur from other causes. Such a case was observed by me in the children's class in the Out-door Department of Belle vue, and Dr. Bulkley details another case in his paper. In the case observed by me the inflamma- tion and enlargement seemed to be strumous. Baumler says : " Dactylitis syphilitica does not always originate in the bone ; similar appearances may be produced through gummous formation in the sheaths of the tendons and in the fibrous structure of the finger;" and again, " Its outward appearance may be produced also by tuberculosis, enchondroma, or sarcoma of the bone- marrow " (art. " Syphilis,"' Ziemssens Encycl.). Mr. J. Hutchinson of London has called attention to the fact that hered- itary syphilis, having perhaps been manifested by the usual symptoms during infancy and then becoming latent, may give FlG - 41 - rise to new symptoms after the fourth year. The most noticeable of these symptoms is a dwarfing of the permanent incisor teeth, which are rounded and peg-like and their enamel notched at the free ends of the teeth. On account of the small size and shape of the teeth there are interspaces between them. This abnormal development is most marked in the central incisors of the upper jaw, and in certain cases it is limited to them, and it never appears in the other incisors unless it does also in them. Another symptom, which only appears in hereditary syphilis, is an interstitial keratitis occurring on both sides and attended by the deposition of fibrin in the substance of the cornea. In a few weeks the inflammation declines, but a slight opacity of the cornea remains. The cerebral nerves may become affected, usually a single pair — if the auditory, deafness resulting ; if the optic, dimness of sight. Occasionally there are other manifestations of syphilis in this period, as enlargement of spleen and liver and nodes upon the long bones. Prognosis. — This depends in great part on the general condition of the patient. If there be much emaciation and the symptoms indicate a deeply- seated cachexia, a considerable proportion of the patients perish. On the other hand, if the general health be not greatly impaired, although the local affections are pretty severe, the prognosis with correct treatment is good. The younger the infant when the symptoms of syphilis appear, the more unfavorable, as a rule, is the prognosis. Treatment. — Parents who beget syphilitic children ought, from a due regard for their offspring to make use of antisyphilitic remedies, although they present in their persons no evidences of syphilitic taint. A good pre- scription for the parents is one-sixtieth of a grain of corrosive sublimate in the compound tincture of bark, given twice or three times daily for several months. If the father have had syphilis, both parents should be subjected to this treatment, and it may be continued, at least on the part of the mother, during the first months of her gestation. So small a dose of the mercurial does not, in my opinion, materially increase the liability to miscarry. There is much more danger of miscarrying from allowing the syphilitic taint to remain uncontrolled. Some prefer the use of mercurial ointment in the treatment of pregnant women having syphilis, in the belief that it is less likely to produce abortion. It is used for this purpose in the proportion of one drachm to the ounce. It is equally effectual in the eradication of the syphilitic taint with the small dose of corrosive sublimate recommended above for internal administration ; but it is impossible to determine the quantity of SYPHILIS. 239 mercury which enters the circulation when inunction is employed and saliva- tion is more likely to occur. The following is, however, probably the best prescription for the treatment of parents infected by the syphilitic virus. It should be given for several months : Or R. Hydrarg. biniodidi, Rt. j ; Liq. potassii arsenit., 3J; Tine, belladonnse, 3y ; Potassii iodidi, .Iss; ad 5iv.— M. Aquae, q. s. Dose : One teaspoonful three times daily after the meals. R. Yini, s v J; Pepsini pari in lamellis, 3ij; Potassii iodidi, 3y ; Liq. potassii arsenit., 3y; Hydrarg. biniodidi, g r - j ; Qui. et ferri citratis, 3*j ; Syr. simplic., gij; 01. anisi, gtt. iij. — Misce. Dose : One dessertspoonful three times daily. The nutrition of the infant that has unfortunately inherited the syphilitic taint requires special attention. Besides exhibiting the characteristic symp- toms of the disease, it usually suffers from innutrition, and sometimes passes into a state of decided marasmus. The mother who has given birth to a syphilitic infant should, if possible, wet-nurse it. Even if she never has exhibited any symptoms of the disease in her own person, she cannot contract syphilis from her infant. Colles wrote as follows in 1837 : " One fact well deserving our attention is this : that a child born of a mother who is with- out obvious venereal symptoms, and which, without being exposed to any infection subsequent to its birth, shows this disease when a few weeks old, — this child will infect the most healthy nurse, whether she suckle it or merely handle and dress it ; and yet this child is never known to infect its own mother, even though she suckle it while it has venereal ulcers of the lips and tongue." This remarkable law relating to the immunity of mothers has been fully accepted by all subsequent syphilographers. On the other hand, a wet- nurse employed to suckle a syphilitic infant is very liable to contract the dis- ease, through her nipples, from the infected lips of the infant. If a wet-nurse be employed for such an infant, she should be aware of the risk she incurs, and should protect herself by the use of an artificial nipple. At the same time, the infant should be placed fully under antisyphilitic treatment. Arti- ficial feeding, though usually disastrous, is preferable to the propagation of the disease to a healthy wet-nurse. Syphilis in the infant requires mercurial treatment as in the adult. Mer- cury may be employed internally or by inunction. Some prefer inunction in the treatment of ordinary cases in the manner recommended by Sir Benjamin Brodie. " I have spread," says he, " mercurial ointment, made in the pro- portion of a drachm to an ounce, over a flannel roller, and bound it round the child once a day. The child kicks about, and, the cuticle being thin, the mercury is absorbed. It does not either gripe or purge, nor does it make the gums sore, but it cures the disease. I have adopted this practice in a great many cases with the most signal success." The oleate of mercury, 10 per cent., is a better preparation for inunction. Five drops may be rubbed in three times daily. Trousseau, on the other hand, discountenances the use of inunction, since mercurial ointment applied to the skin produces irritation 240 CONSTITUTIONAL DISEASES. and increases the suffering and restlessness of the child. He prefers the fol- lowing solution, which is known as Van Swietens, for internal treatment : R. Hydrarg. bichlorid., 1 part ; Aquae, 950 parts ; Spts. rectific, 100 parts. — Misce. Dose : One or at most two grammes (15.434 to 30.868 grains), in milk, daily. In order to avoid the risk of establishing a diarrhoea, and to leave the stomach free for the employment of other medicines, as cod-liver oil and the iodide of iron, I prefer and commonly prescribe for infants inunction with the mercurial ointment diluted with eight times its quantity of lard, cold cream, or vaseline. It should not be applied as a plaster, but a quantity of the size of a large chestnut should be rubbed three times daily upon the neck or breast of an infant of three or four months. For children over the age of eight or ten months, Van Swieten's or one of the following formulae may be employed : R. Hydrarg. cum creta, gr. iij-vj ; Sach. alb., 9j. — Misce. Divid. in chart. No. xii. One powder three times daily. R. Hydrarg. chlor. corros., gr. ss-j ; Syr. sarsse. comp., 31J ; Aquae, o vn J- — Misce. Dose : One teaspoonful three times daily. R. Hyd. chlor. corros., gr. ss ; Potas. iodid., gj ; Ferri et ammon. citrat., gj ; Syr. simplic, ^vj. — Misce. Dose : One teaspoonful three times daily for a child of three to five years. R. Hyd. chlor. corros., gr. j ; Potas. iodid., gij ; Syrup, simplic, Aquae, da. ^ij. — Misce. Dose : Six drops three times daily for a child of three months. Prof. A. Jacobi recommends, in the treatment of syphilis of the newly- born, one-twentieth of a grain of calomel, to be given three times daily. An important advantage of its use is the rapidity and certainty of its action. Mercury, in whatever way employed, should not be discontinued entirely till several weeks after the syphilitic symptoms have disappeared ; it is proper to continue it for a time, in diminished quantity and fewer doses, after the health seems fully restored. When the mercurial treatment is omitted tonics are often required. The preparations of cinchona are useful in certain cases, as are also those of iron. If the patient remain feeble and pallid, presenting evidences of struma, cod- liver oil and syrup of the iodide of iron will be found beneficial, continued for some weeks or months after the mercury is discontinued. Attention should always be given to cleanliness and the hygienic management of the patient. In some instances direct treatment of the local affection is serviceable. To aid in the cure of syphilitic coryza the following ointment should be applied within the nostrils by a nasal sponge three times daily : R. Ung. hydrarg. nitratis, £ij ; Ung. zinci oxidi, Jij. — Misce. SYPHILIS. 241 Recently I have been in the habit of employing Squibb's oleate of mer- cury, 2 per cent., for syphilitic coryza of infants, and the effect has been satisfactory. It may also be employed by cutaneous inunction in the treat- ment of the general disease. Condylomata or mucous patches seated upon the cutaneous surface should be dusted with calomel. At my clinique in April, 1871, a child two years and ten months old was presented, with a large condylomatous outgrowth near the anus. The history of the child showed that in all probability the disease had been contracted within a year from syphilitic children in one of the public institutions. Within three weeks this affection disappeared by dusting upon it calomel once daily, with appropriate internal treatment. The infant should be kept clean by bathing it in tepid water twice daily, and excoriations upon its lips or mucous patches should be bathed before the nursing with some mild disinfectant solution, as boric acid. The best pos- sible hygienic conditions should be provided for the infant, since cachexia is commonly present. It should be taken outdoors frequently in suitable weather, and its removal from the city to the country, especially in hot weather, may be advisable. The cachexia which remains after the disappearance of the syphilitic manifestations requires the use of tonics, as cod-liver oil and syrup of the iodide of iron. Syphilitic symptoms may reappear during childhood. The exanthemata rarely appear at this age when the proper treatment has been employed in infancy, but condylomata and gummy tumors may, and they require a return to the mercurial treatment. If the bones are affected the iodide of potassium is the proper remedy. It causes the disappearance of the periosteal pains and swelling, and manifest improvement in the symptoms generally. 16 SECTION" II. ERUPTIVE FEVERS. CHAPTER I. MEASLES. The disease known in the vernacular as measles has also the names rubeola and morbilli. It is a common exanthematic affection occurring at any age, but most frequently in childhood. It affects once the majority of mankind. Writers recognize three stages of measles : first, that of inva- sion, which ends with the appearance of the eruption ; secondly, the eruptive stage ; and, thirdly, the stage of decline or desquamation. Etiology. — Micrococci have been found in the blood of rubeolar patients by Coze and Feltz. Keating also discovered them during an epidemic of malig- nant measles (Phila. Med. Times, Aug. 12, 1882), and Ransome, Braidwood, and Vacher found them in the breath of patients as well as in their tissues (Brit, lied. Journ., Jan. 21, 1882). It seems probable that they are the specific principle ; if so, they remain dormant in the system about twelve days, which is the incubative period. Additional observations are required in order to determine positively whether this micrococcus be the causal agent in measles, or whether it may not be some other microbe. Symptoms. — This disease commences with such symptoms as usually occur in mild but pretty general inflammation of the air-passages — to wit, cough, fever, anorexia, and thirst. The eyes present a suffused, moderately injected, and brilliant appearance, and the buccal and faucial surfaces are injected. The Schneiderian membrane and that lining the larynx, trachea, and bronchial tubes participate in the increased vascularity. The cough at first is dry, and sometimes distinctly croupy. Catarrhal or false croup, indeed, is not infrequent in the initial period of measles. The cough is attended with slight acceleration of respiration and by little or no pain in the respiratory movements. If auscultation be practised at this early stage, we observe the vesicular murmur, somewhat harsh in character, and sometimes sonorous and sibilant rales. A little later rales of a moist character appear. The patient, if old enough, commonly complains of headache and of dull pain in the epigastric region or the centre of the sternum, due to the bron- chitis. With these local symptoms febrile reaction occurs. The temperature rises to about 102° or 103°, as indicated by the thermometer in the axilla. The pulse numbers from 110 to 130 per minute. The febrile movement is greater than in primary tracheo-bronchitis, except when the bronchitis extends to the bronchioles, but it is less than in most cases of scarlet fever. The fever in the premonitory stage of measles after the first day is not uniform. It is attended by remissions and exacerbations, the former occur- 242 MEASLES. 243 ring in the first part of the day, the latter in the evening. Sometimes two exacerbations occur in the day. The face is flushed and somewhat swollen, especially during the times of increase in the fever, and the child is drowsy or restless. Vomiting, so common a symptom in the commencement of scarlet fever, occasionally occurs in measles. While in scarlet fever this takes place in the first twenty-four hours, in measles it takes place with about equal fre- quency at any period previously to the eruption. It was present during the first stage, sometimes almost as late as the eruptive period, in 13. and was absent in 23 cases in which I preserved records in reference to this symptom. The duration of the first stage varies in different cases. It is usually from two to five days, with an average of about four. Occasionally it is more pro- tracted on account of some disturbance in the economy, either from exposure to cold or other cause, which prevents the necessary afflux of blood toward the surface and retards the eruption. In 18 cases in my practice in which the duration of the cough previously to the appearance of the rash was accu- rately ascertained, the time varied from one to five days, with an average of three and one-third; in 10 other cases it had continued, the parents stated, about a week; and in 5, from one to two weeks previously to the eruption. The eruption commences, when the disease pursues its normal course, upon the forehead and neck, then the face, and gradually extends downward, occu- pying from twenty-four to thirty-six hours in passing over the trunk and limbs. It appears first as indistinct red points, not more than a line in diam- eter, which increase in size and become more distinct. Their borders are uneven or irregular or they are finely notched ; their general shape is, how- ever, circular, except as two or more unite, when they may assume any form. The crescentic form which writers describe is due to the union of two points of eruption. The largest of these points, when there is no coalescence, do not exceed a quarter of an inch in diameter, and many are much smaller. Frequently in plethoric children, if there be much fever, there is continuous redness over several inches of surface. The eruption is then confluent. This form is often observed upon the parts of the surface where the capillary cir- culation is most active when it is discrete elsewhere. In some of these cases diagnosis of measles from scarlet fever is attended with difficulty. The rubeolous eruption is slightly elevated, the elevation not being appre- ciable to the sight, but it can be ascertained by passing the finger over the skin, when roughness is felt at the point of eruption. Sometimes the eleva- tion, especially in the commencement of the efflorescence, is not appreciable, even to the touch. The eruption is broad and flat, never acuminate, never changing its form to the vesicular or pustular. It disappears by pressure, and immediately reappears when the pressure is removed. It has been com- pared in appearance to flea-bites. Small, pointed, papular, vesicular, or pustu- lar eruptions are sometimes seen in connection with those of measles, but they are accidental, occurring in other states of the system as well as in measles, if there be the same augmented temperature. In the commencement of the eruptive period the severity of the consti- tutional and local symptoms increases. The pulse and temperature corre- spond with the character which they presented during the exacerbations of the first stage. The features are slightly swollen; the eyes still watery and sensitive to light ; the conjunctiva, ocular and palpebral, and the mucous membranes of the cavity of the mouth and of the air-passages, continue injected. The tongue is covered with a moist thin fur, and its papillae are prominent, though less so than in scarlet fever. The cough continues fre- quent, and is seldom attended with much expectoration in uncomplicated cases; often there is no expectoration whatever. The appetite is lost, but drinks are readily taken on account of the thirst. Diarrhoea sometimes 244 CONSTITUTIONAL DISEASES. occurs on the first day of the eruption, but it lasts only a few hours, and, if the disease pursue its usual course, abates of itself. With the exception of this the bowels are regular or a little constipated during the. eruptive period. On the second day of the eruption, or sixth of the fever, the symptoms begin to abate. The pulse is less accelerated and the temperature diminishes ; the cough is less frequent and is easier, and the flushed and swollen appear- ance of the face declines. By the close of the third or on the fourth day the rash has disappeared in the order in which it extended over the body. There only remain faint maculae, which in the course of a day or two fade completely. With the disappearance of the rash the fever nearly or quite ceases, but a slight and painless cough continues for several days. Occasionally the eruption presents a livid appearance ; this is the rubeola nigra of writers. From cases which I have observed it is my opinion that this should not be considered a distinct species in the vast majority of patients, but that the dark color is due to internal inflammation, usually capillary bronchitis or pneumonia, which prevents full decarbonization of the blood. Rarely, rubeola nigra is due to the vitiated state of the blood or the malignant nature of the disease. The course of the eruption in this form of measles is somewhat different ; it continues longer, fades more slowly, and does not disappear so readily on pressure. Traces of it are observed a week or more after its first appearance ; it is likely to be fatal. Measles may pre- sent this form from the beginning, or, commencing as vulgaris, it may pass into rubeola nigra, Measles may be irregular in form, but aberrations are less frequent than in scarlet fever. Writers describe measles without catarrh, and, on the other hand, with catarrh, but without the rash. But positive diagnosis in such cases must be difficult. It is probable that simple catarrh and roseola have sometimes been mistaken for the two forms of irregularity mentioned ; but when a child in a family of children affected with measles presents all the symptoms of that disease except the catarrh or except the eruption, the diagnosis of irregular measles would, as a rule, be correct. Occasionally the stage of invasion is very short or even absent. In one case the parents informed me that the catarrhal symptoms began on the day when the eruption appeared. Convulsions sometimes occur at the commence- ment of measles, as well as during its progress. A single convulsive attack at the commencement is usually not dangerous ; when repeated it is more serious; it is also more serious when it occurs in the course of measles. In certain patients the eruption appears in an irregular and partial manner, occurring perhaps at a late period, and indistinctly, upon the trunk alone or upon the trunk and partially upon the legs. In many cases of deferred or partial eruption there is internal congestion or inflammation of some part, which causes withdrawal of blood from the surface, and thus prevents the normal development of the rash. When the eruption disappears the third stage commences, that of de- squamation. It is characterized by a scanty furfuraceous exfoliation of the epidermis. The desquamation is seldom as great as in scarlet fever, and it occurs most where the eruption has been thickest and the epidermis most inflamed. Exfoliation occurs between the fourth and seventh days after the commencement of the eruption, the eighth and the eleventh of the disease. Frequently it does not take place, or is so slight as not to be observed. With the disappearance of the rash the symptoms rapidly abate. The pulse becomes more natural, the temperature is reduced, the digestive organs MEASLES. 245 return to their normal state-, and convalescence is established. The cough continues several days after the other symptoms abate, but it is less and less frequent, and is not painful. Complications.— The complications of this disease are important. Much of the success of the physician in the management of measles depends upon a correct diagnosis and understanding of them. The most frequent of these complications are bronchitis and broncho-pneumonia. Slight bronchitis is uniformly present in measles, but if it increase so as to cause embarrassment of respiration and become a source of danger, it is properly a complication. This complication, as well as pneumonia, may occur at any period of measles, but it commences most frequently in the first stage. Occurring in the first stage, it may prevent the regular appearance of the rash ; if in the second stage, it often causes retrocession of it. When bronchitis becomes really serious it usually has invaded the minute bronchial tubes. This disease, designated capillary bronchitis or suffocative catarrh. I have elsewhere described. The clinical history of fatal bronchitis as a complication of measles is as follows : The respiration, at first not notably altered, becomes by degrees accelerated and the patient more and more fret- ful. The pulse, instead of becoming less accelerated, as after the first days of simple measles, is daily more rapid and the respiration more frequent and labored. The dyspnoea gradually increases, the inframammary region is depressed during each inspiration, and the subcrepitant rale is heard on both sides of the chest. There is probably collapse or inflammation of some of the lobules. Finally, the prolabia and fingers become livid, and death occurs from apnoea. Capillary bronchitis, occurring as a complication and continuing as a sequel of measles, usually becomes a broncho-pneumonia. A large propor- tion of those affected under the age of three years die. The anatomical cha- racters of fatal bronchitis occurring in connection with measles we have had frequent opportunities to inspect in the Foundling Asylum and Infant Asylum. In some cases there have been evidences of continuous inflammation from the epiglottis downward, ending in lobular or broncho-pneumonia. Broncho- pneumonia as a complication does not differ materially from the idiopathic inflammation, except that it is more protracted and fatal. The next most frequent serious complication of measles is entero-colitis. This may commence at any period during the course of the disease. If the colon be more especially the seat of inflammation, the evacuations contain mucus and blood, unless in young children, in whom the stools, even in severe colitis, commonly have a green color. The anatomical character of this complication varies in different cases, like the idiopathic form of inflam- mation. Sometimes there is simple arborescence of the intestinal mucous membrane, with tumefaction of its follicles ; in other cases, in addition to increased vascularity, the mucous coat is softened and thickened ; and in others still, especially if the inflammatory action has been protracted, ulcer- ation occurs, for the most part in the site of the solitary glands. Excep- tionally, in fatal cases of measles attended with diarrhoea, no vascularity is observed after death, although the intestines may be thickened and softened. In such cases the diarrhoea was probably inflammatory, the injection of the vessels having disappeared after death. Severe and obstinate diarrhoeal affections occurring with measles usually commence as the primary disease is about declining. They then become sequelae, ending fatally in many instances, especially in the summer months, several days or perhaps weeks after the disappearance of the eruption, Diarrhoeal attacks occurring in or previously to the eruptive stage arc. as a rule, mild and easily relieved. In some grave cases measles have a tendency from the first to affect the 246 CONSTITUTIONAL DISEASES. internal organs more than the surface. Bronchitis, pneumonia, and entero- colitis may coexist with indistinctness of the eruption on the skin. Such complications render a fatal result highly probable. Eclampsia is also an occasional very dangerous complication. It some- times occurs very suddenly and unexpectedly. A child of five years, in my practice, apparently progressing favorably with measles, was allowed to sit at dinner with the family ; suddenly and without premonition eclampsia occurred, the rash receded, and notwithstanding vigorous treatment death resulted in a few hours. Eapidly-developed cerebral congestion seemed to be present. To prevent such a complication the patient should remain quiet in bed dur- ing the eruptive stage. Another very fatal complication and sequel is pseudo-membranous laryn- gitis, commencing when rubeola is beginning to decline ; but it is less frequent than pneumonia or entero-colitis. In catarrhal or false croup — which, as has been previously stated, is not infrequent at the commencement of measles — the cough has a loud, ringing character. In membranous laryngitis, on the other hand, it is hoarse or harsh and less distinct, on account of the presence of the pseudo-membrane in the larynx. This form of laryngitis, always a grave disease, is more serious when it occurs as a complication of measles than when it is idiopathic, not only because the blood is vitiated and the system reduced by the primary affection, but because the inflammation of the mucous surface is in general more extensive, as is also the pseudo-membrane. This membrane in the croup of measles often extends so far down the air-passages that neither intubation nor tracheotomy can produce any decided ameliora- tion of symptoms. This complication, though always grave, is not, however, necessarily fatal. I have known cases recover by inhalation of solvent sprays when for days there had been dyspnoea and other evidences of a pretty firm pseudo-membrane. True croup causes continuation of the fever, which had perhaps begun to abate. Diphtheria, when epidemic, also frequently complicates measles. Much of the mortality from measles in this city since the year 1858 was due to this cause. In cases observed by myself, diphtheria usually began while the fauces were still inflamed, and sometimes before the eruption had begun to fade. The pseudo-membranous laryngitis or true croup mentioned above is, in most instances, in localities where diphtheria prevails, a local manifestation of this disease. These are the most common complications of measles. There are others of less frequent occurrence, among which may be mentioned stomatitis, pha- ryngitis, and otitis sufficiently severe to be considered complications. Rarely, also, purpura, attended by hemorrhages from the different mucous surfaces, occurs in connection with measles. This complication is, however, more fre- quent in certain other constitutional diseases, as scarlet fever, and especially variola. It is seen that the inflammations which occur in the course of measles are chiefly of the mucous surfaces. In scarlet fever, on the other hand, the inflammations are more frequently of serous surfaces. There are other affections originating in measles which are rather sequelae than complications. Gangrene of the mouth is one which, as stated in another part of this book, occurs more frequently after measles than any other disease. After a severe epidemic of measles in the New York Foundling Asylum in 1874 three cases of gangrenous vulvitis occurred in those who had been affected. Ophthalmia commencing in measles often persists for weeks or months. It may give rise to granulation of the lids, and cases have been reported of violent inflammation of a purulent character producing ulcera- tion of the cornea and destroying vision. The ophthalmia is sometimes very MEASLES. 247 intractable. Inflammation of the Schneiderian membrane, commonly present during measles, often continues as a sequel, extending back as far as the Eustachian tube, where it may cause swelling, with impairment of hearing, and forward to the lip, where it may produce chronic eczema. Prof. Moos has described the lesions which occur in the labyrinth in measles when the ear is affected. Cells and coagulated lymph fill the semicircular canals and the cochlea, and collect in the lymphatics. The blood-vessels in the Haversian canals and in the spiral ligament are nearly destroyed. The nerves become gelatinous and atrophied ; the muscular fibres undergo waxy degeneration. Notwithstanding such lesions, permanent deafness is rare and reparation seems possible (Congress at Wiesbaden, Sept. 22, 1887). Anatomical Characters. — I have made or witnessed, mainly in insti- tutions, a considerable number of post-mortem examinations of those who have died in or after an attack of measles. In all there were lesions due to complications. Indeed, death directly from measles is so rare that few have had an opportunity of studying the anatomical characters apart from the complications. In those who have died without any obvious coexisting dis- ease — and these cases chiefly occur in the malignant form — there has been congestion of the internal organs, especially marked in the lungs, and some- times the tissues appeared softened. The blood also in the malignant form has a darker hue than natural, and ecchymotic patches have been observed upon the mucous surfaces and elsewhere, corresponding in character with the petechiae under the skin which sometimes occur in this form of measles. In cases resulting fatally from bronchitis or pneumonia the bronchial glands are commonly tumefied in the same manner as the mesenteric glands are enlarged in enteritis and the glands of the mesocolon in dysentery. Nature. — Rubeola, like the other exanthematic fevers, is due to a mate- ries morbi, probably micrococci, as has been stated above. It is highly con- tagious through the air. It has been inoculated by the serum from vesicles which sometimes occur in connection with the rubeolous eruption, and also by the blood from a patient. Inoculation does not appear to moderate the disease, and as measles, when contracted in the ordinary way, is not in itself dangerous, but dangerous only from complications, inoculation is not per- formed except as a matter of scientific interest. The usual mode of propa- gation is through the air. Measles is communicated by the breath and prob- ably by exhalations from the surface. Under whatever circumstances it occurs, the specific principle has been communicated from some infected person. We frequently meet cases, as in a sparsely-settled district that has come to my knowledge, in which exposure cannot be traced. Yet the im- munity of certain islands for centuries till infected through commerce renders the doctrine of an origin de novo improbable. Twelve to fourteen days elapse from the time of infection to the com- mencement of the eruption. In cases observed in the children's department of Charity Hospital the incubative period was ascertained to be about twelve days. In those who have been inoculated the incubative period is said to have been about one week. Rubeola prevails epidemically, like the whole class of infectious diseases, and in different epidemics the type may vary as well as the character of the complications. Diagnosis. — The diagnosis of measles previously to the eruption is often difficult. The catarrhal symptoms then predominate, and these are such as may occur independently of any constitutional or blood disease. The first stage, therefore, is not infrequently mistaken for corvza or mild bronchitis. The points of differential diagnosis are the suffused appearance of the eyes. the greater degree of fever on the first day than would be likely to arise from so moderate an amount of local disease, and morning remission and evening 248 CONSTITUTIONAL DISEASES. exacerbation of the fever. Measles in the first stage has been mistaken for remittent fever. The catarrhal symptoms should prevent such an error. Sometimes roseola closely resembles measles in appearance, but the rash of roseola appears within a few hours after the commencement of febrile symptoms, and almost simultaneously over the whole body, and without those local symptoms referable to the mucous surfaces which characterize measles. Variola on the first clay of the eruption has sometimes been diagnosticated measles. I recollect once being called to an infant with fatal confluent small- pox who was said to have measles. A physician a few days previously, observ- ing the red points in the commencement of the eruption, had made this absurd diagnosis, and, predicting a favorable result, had not thought it necessary to repeat his visit. In case of doubt it is the part of prudence to defer making a positive diagnosis. A few hours suffice to show the distinctive characters of rubeolous and variolous eruptions. But the anxiety of friends often neces- sitates the expression of opinion. The absence or lightness of catarrhal symp- toms, the earlier appearance of the eruption, and its papular feel under the finger in smallpox, enable us to discriminate between the two diseases in the commencement of the eruptive stage. Moreover, the symptoms in the initial periods are different, as will be seen in our description of smallpox. Prognosis. — This is favorable, provided that no serious complication arises. With internal inflammatory complication, on the other hand, the disease becomes much more grave. A large proportion thus affected die. The prognosis is less favorable in feeble children with scanty eruption or an eruption appearing at a late period and irregularly. Dyspncea, persistent and great acceleration of pulse, and coma indicate an unfavorable ending. Con- vulsions occur much more rarely in the course of measles than in scarlet fever, and when they occur after the initial period they usually end in coma and death. The mortality from measles varies greatly according to the severity of the type, but more according to the season, the locality, the sur- roundings, and the care which the patients receive, which determine the lia- bility to complications. Thus in the cities the mortality is large from measles in the hot months among infants, who at this time are very liable to gastro- intestinal catarrh. It also seems to be larger in the asylums than in family practice. In epidemics in Boston and Pont de l'Arche the mortality was 5 per cent, of the cases, in Neufchatel, Switzerland, 2 per cent., and among the Sioux Indians, at Crow Creek Agency, Dakota, 6.66 per cent. (Therapeutic Gaz., July 16, 1888). Treatment. — Uncomplicated rubeola requires little medicinal treatment except to palliate symptoms. The child should be kept in an airy apartment at a uniform temperature of about 70°. A temperature so elevated as to be uncomfortable to the nurse is injurious to the patient. But while the popular idea is erroneous that he should be kept in a heated atmosphere, it is correct that currents of air and sudden reduction of temperature are dangerous. A violent and fatal attack of croup occurred in my practice in a girl of fifteen in consequence of exposure at an open window at the close of the eruptive stage. The diet should be mild, and for the most part liquid. The patient, indeed, refuses solid food, but on account of the thirst takes liquids more readily. Farinaceous substances, with milk, afford sufficient nutriment in ordinary cases. If the previous health have been poor and the vital powers reduced, or if there be a complication, more sustaining diet is required. Stimulation by wine or brandy is needed in these cases. During the two or three weeks succeeding an attack of measles care should be taken to avoid exposure to cold or changes of temperature, since during this period there is great liability to inflammations of the mucous surfaces. MEASLES. 249 The cough ordinarily requires treatment, inasmuch as the suffering of the child and loss of sleep are largely due to this symptom. Demulcent drinks, as flaxseed tea. infusion of slippery-elm bark, or solution of gum Arabic, are useful, to which, to render them more palatable, lemon-juice may be added. A small Dover's powder or the mistura glycyrrhizae composita of the Pharma- copoeia, given occasionally, relieves the severity and diminishes the frequency of the cough. As the chief danger in measles is from inflammation of the respiratory organs, local treatment directed to the chest is important. The chest should be covered with cotton wadding or in cold weather even oil-silk, unless in the mildest cases. This increases the amount of eruption upon the surface underneath, and, I believe, tends greatly to prevent complication by capillary bronchitis and pneumonia. If the eruption be tardy in its appearance or indistinct, it is well to produce moderate counter-irritation by some gentle irritant underneath, as camphorated oil, to which in older children a little turpentine may be added. Affections which complicate measles should receive, for the most part, such treatment as is appropriate for them when idiopathic. Secondary dis- eases, however, require sustaining measures more than primary. In bronchial and pulmonary inflammations — which if they occur early in measles, prevent the regular appearance of the eruption, or if in the eruptive stage cause its disappearance — prompt counter-irritation over the chest by sinapisms or other- wise is required. Trousseau states that he has derived benefit in these cases from what he designates urtication. This is produced by stroking the chest two or three times daily with the nettle (Urtica dioica or Urtica wrens). This causes a prompt and abundant eruption, and with a less amount of suffering than one would suppose. The fever abates, and the respiration becomes more natural in proportion to the amount of nettlerash. On the second day the effect is less than on the first, and after three or four days, says Trousseau, no further irritation results from the nettle. When counter-irritation is pro- duced, by whatever method, the chest should be covered with a warm and soft poultice, as the ground flaxseed ; derivatives to the extremities are useful in such cases. In capillary bronchitis and pneumonia stimulating expectorants are required, as carbonate of ammonium. I frequently write the following prescription. It is useful both as an expectorant and cardiac stimulant. Given in milk or after food is taken, it does not produce gastritis, as it often does in a more concentrated form : R. Ammon. carbonat., gr. xvj-^ss ; Aquae purse, ^ij. Give one teaspoonful in three or four of milk every hour or two. Chloride of ammonium is also a good remedy in these cases, employed in double the dose of the carbonate. Quinia to reduce the fever and digitalis or strophanthus or camphor as a heart tonic are also very useful in these inflammations, given alone or alter- nately with the above. The cases of gangrenous vulvitis alluded to above were treated with a flax- seed poultice, and iodoform dusted over the surface each day or second day. with a satisfactory result. As regards the treatment of other complications the appropriate measures are detailed elsewhere. 250 CONSTITUTIONAL DISEASES. CHAPTER II. SCARLET FEVER. It is supposed by some who have studied the history of scarlet fever that it is of ancient origin, but the descriptions of diseases left us by the old writers, and by those in the Christian era until after the Middle Ages, are so obscure or differ so widely in the statements made from the symptoms of scarlet fever as it occurs in modern times that the impartial critic fails to find any clear evidence of its occurrence prior to the last four or five centuries. The first clear and undoubted portrayal of this disease is found in the medical literature of the sixteenth century. Sydenham and his contemporaries in the seventeenth century witnessed epidemics of it and studied its nature more thoroughly, and consequently acquired a more accurate knowledge of it than that possessed by their predecessors. It was in this century that measles and scarlet fever were differentiated. During the last two hundred years scarlatina has been the subject of monographs too numerous to mention. It has long been regarded as one of the most important maladies of childhood, on account of its frequency and the great mortality that attends it, so that numerous cases and many epidemics are every year related in the medical journals. By this vast accumulation of observations and the patient and thorough use of the microscope our knowledge of scarlet fever has become full and accurate. As with most of the infectious maladies, scarlet fever was introduced into the Western Hemisphere by European navigators. It was brought to North America about the year 1735. Tardily it spread to South America, where it appeared in 1829, and more recently it has been established in Australia. It entered Iceland in 1827 and Greenland in 1847. Etiology. — As yet, observers do not agree in regard to the parasite which is supposed to sustain a causal relation to scarlet fever. Klebs states that it is highly probable that both measles and scarlet fever are produced by micrococci, and he has sketched the design and described the development of a microbe which he designates the Monas scarlatinosum. The London Medical Times and Gazette for Jan. 28, 1882, contains an account of the supposed discovery of the scarlatinous microbe by Eklund of Stockholm, an authority in the microscopic examination of parasites. He says that scarlet fever is rarely absent from the Swedish capital and from the barracks and dwellings on the Isle of Skeppsholm. In the urine of scarlatinous patients he has constantly found a prodigious number of discoid corpuscles, oval or round, their diameter being less than i^^oo millimetre, and from -^ to ^ that of a red blood-cell. They are colorless or yellowish-white, surrounded by a distinct cell-wall, each containing a well-defined nucleus of a deeper hue. Sometimes one, sometimes more, of them are seen in the field of the microscope. They exhibit rotary or oscillatory move- ments, especially observed when a drop of water is added to the fluid. In 1886, Dr. Edington of Edinburgh isolated a diplococcus and a bacillus from the blood and epidermis of scarlatinous patients. He states that inoculation of the bacillus in rabbits caused erythema, followed by desquamation. But these obser- vations, as detailed in the Lancet, show possible sources of error, and have therefore attracted but little attention. Dr. E. 0. Shakespeare describes the bacillus scarlatinas of Edington as "rods measuring 0.4 m. in thickness and 1.2 m. to 1.4 m. in length, most usually forming excessively long-pointed and curved leptothrix filaments, motile ;" and he" remarks, " It is pretty well proven that this bacillus scarlatinse is the specific cause of scarlet fever." 1 1 Annual of Med. Sci., vol. v., 1888. SCARLET FEVER. 251 Whatever may be the micro-organism which causes scarlet fever, its mode of action and effects have been ascertained by clinical observations. Without doubt, it commonly enters the system by the breath, but it probably may enter in the ingesta, and it infects the blood. That it resides in the blood has been ascertained by inoculation with this liquid, by which scarlet fever has been reproduced in its typical form. From the blood it enters the tissues and secretions. Hence handkerchiefs or linen containing the saliva or mucus of a patient, the epidermic scales shed abundantly in the desquamative period, and probably also the urinary and fecal evacuations, contain the poison, so as to be highly infectious. Even the discharge of a scarlatinous otorrhcea is thought by some to be contagious for a considerable time. Scarlatina is communicable not only by direct exposure to a patient, but also by exposure to objects which happen to be in his room during his illness, and to which the poison becomes attached, such as clothing, books, and toys ; small packages, as we have stated above, sometimes convey and disseminate the contagious principle. Observations have been made which show that scarlatina has been communi- cated by infected milk. The following instance was published in a British journal : Scarlet fever occurred in the family of a milkman, and the milk, before it was dis- tributed, remained for a time in a kitchen which had been occupied by the patients. This milk was taken by twelve families, and in six of these scarlatina occurred almost simultaneously at a time when few cases were occurring in the locality. There had been no direct exposure to the carrier of the milk nor to members of the affected family (Taylor). In another instance a woman and her son had scarlet fever while they were serving milk to several families, and the disease appeared in all these families except one, which consisted of old people (Bell). It is known that milk absorbs volatile substances so as to be flavored by them, and is shown in the experiment of placing it in an open vessel in a box with a pineapple; and it may in a similar manner become infected by the specific principle of scarlet fever, or it may be infected by detached particles of epidermis ; which is not improbable when one convalescing from scarlet fever is allowed to milk the cows or prepare the milk for distribution. In 1885 an epidemic of scarlet fever in London was traced to the milk-supply coming from a certain dairy in Hendon. The health officer of Hendon discovered a contagious disease in the cows of this dairy communicable to healthy cows by inoculation from the teats, and also communicable to man. The symptoms in the cow were fever, cough, sore throat, discharge from nostrils and eyes. Com- municated to man, the disease produced malaise, and in four or five days a vesicle. Crookshank believes that the Hendon disease was the Jennerian cowpox, and the symptoms certainly bore a closer resemblance to cowpox than to scarlet fever. Probably, therefore, the scarlet fever in London originated from some other source (London Lancet). The scarlatinous virus surpasses that of any other eruptive fever except small- pox in its tenacious attachment to objects and its portability to distant localities. Hence in the literature of the disease are the records of many cases in which the poison was conveyed long distances, retaining its virulence to the full extent and causing an outbreak of the malady in the localities to which it was carried. In New York, so frequently has scarlet fever as well as measles and diphtheria been contracted from the persons or clothing of well children who come from infected houses, that the Health Board now exclude from the public schools all children who come from such houses, even though they live on separate floors from those occupied by the sick. In one instance that came under my notice a washerwoman whose child had scarlet fever communicated the disease to an infant in the house- hold where she was employed, by placing her shawl over the cradle in which it was lying. A physician of my acquaintance went from a scarlet-fever patient ro a family several streets distant, and took one of the children upon his lap. After the usual incubative period this child sickened Avith a fatal form of the malady, and the remaining children of the household were in time affected. In New York scar- let fever has seemed to me to be not infrequently communicated through school- books, which, profusely illustrated by pictures and rendered attractive to the young. are often allowed to lie upon the bed of a scarlatinous patient, and be handled by 252 CONSTITUTIONAL DISEASES. him during convalescence or even during the course of the fever if it be mild. The young librarian of the circulating library of a Sunday-school, whose pupils came largely from the tenement-houses, was occupied a considerable part of a day in covering and arranging the books. After about the usual incubative period of scar- let fever he sickened with the disease. His two sisters were immediately removed to a rural township three hundred miles away, and to an isolated house where scar- latina had never occurred. About one month after his recovery, and after his room had been disinfected by burning sulphur and his bedclothes and linen had been thoroughly washed, and all articles suspected to hold the poison had been either disinfected or destroyed, the brother visited his sisters in the country. Three weeks subsequently to his arrival one of these sisters sickened with scarlet fever, and a week later the other also. It seems that the exposure must have occurred several days after his arrival in the country from some books or other infected article in his possession. About two months elapsed after the last case : the family had returned to the city, the infected room in the country-house had been thoroughly fumigated by burning sulphur from morning till evening, when a little girl from an inland city remained a few days in this house, and probably often entered the room where the young ladies had been sick. In a few days she also sickened with a fatal form of scarlatina. Such histories and experiences are not infrequent. They are common during epidemics of scarlet fever. They indicate an extraordinary attachment of the scarlatinous poison to objects, and show that it is not gaseous nor readily volatilized. A striking example of this fixity of the poison occurred in the practice of the late Kearney Rogers, formerly a prominent and much-esteemed sur- geon of New York City. Six children in a family had scarlet fever. Three and a half months subsequently another child, living at a distance, was allowed to return home and occupy the apartment in which the sickness had occurred. One week subsequently to the date of the return this child sickened with the same malady. Elliotson states that a patient with scarlet fever was admitted into one of the wards of St. Thomas's Hospital, and for two years subsequently young persons who were admitted into the ward were apt to take the disease. Richardson of London relates the following experiences of a family whom he attended in the rural district : "At a short distance from one of our villages there was situated on a slight eminence a small clump of laborers' cottages, with the thatch peering down on the beds of the sleepers. A man and his wife lived in one of these cottages with four lovely children. The poison of scarlet fever entered the poor man's door, and struck down one of the flock." The remaining children were now removed some miles away, and after several weeks one of them was allowed to return. Within twenty-four hours he also took the disease, and quickly died. The walls of the cottage were now thoroughly cleaned and whitewashed, the floors scoured, and all the wearing apparel either destroyed or washed. Four months elapsed after the last sickness when one of the remaining children returned. " He reached his father's cottage early in the morning ; he seemed dull the next day, and at midnight I was sent for. to find him also the subject of scarlet fever. The disease again assumed the malignant type, and this child died." Richardson believes that the contagion was attached to the thatch, which could not be thoroughly disinfected. The fact of this remarkable long- continued attachment of the poison to objects, indicating by this fixity that it is a solid, is consonant with the theory that it is an organism. Incubative Period. — The duration of the incubative period varies in different cases. It is sometimes less than twenty-four hours, as in the above case reported by Richardson ; in the following well-known case, observed by Trousseau, it was one day : A girl arrived in Paris from Pau, where there was no scarlet fever, and occupied the same apartment with her sister, who was sick with this disease. Twenty-four hours after her arrival she was also attacked with the same malady. SCABLET FEVER. 253 Russeberger attended a child who was exposed at noon to scarlet fever, and took the disease on the following night. B. W. Richardson (Clinical Essays, 1S61. vol. i. p. 94) gives his own experience. He had applied his ear to the chest of a patient suffering from scarlet fever, and was conscious of a peculiar odor emitted from the patient. He was immediately nauseated and chilly, and from that moment he dated the beginning of an attack of scarlet fever. In the Transactions of the Clinical Society of London, vol. ix., 1878, the late Charles Murchison gives the statistics of 75 cases showing the incu- bative period, as follows : In 4 cases it was not more than . 24 hours. " 2 " " " " 30 " " 3 " " " " 36 " " 4 " " " " 40 " it j it a u u . 41 " " 4 " " " " 58 " " 1 " " " " 54 " " 1 " " " " m 2Jdays. " 31 cases it was within (time not accurately ascertained) ... 4 " " 2 cases the incubation did not exceed 4i " " 17 " " " " " 5 " n 9 " u " " " A " In 3 cases Murchison believes that the incubation was precisely fixed at thirty-six hours, three days, and four and a half days. Watson says that a man reached Devonshire at mid-day to see his daugh- ter, who had scarlet fever. Two days later he was also attacked. Rehn saw a child who was attacked two days after its grandmother returned from a case of scarlet fever ; and Zengerle, a girl of ten years, residing at Wangen, where there was no scarlet fever, who took the disease two days after her mother had returned from visiting a family affected with it. Loochner states that a boy aged four and a half years was attacked one and a half days after admission into the infected wards of an hospital. Armistead, in his annual report on the health of the Newmarket rural district, states that three chil- dren, coming from a different part of the district, visited Wesley, and stayed next door to a child who had had scarlet fever six weeks previously, and who was allowed to play with these children on the evening of August loth and morning of the 14th. The family then returned home, and on the 18th. four days after the exposure, all three children sickened with scarlet fever (British Medical Journal, September 30, 1882). Ordinarily, therefore, the incubative period, though varying in different cases, is within six days. Many cases, however, occur in which it seems to be longer. Thus, in my practice scarlet fever appeared in a family on April 26, 1882. The patient was immediately removed to the third floor and the other children to the basement. All communication between the infected room and the basement was forbidden, but on May 8th, twelve days alter the separation, one of these children sickened with the disease. Many observers. among whom may be mentioned Niemeyer and Copland, believe that the incu- bative period may be longer than one week, but on account of the subtlety of the poison and the many modes of transmission, it is possible that in the instances of an apparently long incubative period there were other and unsus- pected exposures. When scarlet fever has been communicated by inoculation, as in the experiments of Eostan and others, the incubative period has been about seven days, but Gerhardt states that a man was attacked four days after an abscess was opened by a knife used upon a scarlatinous patient. This variation in the incubative period, which also occurs in some other infec- tious diseases, as diphtheria, is probably due mostly to individual differences, 254 CONSTITUTIONAL DISEASES. some being more susceptible than others ; but it may be due partly to those obscure meteorological conditions which we designate the epidemic influence. Probably, as a rule, when the disease is quickly developed after exposure the attack is more severe than when several days elapse. Contagiousness. — The area of the contagiousness of scarlet fever is small : it apparently embraces only a few feet. Therefore, close proximity is the necessary condition of its propagation. Hence many who are exposed, particularly of those who are remotely exposed, do not contract the disease. There is also an idiosyncrasy in some children, so that they resist infection even when repeatedly and closely exposed. In the New York Medical Record for March 23, 1878, C. E. Billington states that of 90 children in 26 families who were exposed to scarlet fever, 43 contracted the disease and 47 escaped ; whereas, as is well known, comparatively few unprotected children escape pertussis, variola, varicella, or measles if exposed to either of these diseases. By strict isolation, therefore, the spread of scarlet fever is more easily pre- vented than that of most other acute infectious maladies. In the New York Foundling Asylum for a number of years children with scarlet fever were isolated in a small room attached to one of the wards. The door between the two rooms was closed, and not opened during the continuance of the sickness. Entrance into the small room was through another door, and a nurse was assigned to the scarlet-fever cases, with strict directions that she should not mingle with the other children. These simple precautions were found sufficient in the various epidemics of scarlet fever which occurred in the city to prevent the spread of the malady through this institution ; whereas, similar measures were much less effectual in arresting the spread of measles and pertussis. Consequently, an outbreak of scarlet fever in this institution was usually limited to a few cases, while the extension of measles and pertus- sis was arrested with difficulty till a more efficient quarantine was established. Variations in Type. — The type of scarlet fever varies greatly in different epidemics, and frequently also in cases which occur in the same epidemic, even in the same family. One child may have scarlatina so mildly that little treat- ment is required and convalescence soon begins, while another has the malig- nant form, and soon succumbs, notwithstanding the prompt employment of the most efficient and appropriate measures. Ordinarily, however, if the first case in a family be very severe, subsequent cases will present a similar type ; but there are notable exceptions. This variation in type in different years and different epidemics is probably not equalled in any other infectious malady. Consecutive epidemics may present this variation, or the same type may con- tinue for a series of years, and then, from some unknown cause, change to one milder or more severe. In England, during Sydenham's life, scarlet fever was so mild that he regarded it as a trivial affection, requiring little attention, like rbtheln of the present time ; but after the death of Sydenham, Morton and his contemporaries in London found, to their sorrow, that the type of scarlet fever was very different from that described by Sydenham's pen. The late Dr. Graves of Dublin and his contemporaries treated a mild type of scar- let fever with a very small percentage of deaths — much less than that during the preceding generation — and they attributed their success to their greater knowledge and more appropriate use of remedies than their ancestors pos- sessed and employed. By and by the type changed, the mortality of former years was restored, and they discovered that their previous success in saving life had been due not to their skill, but to the mild form of the malady. A distinguished physician of Xew York treated more than fifty cases of scarlet fever in one of the institutions without a single death. A few months after- ward the type of the malady changed, and his own son perished from it. The diseases known as surgical scarlatina and obstetrical scarlatina are certainly SCARLET FEVER. 255 at times a true scarlet fever, but it is probable that the pathological states to which these terms have been applied have in most instances been cases of septicaemia or blood-poisoning with accompanying dermatitis so common in surgical and obstetrical practice. The following were cases of the kind alluded to. They occurred in Guy's Hospital, and were published by H. G. Howse in Guy\s Hospital Reports for 1879 : On March 15, 1878, Jacobson performed osteotomy upon a child suffering from ex- treme rachitis. The operation was followed by a moderate febrile movement (100° to 101°). and after three days by the appearance of an efflorescence, with sore throat and the strawberry tongue. The osteotomy had been performed under carbolic-acid spray and with all the details of antiseptic surgery. The rash soon faded, the tem- perature fell, and the child, temporarily separated from the other patients from the suspicion that the disease was scarlet fever, was brought back to the ward. The subsequent history confirmed the diagnosis of scarlet fever, for the skin desqua- mated, and on April 1st abundant albumen was found in the urine. The case ter- minated favorably. Three months previously the same operation had been per- formed on the other leg, with no unfavorable symptoms. On April 5th, three weeks after the osteotomy, a lipoma was removed from another patient aged twenty-one years. The following day the temperature rose to 101°, and remained at that till April 8th. when it suddenly increased to 103°, and a rose-rash occurred over the body, with sore throat. On April 9th, Howse excised the elbow-joint of a girl of sixteen years having pulpy disease. On the 10th her temperature began to increase, and on the 11th reached 105.8°. Toward evening a roseoloid eruption appeared ovei her body, and she was isolated. On April 12th, Dr. H. excised a fibroid bursa patellae from a woman of twenty-nine years. On the following day her temperature was 99°, but on the 14th it rose to 100°, and on the evening of the 15th she had rigors and headache. On the morning of the 16th the temperature was 102.5°, and a roseoloid eruption occurred over the face and chest. The surgeons now perceived that an epidemic of the so-called surgical scarlatina was occurring, so as to justify the postponement of other operations. In the same volume of Guy's Hospital Reports, James F. Goodhart gives the histories of nearly thirty cases of this disease occurring during a series of years in the same hospital. The patients were chiefly children, having the most diverse surgical ailments, among which may be mentioned hip disease and abscess, genu valgum without operation, necrosis of femur, hydrocele with explorative operation, a scald, a sinus over the great trochanter, spinal disease with abscess, tenotomy for club-foot, and vesical calculus with operation. The most common disease was caries or necrosis with abscess. In cases operated on the intervals between the operations and the occurrence of the efflorescence varied from two days to more than two weeks. Goodhart, after a careful examination of these cases, came to the conclusion that they were for the most part examples of true scarlet fever, especially as a consider- able proportion of them occurred in groups, and there was a known exposure of some of the patients to children admitted into the hospital with the sequelae of scarlet fever. In the British Med. Jour, for Jan., 1879, George May, Jr., reported a case of efflorescence in surgical practice which appears to have been scarlatinous. A child was operated on for the radical cure of hernia on Dec. 4th. Toward the close of the same day he became restless, vomited, and his pulse on the following day rose to 136. Forty-eight hours after the operation a rash appeared on the chest and arms, the abdomen became tense and painful, and on the following day he died. The poison, however, in this case may have been septic. Hillier remarks {Diseases of Children): " In the hospital for sick children, of the children who contract scarlatina a very large proportion have been the subjects of a surgical operation within a week before the rash appears." Gee says (Rey- nolds's System of Medicine) : " It has been doubted by some whether the scarlatini- form rash which sometimes follows operations is really scarlatinal. The eruption appears from the second to the sixth day after the operation, and, in the eases which have caused the doubt, is very fugitive and the first and only symptom. Yet that the disease really is scarlet fever would seem to be proved by the following observa- tions : first, that the disease occurs in epidemics -, secondly, that in a given epidemic a severe case occasionally relieves the monotonous recurrence of the very mild form : thirdly, that a precisely similar scarlatinilla attacks in the same epidemic patients who have not been subjected to operation and who have no open sores ; and lastly. by way of a veritable experimentum crucis, that, however freely the patients are 256 CONSTITUTIONAL DISEASES. exposed to ordinary scarlet-fever contagion afterward, they do not contract that disease." Paget and other distinguished London surgeons who have observed this complication of surgical cases believe that the patients have been previously" exposed to the scarlatinous poison, and that the surgical diseases or operations furnish favor- able conditions for the occurrence of scarlet fever, so that the exposure, which prob- ably would have been without result in ordinary health, causes an outbreak of the malady. Those who have reported cases of this form of efflorescence have for the most part neglected to state whether the patients had had scarlet fever previously, know- ledge of which would have aided in the diagnosis ; but from an examination of the histories of cases, especially those published in the London journals in the last four or five years, there can, I think, be little doubt that surgical maladies of a certain kind, especially traumatism, do produce a state of system which predisposes to scarlet fever, so that this class of patients are especially liable to contract it. There- fore, in my opinion, a considerable proportion of reported cases of surgical scarla- tina are genuine, but in a considerable number, perhaps an equal number, of such cases the histories and symptoms indicated a septic rather than scarlatinous efflores- cence, and in not a few instances, when consultations have been held, opinions dif- fered, some diagnosticating scarlet fever, others septicaemia. In some of the cases I find it stated that the fauces presented the normal appearance. Now, faucial red- ness is so generally present in scarlet fever, antedating that of the skin and coex- isting with it, that its absence is strong evidence that the disease is not scarlatinous. Moreover, when, as was true of certain of the reported cases, the rash appeared irregularly upon the surface, and faded away in two or three days with the abate- ment of the fever, and the conditions of septic absorption were present, the efflores- cence was probably septicsemic. The following were apparently cases of septicEemic efflorescence : A child aged five years {Brit. Med. Jou?\, Feb. 15, 1879) had inflammation of the lymphatic glands in the groin, which suppurated. At the time when the abscess was fully formed a rash appeared over the entire body. It consisted of numerous red points, but was paler than that of ordinary scarlet fever ; temperature never above 99° : no sore throat nor desquamation of cuticle. No child exposed to her took scarlet fever, and her sickness could not be traced to infection. In the British Med. Jour., Jan. 4, 1879, L. Braxton Hicks states that his son, attending school at Reading, was seized with a severe attack of pyrexia, accompanied on the second day by delirium and the occurrence of a rash-like scarlet fever over the entire surface. He had no decided redness of the fauces, though it was perhaps slightly flushed. The right buttock was swollen from inflammation, and a large, deep-seated abscess formed near the tuberosity of the ischium. When the delirium abated the boy said that he was standing the day before the fever began with his legs far apart, when a schoolfellow stretched them farther by suddenly pulling on one of them. The rash, which was nearly universal, lasted three days, and was not followed by desquamation. No case of scarlet fever occurred in the school before or afterward. In the same volume of the British Medical Journal. Surgeon Frolliott, of the East India Service, relates the case of a private, aged twenty-three years, and three years in India, who, when on duty in the Punjab, was injured by the explosion of an Afghan powder-magazine. The accident occurred Dec. 21, 1878. On Dec. 25th a bright scarlet rash appeared upon the abdomen and spread over the entire body. The following day the erup- tion was very vivid, like a boiled lobster, and it lasted five days. The temperature, which in the beginning had been 101°, abated to the normal after the rash appeared. No soreness of throat nor redness of the buccal surface occurred, but the epidermis desquamated, even from the palms of the hands and soles of the feet. Now, the febrile movement of scarlet fever does not cease while the efflorescence is distinct. It does not even diminish when the eruption appears, while in the above case it fell to the normal — a common occurrence in septicaemia, even when the blood-poisoning is profound. Moreover, scarlet fever is so rare in India that Frolliott, after twelve years' service, had onlv - heard of one case among Europeans and natives. The surgeons who consulted over the case of this private disagreed in opinion, some regarding the disease as septicaemic, others as scarlatinous. But a better knowledge of the clinical history of scarlet fever on the part of these army surgeons would, I think, have removed all doubt as to the diagnosis. It is the opinion of some reputable surgeons that the exposure of traumatic patients to the scarlatinous poison sometimes aggravates the inflammation of SCARLET FEVER. 257 wounds, causing them to assume an unhealthy appearance, even though no scarla- tina be produced. The late Dr. Solly made the remark, "Whenever a case of surgery in private practice takes on a highly phlegmonous appearance, I am always sure to find break out. in the inmates of the house, either erysipelas or scarlet fever" (British Med. Jour., Feb. 15, 1879). We will see that the scarlatinous poison sometimes causes pharyngitis or nephritis without producing the general disease. In a similar manner it seems that it may aggravate open wounds, intensi- fying the inflammation in them, while there is no efflorescence or other symptom to show that scarlatina itself is present. The poison appears to act entirely locally in such cases. Paget, in his Clinical Lectures, says: "I think it not improbable that in some cases results occurring with obscure symptoms within two or three days after opera- tions have been due to the scarlet-fever poison, hindered in some way from its usual progress."' Playfair, in his remarks on the puerperal state, adds: "Mr. Spencer Wells informs me that he has seen cases of surgical pyaemia which he had reason to believe originated in the scarlatinal poison ; and his well-known success as an ova- riotomist is no doubt, in a great measure, to be attributed to his extreme care in seeing that no one likely to come in contact with his patients has been exposed to any such source of infection. " Opinions like these, held by such prominent mem- bers of the profession and sustained by many observations, should certainly induce physicians to prevent, as far as possible, exposure of their surgical patients, espe- cially if they have sores or wounds, whether by traumatism or scalpel, to the scar- latinal poison. Women during convalescence after childbirth are very liable to contract scarlet fever. In the New York Infant Asylum, which has maternity wards, a woman was admitted from a house in which scarlet fever was prevailing, and assigned to a cot next that occupied by one of the waiting-women, who was confined soon afterward. Her labor was favorable, but three days afterward she took scarlet fever, and another lying-in patient contracted it from her. The sore throat and desquamation were characteristic. It has come to my knowledge that a physician of New York, in whose family scarlet fever was occurring, attended three women in succession in their confinement, and all contracted scarlet fever, which presented the character- istic symptoms, and two of them died. Experienced and cautious physicians of New York, aware of the danger, do not go directly from a scarlatinous patient to an obstetrical case, but avoid the risk by intermediate visits to other patients or by remaining for a time in the open air. As an additional precaution, I never attend a case of midwifery without first soaking my fingers in a solution of corrosive subli- mate. Playfair, remarking on this subject, says : " There is good reason to believe that the contagium of zymotic diseases may produce a form of disease indistinguishable from ordinary puerperal septicaemia, and presenting none of the characteristic fea- tures of the specific complaint from which the contagium was derived. This is admitted to be a fact by the majority of our most eminent British obstetricians, although it does not seem to be allowed by continental authorities, and it is strongly controverted by some writers in this country. It is certainly difficult to reconcile this with the theory of septicaemia, and we are not in a position to give a satisfac- tory explanation of it. I believe, however, that the evidence in favor of the possi- bility of puerperal septicaemia originating in this way is too strong to be assailable. The scarlatinal poison is that regarding which the greatest number of observations has been made. Numerous cases of this kind are to be found scattered through our obstetric literature, but the largest number are to be met with in a paper by Braxton Hicks. Out of 68 cases of puerperal disease seen in consultation, no less than 37 were distinctly traceable to the scarlatinal poison. Of these, 20 had the character- istic rash of the disease, but the remaining 17, although the history clearly proved exposure to the contagium of scarlet fever, showed none of its usual symptoms, and were not to be distinguished from ordinary typical cases of the so-called puerperal fever. On the theory that it is impossible for the specific contagious diseases to be modified by the puerperal state, we have to admit that one physician met with 17 cases of puerperal septicaemia in which, by a mere coincidence, the contagion of scarlet fever had been traced, and that the disease nevertheless originated from some other source — an hypothesis so improbable that its mere mention carries its own refutation." Parturition, like traumatism, furnishes in an eminent degree the conditions in 17 258 CONSTITUTIONAL DISEASES. which septic poisoning occurs, and the efflorescence which often accompanies septi- caemia bears, as we have seen, a very close resemblance to that of scarlet fever. Hence in many instances the same difficulty is present in making a differential diag- nosis between septic and scarlatinous blood-poisoning in obstetrical cases which occurs in surgical practice. But, according to my observations, an efflorescence occurring during the week following parturition is in most instances septic. It is only in exceptional cases that it is scarlatinous. But if, as Playfair believes, the scarlatinal poison sometimes produces in parturient women a puerperal fever in which the characteristic scarlatinal symptoms are lacking, and which, in the present state of our knowledge, is not distinguishable from ordinary septic fever, certainly the scarlatinous virus sustains a more frequent causal relation to childbed fever than has been heretofore supposed. Age. — Infants under the age of six months do not ordinarily contract scarlet fever, although fully exposed, and those under four months nearly possess immunity. Still, this disease has been observed in new-born infants, contracted, apparently, through the placental circulation. Tourtual states that a woman waited upon her own husband and child, both of whom had scarlet fever, during the eighth and ninth months of her pregnancy till near her confinement. Though she had no symptoms of scarlet fever, her infant had unusual redness of the skin and buccal surface and difficulty of swallow- ing up to the fifth day. On the ninth day desquamation began, and at a later stage the nails of the fingers and toes separated. A case having a his- tory in some respects similar is related by Megnert, but the symptoms were anomalous for scarlet fever, and the disease may have been ordinary septic fever. On the other hand, in one instance in my practice a mother had scarlet fever, beginning about the third day after her confinement, and although she suckled her infant and it was constantly in bed with her, it had no symptoms of scarlet fever, but became affected immediately afterward by a severe form of eczema, probably from the altered quality of the milk : and in two instances observed by Murchison new-born infants remained healthy, although their mothers suffered from scarlet fever. After the age of six months the liability to scarlet fever increases till the close of infancy, children between the ages of six months and one year being less liable to contract the malady than during the second year, and those in the second year being less liable to it than those in the third year. Murchison collected the statistics of deaths from scarlet fever in England and Wales during a series of years ending with 1861. The number of deaths aggregated 148,829, and the percentage of deaths at different ages was as follows : Deaths under 1 year . between 1 and 2 and " 3 and 4 " 4 and 5 5 and 10 " 10 and 15 " 15 and 25 " 25 and 35 over the age of 35 6.7 per 2 years 14.09 00 13 9 9 cent. 16. 15. 11. 25. 5. 2. 0. 0. Among the deaths were 10 cases above the age of 85 years, so that scarlet fever, though especially a disease of childhood, may occur in any decade of life; but old age, like early infancy, almost possesses immunity from it. I have preserved the records of the ages of 145 consecutive cases occurring in private practice. If we add to these 58 cases observed by Prof. Octerlony (Amer. Journ. of Med. Set., July, 1882), we have the statistics of the ages of 203 cases, which are embraced in the following table : SCARLET FEVER. 259 Under 1 year 3 From 1 to 2 years t ... 25 " 2 to 3 " 43 " 3 to 5 " 57 " 5 to 10 " 53 " 10 to 15 " 13 " 15 to 20 " 3 " 20 to 30 " 4 " 30 to 40 " 2 Total 203 Clinical Facts regarding Scarlet Fever. As a rule, scarlet fever occurs but once, one attack conferring immunity from the disease for life ; but there are exceptions. In 1860, I attended a child with fatal scarlet fever who three years previously, it was stated, had passed through a first attack with all the characteristic symptoms. The following case occurred in a family attended by the late Dr. Herzog : II , a boy of six years, had scarlet fever in a mild form in January and February, 1875, followed by moderate desquamation. In July of the same year he was kicked by a horse in the street, receiving a deep scalp-wound which required stitching. Three days afterward he had, to appearance, a second attack of scarlet fever, attended by high febrile movement and followed also by desquamation. It was believed by Dr. H. to be a genuine case, and was so treated. I am not able to state as regards the presence of soreness of the throat, and doubt arises whether the second attack may not have been septicsemic. In April, 1876, a third attack occurred, which I saw from the beginning. It was accompanied by all the characteristic symptoms — injection of the fauces, an efflorescence continuing the usual time, followed by des- quamation and albuminuria, the latter remaining several weeks. Richardson states that three distinct attacks occurred in his own person, and a student attending the lecture at which this was mentioned informed the doctor that he also had scarlet fever three times. Sometimes a second attack occurs so soon after the first that it has been described as a relapse. The following was a case in point in the practice of Godneff (Meditz. Vestnik, No. iv., N. Y. Med. Rec, April 30, 1881): A youth of seventeen years contracted scarlet fever while taking care of a child. It began with a chill, and he had the usual efflorescence, sore throat, and tumefaction of the cervical glands. An exudation appeared upon his tonsils and uvula, and his temperature reached 104°. The urine contained a trace of albumen ; the rash in due time faded ; and the epi- dermis exfoliated. On the fifteenth day, when he was about ready to leave the hos- pital, he again had a chill, followed by fever. The temperature reached 105.2°, the rash reappeared over the entire surface except the face, diphtheritic exudations occurred upon the fauces, and the urine, the quantity of which was diminished, again became albuminous. The second efflorescence faded on the twenty-fourth day, and on the twenty-seventh exfoliation began. Hillier says : "I have seen a young woman in the fever hospital suffering from a second attack of scarlatina, the first attack having occurred five weeks previously. She had quite recovered from her first illness, and was acting as nurse. In both seizures the rash, the sore throat, and other symptoms were characteristic. The relapse or recurrence was less severe than the primary disease. 1 ' Cases of a fourth attack, or even of a greater number, have been reported. The first seizure is sometimes milder, but in other instances is more severe, than those which follow. Exposure to the scarlatinous poison not infrequently produces pharyngitis with- out the occurrence of scarlatina, and the inflammation is usually severe, accompa- nied by pain in swallowing and marked febrile movement. This phlegmasia is distinguished from scarlet fever by its shorter duration and the absence oi' the efflor- escence. It occurs in adults as well as in children, and in those who have had. as well as in those who have not had, scarlatina. So far as 1 have heard, it is very seldom accompanied or followed by any of the complications or sequelae so common in and after scarlet fever. It cannot be distinguished from ordinary pharyngitis except in the manner in which it occurs, and one attack does not preclude another. The late George B. Wood made the remark that he never attended a ease of scarlet 260 CONSTITUTIONAL DISEASES. fever without suffering from sore throat. The following were examples of this form of pharyngitis : On Jan. 17, 1882. I was called to a boy of three years with severe scarlet fever, ushered in by convulsions. On the following day his sister, aged seven and three-fourths years, whom I had attended a year previously during a severe attack of scarlatina, and who had been almost constantly with the brother, became very ill, with a temperature of 103.5°. Examination revealed severe inflammation of the fauces, without pseudo-membrane or any other exudation except muco-pus. On Jan. 19 an older brother, nine years, whom I had attended in scarlet fever three years previously, was affected in the same way, his temperature being 104° and his respiration guttural and noisy, especially during sleep, in consequence of the great amount of faucial swelling. At times he was delirious. The inflammation in both cases began to abate about the third day, and had disappeared by the close of the week. That the contagium of scarlet fever may be received into the system and cause pharyngitis while the patient has immunity from scarlet fever through a pre- vious attack, and that this inflammation may occur any number of times, as in the case of Dr. Wood, are remarkable facts. Now and then cases occur which appear to show that the scarlatinous poison may affect the kidneys, producing nephritis, while there is no other manifestation of its influence. Thus in my practice a lady of about forty-five years constantly attended her son, sleeping by his side, during an attack of scarlet fever. Her health had previously been good. When the boy was convalescent, as her appetite failed and she was indisposed, a careful examination revealed the fact that she had albu- minuria, although she had had no sore throat or other symptoms of scarlet fever. After several weeks of treatment her disease was removed, and she has remained well since. In the British Med. Jour, for Nov. 29, 1879, it is stated that in a family four girls were found to be suffering from desquamative nephritis. One of them had recently had scarlet fever, but the other three had presented no symptoms whatever of this disease. Such cases, although probably rare, appear to show that, as the scarlatinous poison may produce inflammation of the fauces without the occurrence of scarlet fever, so it may cause nephritis without producing the general disease, or apparently disturbing the functions or changing the state of other parts, except the kidneys. Symptoms. — Ordinary Form. — Scarlet fever usually begins abruptly so that the exact time of its commencement can be fixed. If any premonitory symptoms occur, they are slight, so as scarcely to attract attention, as languor or the appearance of fatigue. A dusky aspect of the surface may occasion- ally be observed during the few hours preceding the attack. In some children the first symptom is chilliness, and occasionally a distinct chill occurs. In the adult a chill is ordinarily the first symptom. With or without the initial chilliness fever occurs, of variable intensity according to the severity of the type, and accompanied by such symptoms as usually arise in a febrile state of system, as cephalalgia, anorexia, and thirst. The pulse rises to 110, 120, or more per minute, the temperature to 102°, 103°, or 104° ; the skin is hot, face flushed, and the eyes bright. Even in cases that are not malignant or grave, and that give indications of a favorable result, there is often more or less stupor, with transient delirium and sudden starting or twitching of the extremities, showing that the cerebro-spinal axis is involved. Vomiting is a common symptom in the beginning of scarlet fever, occur- ring before the appearance of the efflorescence. It therefore has diagnostic value when the nature of the case is still doubtful. In some patients it is an initial symptom, but in others some hours have elapsed when it occurs. I recorded its presence or absence in 214 patients, with the following result : present in 162 patients, absent in 52. In severe forms of the disease it is rarely absent, and if it do not occur it is probable that the case will be mild, requiring little treatment and having a favorable termination. In epidemics of unusual mildness the number of cases without vomiting may be in excess of those in which this symptom occurs. It appears to be due to functional disturbance of the cerebro-spinal system, and may therefore be properly SCARLET FEVER. 261 regarded as a nervous symptom. In severe cases the vomiting is usually repeated, not only on the first but on subsequent days, and we shall see that in eases of great gravity, in which a fatal termination is not improbable, per- sistent vomiting, by which the food and stimulants so urgently required are rejected, interferes seriously with successful treatment. In a few cases embraced in my statistics nausea without vomiting was recorded. The bowels in ordinary scarlatina act regularly or are slightly constipated. Diarrhoea, which so commonly accompanies the persistent vomiting in malignant cases, if it occur in this form of the malady is slight and transient and due to acci- dental causes. The food, if it be given in the liquid form and cool, is usually taken readily on account of the thirst, except when deglutition is rendered painful by the pharyngitis. The symptoms pertaining to the nervous system vary according to the severity of the disease and the temperament of the patient. Many children during the progress of the common form of scarlet fever present a dull or apathetic appearance. They lie much of the time with their eyes closed ; others are more restless, and not a few, if the fever be considerable, have occasional twitchings of the limbs and more or less headache. Eclampsia sometimes occurs on the first day, especially in those predisposed to it, even when the subsequent course of the disease is mild and favorable. This com- plication, very grave and usually fatal when it occurs at a later stage, is in most instances, when it takes place on the first day, readily controlled by proper remedies and with little detriment to the patient. But if it be attended by high elevation of temperature and marked drowsiness, approaching the comatose state, it is very serious upon the first as well as upon the subse- quent days. Nervous symptoms occurring in the beginning of scarlet fever, when it has the ordinary favorable type, begin to abate in three or four days, but if they supervene at a later date, and especially in the declining stage, they possess more gravity, since they then not infrequently result from and indicate renal complication. Early in the disease, nearly as soon as the commencement of the fever, the faucial and buccal surfaces become inflamed, as shown by redness, swell- ing, and tenderness. The physician summoned in the beginning of an attack will already, at his first visit, observe hyperemia of the fauces, with points of deeper injection than over the general faucial surface, and soon the buccal surface also participates. The inflammation at first produces preternatural dryness, and this is followed by a viscid secretion. The papillae of the tongue enlarge and become prominent, giving rise to the appearance known as straw- berry tongue, which is so common in scarlet fever. This state of the buccal and faucial membrane continues throughout the disease. A thin fur appears upon the tongue on the first day, and it increases on the second and third days, after which it is usually detached, exposing the surface of the organ, which has a deep-red hue, but in not a few patients the fur remains or is reproduced as soon as shed. Except in the mildest cases the Schneiderian membrane also participates in the inflammation as the disease advances, so that a thin, irritating discharge containing leucocytes or pus-cells flows from the nostrils. The skin is hot and dry and cutaneous transpiration is nearly checked. The respiratory system is rarely involved in any notable manner unless there be a complication. Many have no cough whatever, while others have a slight cough, due to the fact that the catarrhal inflammation has extended from the fauces to the surface of the glottis. Slight acceleration of respiration, corresponding with the degree of fever, may also be observed. The kidneys commonly act regularly and normally during the first da vs. any serious' impairment of their functions being rare before the close of the first week. 262 CONSTITUTIONAL DISEASES. When the symptoms described above have continued from six to eighteen hours the efflorescence appears. It is first observed about the ears, neck, and shoulders in reddish patches fading into the normal hue. These patches extend and unite, and in the course of a few hours the trunk and upper extremities, and finally the legs, are covered. The scarlatinous rash usually, when fully developed, resembles that produced by external heat or the application of a sinapism. It has been likened to the appearance of a boiled lobster, but there are numerous minute points of a deeper or duskier hue than the surface generally. In many patients the rash appears, especially over the abdomen and lower extremities, as minute, thickly-set points, with the skin of normal appearance between them. Henoch of Berlin says of scarlet fever : " In general, the moderate grades of eruption prevail, the skin, when seen from a distance, presenting a diffuse, more or less scarlet redness, while on closer inspection it is found that this redness is composed of innumerable red points closely situated together, and separated from one another by very small paler portions of skin. The dark -red points appear to correspond to the hair- follicles." On passing the finger over the efflorescence no distinct promi- nences are observed, but a sensation of roughness is sometimes imparted from engorgement of the cutaneous papillae. The rash disappears on pres- sure, but it immediately reappears when the pressure is removed. Its slow return is evidence of sluggish circulation, and it indicates a grave and dan- gerous form of the malady. The color is then usually a dusky instead of a bright red. The efflorescence is most marked in dependent parts, as along the back, over the chest and abdomen, and in the flexures of the joints. Parts pressed upon by the bedclothes, which confine and intensify the heat, present a deeper coloration than other portions of the surface. Often, espe- cially in mild cases, the rash is absent from portions of the surface where it commonly appears, while it presents its typical character elsewhere. Tardy and incomplete establishment of the rash when the symptoms indicate an attack of ordinary or more than ordinary severity is commonly due to some perturbating cause, especially diarrhoea. In the London Lancet for Aug. 16, 1879, cases are related of supposed scarlet fever without the rash — cases in which pharyngitis and stomatitis with the strawberry tongue occurred, with- out efflorescence upon the skin ; but it is to be remembered, as stated above, that the inflammations which commonly attend or follow scarlet fever, par- ticularly the pharyngitis and nephritis, not infrequently occur in those who have already had scarlatina, and occur more than once from fresh exposure to scarlatina patients. These inflammations, occurring under such circum- stances, appear to be purely local maladies, produced by the scarlatinous virus ; and it seems to me a question whether, in the so-called scarlatina without efflorescence, the inflammations which are present, and which undoubt- edly have a scarlatinous origin, are not local in their nature, instead of being local manifestations of the constitutional disease. The burning and itching sensation produced by the rash increases the restlessness of the patient, and is sometimes the most annoying of the symptoms. The temperature in the common favorable forms of scarlet fever usually varies from 101° in the mildest cases to 103° or 104° in those more severe. If it attain 105° or over, the case is properly designated grave or severe. The febrile movement ordinarily fluctuates but little from day to day till the fourth or fifth day, when, if the case be favorable and no complication occur, it begins to decline. The temperature is as high in the beginning of the attack as subsequently. The symptoms pertaining to the digestive system during the initial period of scarlet fever have been sufficiently described. The subsequent symptoms referable to this system do not differ materially from those present in the SCARLET FEVER. 263 beginning, except the absence of vomiting. The lips are dry and often cracked. The inflammation of the mouth and throat continues, with anorexia and thirst. With the decline of the disease the appetite gradually returns, but it is not till the close of the second week that it is fully restored. Great and continued disturbance of the digestive apparatus, seriously interfering with the nutrition, pertains to the malignant forms of scarlet fever. The urine is high-colored, and in robust children during the first days of scarlet fever it frequently deposits urates on cooling. Gee, who has carefully investigated the state of the urine in scarlet fever, says that the quantity of water is diminished and the urea is not necessarily increased during the pyrexia ; that the chloride of sodium is diminished till the fourth, fifth, or sixth day ; and that the phosphoric acid is diminished during the climax of the pyrexia, though not in the first three or four days. In one case he made a daily estimation of the amount of uric acid, and found it greatly diminished on the second and third days, normal on the fourth, and much increased on the fifth. He believes that similar variations are common in the quantity of the products excreted in the urine. Bile may also appear in the urine, coincident with a yellow tinge of the conjunctiva. 1 The duration of scarlet fever varies in different cases. If the attack be very mild, with little efflorescence, the febrile movement may decline by the fourth or fifth day ; but if the disease be severe, little or no amelioration of symptoms may occur before the twelfth or fourteenth day, even when no complication has occurred to increase the temperature or cause aggravation of symptoms. Octerlony, who estimated the duration of scarlet fever from the commencement of febrile symptoms to " the disappearance of fever, with marked improvement in leading symptoms," . . . . " found that the average duration of the disease in forty cases was six and one-sixth days. The minimum duration in a very slightly marked case was three days : the maxi- mum duration was fourteen days." In general, prolongation of fever beyond the usual time is due to some complication — more frequently to unusually severe pharyngitis, with accompanying cellulitis, than to any other cause. The malady whose commencement was so abrupt declines gradually. In ordinary cases, by the close of the first week or in the beginning of the second the rash becomes less and less distinct, and finally disappears, as do also the redness and swelling of the buccal and faucial surfaces. The engorge- ment of the tonsils and of the papillae of the tongue subsides, the appetite returns, the countenance brightens and becomes natural, and the child, who during the height of the fever scarcely noticed objects or noticed them with indifference or even repugnance, can be amused as before his sickness. Desquamation succeeds. This begins at about the sixth day, and is not completed till the tenth or twelfth day, often not till the close of the third or in the fourth week. The amount of desquamation corresponds with the intensity and duration of the efflorescence, or rather of the dermatitis which produces the efflorescence. If the efflorescence have been slight and partial, it will be slight, perhaps scarcely appreciable, but if the rash have been general, full, and protracted, exfoliation occurs upon every part. It begins about the face and neck, and within a day or two appears upon other parts. Where the skin is thin the epidermis as it is detached presents a furfuraceous appearance ; where it is thick, as upon the palms of the hands or soles o'l the feet, it separates in layers of considerable thickness. Such is a brief description of scarlet fever when it pursues its normal course without any disturbing element, but there is no other disease in which complications and sequelae so frequently occur. The liability to them renders 1 Article on Scarlatina in Kevnolcls's System of Medicine. 264 CONSTITUTIONAL DISEASES. the prognosis in every case doubtful. They largely increase the percentage of deaths. They occur both in mild and severe forms of scarlatina.. The difference in type in different cases and epidemics has already been alluded to. Scarlet fever is sometimes so mild and its symptoms so slight that the diagnosis is necessarily uncertain. In the spring of 1866, I was called to an infant thirteen months old who had slight pharyngitis and an indistinct rash over a part of the surface. In two days the eruption had disappeared, and the health within a day or two was apparently fully restored. Diagnosis would have been doubtful except for sequelae which clearly indicated the scarlatinous nature of the attack. In another instance two children passed through the entire course of scarlet fever, playing every day in the street. Although the intelligent grandmother saw the rash upom them, its nature was not suspected, as it was midsummer and cases of prickly heat common, till nearly two weeks afterward, when one of the children had nephritis and anasarca, ending fatally. In cases so mild as these the heat of the surface is but slightly increased, the pulse but little accelerated, and the rash usually does not occupy so much of the surface as in ordinary cases ; the appetite is not lost, though diminished, and the thirst is moderate. Between scarlet fever so mild that it terminates in four or five days, and that of the grave or malignant type presently to be described, all grades of severity exist. Scarlet fever occurs in all forms from mild to severe, but certain symptoms characterize grave or malignant cases — symptoms which are absent or much less prominent in ordinary scarlet fever. Therefore the grouping of cases according to the type is proper, and it facilitates the study- ing of the disease. Grave Form (malignant scarlet fever). — This form of the disease is in some epidemics common, while in others it is rare. The symptoms which characterize it are severe from the beginning, those of the nervous system predominating at first, such as intense cephalalgia, restlessness or stupor, sudden twitching of the muscles, and perhaps delirium or even convulsions. Many pass rapidly into coma and die within two or three days, succumbing to the intensity of the scarlatinous poison while the malady is still in its commencement. The rash is dusky. It disappears by pressure, and returns slowly when the pressure is removed, showing extreme sluggishness of the capillary circulation. Some patients are very drowsy, lying in a semi-comatose state except when aroused, and if aroused are very restless. Others are con- stantly restless. If placed in one position on the bed, they throw themselves in another in a half-conscious or unconscious state. They do not speak, or they mutter like those affected by the graver forms of typhus, calling the names of playmates or talking incoherently about things which interested them when well. The thermometer placed in the axilla is found to rise above 103°, which is a safe average, to 105° or even 107°, and the heat of the sur- face is pungent except when the case approaches a fatal termination, when the extremities, ears, and nose may be cool while the trunk and head are extremely hot. The pulse from the first is rapid, ranging from 130 as the minimum in a malignant case to a frequency which can scarcely be counted. A very frequent pulse is nearly always feeble and compressible. Irritability of the stomach is- one of the most common symptoms in grave cases, so that many patients immediately reject the nutriment and stimulants which are so urgently required to sustain the vital powers. The vomiting, therefore, if frequent and severe, greatly increases the danger, and in not a few instances this symptom is associated with diarrhoea, which also tends to increase the prostration. Severe and dangerous nervous symptoms, due to the intensity or activity SCARLET FEVER. 265 of the scarlatinous poison, occur chiefly within the first three or four days. Grinding the teeth, sudden muscular twitching, delirium, convulsions, and profound stupor occur for the most part within this time. Afterward the danger is mainly from exhaustion, unless in the second week or subsequently, when nervous symptoms may arise from uraemia. Those who survive the onset of malignant scarlet fever often have in the course of a few days severe pharyngitis, with extension of the inflammation to the lymphatic glands and connective tissue around the angle of the jaw. These inflammations cause more or less external swelling. The faucial tur- gescence around the entrance of the larynx, with the accompanying secretions of viscid mucus or muco-pus, often causes noisy respiration, and many at this stage of the attack breathe with the mouth constantly open to facilitate the ingress of air. Ordinarily, no discharge occurs at first from the nasal surface, but as the disease continues, if the type remain severe, deflexion of thin muco-pus takes place from the Schneiderian surface, which excoriates the cheek. The lips also are frequently sore and swollen. In malignant cases the disease is more protracted than when the type is mild. Thus in a recent case in my practice the rash was still distinct at the close of the second week, though the temperature had fallen from 105° to 102°, and some desquamation had appeared. Long continuance of the febrile movement is, however, oftener attributable to some inflammatory complica- tion than to the primary disease. In all epidemics of a severe type, cases now and then occur in which the poison is so intense, or it acts with such frightful energy, that death occurs even within the first day. The patient is overpowered at the outset of the disease by the virulence of the specific principle, perishing in coma, preceded perhaps by convulsions. The autopsy in such cases reveals hyperemia of the brain and cranial sinuses, blood of a dark -red color, capillary hemorrhages in various parts, a flabby heart, and perhaps some engorgement of the spleen and kidneys. Usually, malignant scarlet fever exhibits its severe type from the first, but cases sometimes occur which seem mild and favorable for a few days, when severe symptoms suddenly supervene. This change from a mild to a danger- ous disease is, however, most frequently, I think, due to some complication. Irregular Forms. — Deviation from the normal type in scarlet fever is usually due to some perturbating cause, which is often a pre-existing or coexisting disease or a disordered state of system through causes distinct from scarlatina. Thus, a little girl in my practice had the symptoms of scarlet fever, such as febrile movement and inflammation of the buccal and faucial surfaces, nearly a week before the scar- latinous eruption appeared. During this time the patient had an intestinal catarrh, with diarrhoea, which declined when the rash occurred. This intestinal disease was the apparent cause of the irregularity in the malady. If scarlatina occur during a severe attack of entero-colitis attended by purging, the defluxion from the intestinal surface may be such that no efflorescence appears. Severe scarlet fever itself some- times appears to cause gastro-intestinal catarrh, so as to produce an afflux of blood toward the intestinal tract and away from the skin. Practitioners occasionally moor cases like the following, which I recall to mind : In a family where scarlatina was prevailing a little child early after the commencement of the symptoms which seemed to be plainly referable to this exanthem was seized with vomiting and purging, which continued till death occurred on the third day. ^ No efflorescence appeared on the skin, but the symptoms indicated the presence o'l severe intestinal catarrh, complicating and masking scarlatina. We are aided in the diagnosis o\' such cases by observing the faucial redness, and we may discover a faint efflorescence upon parts of the'surface, as about the groin or in the flexures of the joints. In another instance an infant in the warm months, having protracted entero-colitis, the usual summer epidemic of the cities, had the characteristic symptoms of scarlet 26Q CONSTITUTIONAL DISEASES. fever, which was present in the family, but the diarrhoea continued and no rash appeared. In one who is much reduced by an antecedent disease, especially if, like the intestinal catarrh mentioned above, it produces a decided afflux of blood away from the surface and toward the interior of the body, the eruption is commonly tardy in its appearance, indistinct, or wholly absent. On the other hand, some maladies occurring in connection with this exanthem do not change its symptoms, but them- selves undergo modification. Pertussis may be cited as an example, the cough of which is sometimes modified by an intercurrent attack of scarlet fever, the symp- toms of the latter disease undergoing little change. Scarlet fever may also be irregular without any apparent perturbating cause. In 1867, I attended a young lady whose previous health had been good, and whose brother was sick at the time with scarlet fever. She had marked elevation of tem- perature, with severe pharyngitis, and, though her surface was repeatedly examined, no efflorescence was seen. Two weeks subsequently she was aifected with severe nephritis, anasarca, effusion into at least one of the pleural cavities, oedema of the lungs, and, according to my diagnosis, hydro-pericardium, the case ending fatally. Rilliet and Barthez state that a second attack of scarlet fever is more likely to be irregular than the first. Probably this opinion is correct, especially if only a short time have elapsed between the two seizures. Still, as we have already stated, both seizures may be typical, and the second more severe than the first. It would be impossible to make a clear and positive diagnosis of certain cases of irregular scarlet fever, in which cerebral, pulmonary, or gastro-intestinal symp- toms predominate, were it not for the fact that they occur in connection with other cases of scarlet fever or are followed by sequelae which evidently have a scarlatinous origin. Occasionally, the eruption, if it be intense or if a certain condition of system be present in the patient, is accompanied by more or less extravasation of blood- corpuscles from the capillaries, usually in points, so that the redness does not entirely disappear on pressure. In rare instances certain of the exanthematic fevers present an extreme hemorrhagic character, so as to be beyond the reach of remedies and of necessity speedily fatal. Hemorrhagic cases of this severe form are probably more common in variola than in the other fevers, but I have met a notable case in what was diagnosticated scarlatina, in June, 1881, a man in his thirty-second year, whose previous health had not been good, though he had no defined ailment and had been able to follow his occupation of harness-maker, suddenly became very ill, with great elevation of temperature and faucial inflammation, attended by marked prostration. After some hours an intense eruption of a scarlatinous appearanee covered nearly the entire surface, and on the following day hemorrhages began to occur. The urine contained a large proportion of blood ; each conjunctiva was raised by hemorrhages underneath (ecchymosis), so that its natural color was lost, the eyelids were closed with difficulty, and blood flowed from the nostrils, gums, and under the skin, forming hemorrhagic points and blotches. One of the consult- ing physicians, perceiving the resemblance to hemorrhagic variola as described by Hebra, suspected that we had a case of this formidable malady to deal with, but the time for the appearance of the variolous eruption passed by without its occur- rence. Death took place on the fifth day. The temperature during the sickness remained high, though the record of it has been mislaid. Fortunately, such severe hemorrhagic cases, which are necessarily fatal, are rare. Complications and Sequels. — Scarlet fever, if its type be severe, is in itself dangerous to life. Many, as we have seen, perish from its direct effects when it produces profound blood-poisoning. But while the ordinary epi- demics of this malady are necessarily attended by a large mortality from the virulence and depressing effect of the specific principle, unfortunately, of all the diseases of modern times, scarlatina ranks first as regards the number and gravity of its complications and sequelae, so that nearly or quite as many perish from these as from the direct effects of the poison. Nervous accidents occur chiefly at two periods — to wit, in the first days, when they are due to the severity and malignity of the malady and to the impressible nervous temperament of the child ; and in the declining stage or after the termi- SCARLET FEVER. 267 nation of the fever, when they occur from uraemia. If the type be malignant, delirium, jactitation, profound stupor, and convulsions frequently occur on the first and second days : and these are symptoms which properly excite the most alarm and demand all the resources of our art, since they indicate a form of the disease which frequently ends in speedy death. The eyes have a dull or wild expression, the conjunctiva is suffused, the heat of surface pungent, the pulse rapid and com- pressible or feeble, rising above 150, even to 200, per minute, and the temperature is always elevated to a degree that involves danger, the thermometer not infre- quently indicating 105° or 106°. But this severe form of scarlet fever, attended by so great elevation of temperature, is much less dangerous than in former times, even though it be complicated by delirium and convulsions, since we no longer hesitate to reduce bodily heat, when excessive, by the free use of cold baths, and have discovered potent agents in the bromides and chloral for controlling convul- sions. Nevertheless, not a few perish in the commencement of scarlet fever with predominating cerebral symptoms, as delirium or eclampsia, followed by coma, under the best possible treatment. Sometimes the symptoms have closely simu- lated those of acute meningitis, and if the rash have been delayed and the sore throat is as yet slight, the physician may suspect that he is dealing with this disease ; but autopsies in such cases show no inflammatory lesions, but only con- gestion of the cerebral and meningeal vessels. As is stated in a preceding page, in every case of normal scarlet fever inflam- mation of the faucial surface is present, as indicated by redness, tenderness, and increased secretion of mucus or muco-pus. It precedes the efflorescence on the skin, and is announced by pain in swallowing and on pressure with the fingers behind and below the angles of the jaw. In that form of scarlet fever which has been designated anginose the pharyngitis is severe, and is a prominent element in the malady, the uvula, the pillars of the fauces, and the faucial surface in general being infiltrated and swollen. Nevertheless, this inflammation, with the accom- panying tumefaction, is properly a part of the disease, rather than a complication, if it abate with the subsidence of the scarlet fever or begin to abate soon after, and if it produce but slight destructive change in the tissue of the neck. The secretions from the fauces may be foul and offensive ; even superficial ulcerations or gangrene may occur upon the faucial surface, causing it to present a dark-brown or jagged appearance, and the tissues of the neck may be infiltrated to a certain extent, and we designate the disease a form of scarlet fever under the title anginose. But when this condition is greatly aggravated, so that extensive infiltration and swelling of the tissues of the neck occur, with an amount of ulceration or gan- grene which in itself involves danger, continuing after the primary disease abates, prolonging the fever and reducing the strength, it is proper to regard the state of the throat as a complication. In addition to the pharyngitis, which is severe, as described above, the sides of the neck around the angles of the jaw become swollen, hard, and tender. The inflammation has been propagated to the deeper structures of the neck. Poisonous substances, the result of decomposition or vitiated secretions, traverse the lymphatic vessels from the faucial surface, and being inter- cepted in the lymphatic glands, cause adenitis, and the inflammation extends from the glands to the adjacent connective tissue, which becomes hard, tender, swollen, and infiltrated with inflammatory products. This tumefaction sometimes begins by the second or thiru day, but it is usually about the close of the first week or in the beginning of the second week that it becomes so considerable as to consti- tute a source of danger and anxiety. It is in most cases bilateral, though one side .may begin to swell before the other and remain larger throughout. In severe cases of this complication the tumefaction extends from ear to ear. filling up the space below and around the angles of the jaw and under the chin. Not only is deglutition difficult, but it is difficult to open the mouth sufficiently to inspect the fauces, and attempts to do so cause much pain. The lymphatic glands, which lie in the inflamed area and participate in the inflammation, are greatly enlarged by hyper- plasia, the round granular lymph-cells multiplying so abundantly that the glands increase to many times their normal size. Most of the tumefaction is, however, due to extension of the inflammation to the connective tissue of the neck. The cellu- litis, which resembles that occurring in other conditions, is attended by distention of the capillaries, the abundant formation of young round colls, and transudation of serum (Billroth). A moderate amount of tumefaction may disappear by resolu- tion, but if it be considerable it seldom abates in this way, but by the tedious and 268 CONSTITUTIONAL DISEASES. exhausting process of suppuration or gangrene. If the swelling at its most prom- inent point presents a reddish hue, all hope of producing resolution must be aban- doned ; it cannot be effected by any medicine or appliance within the resources of our art. The abscess which forms is likely to be diffuse, so as to involve danger of pyaemia, unless it be soon opened and properly washed out. With the discharge of the pus the swelling gradually softens and declines. In other cases gangrene results. The vessels in the inflamed part are compressed by the inflammatory prod- ucts, so that they no longer convey the blood which is required for the purpose of nutrition. It is a law of the system that whenever the circulation ceases the tissues which receive their nutritive supply through the obstructed vessels lose their vitality. Hence gangrene occurs in all that portion of the swelling in which the circulation is arrested. The skin over it peels off, the dead tissue underneath is brown or dark, and soon, if life be prolonged, the slough begins to separate. The prognosis as regards this complication depends largely on the size of the slough. If it be large, death will probably result, since the strength of the system is already reduced by the primary disease, and the reparative process will necessarily be slow, while abundant suppuration tends to increase the exhaustion. In some of the worst cases of cervical gangrene which I have seen the slough has laid bare the muscles and vessels of the neck, producing in one case a cavity or excavation suffi- ciently large to admit a hen's egg. Often the slough extends under the skin, so that the deepest recesses of the cavity are not visible, and occasionally, in cases which have ended fatally in my practice, severe hemorrhage occurred from the concealed vessels. If the ulcerative or gangrenous process extends so deeply into the tissues of the neck that hemorrhages occur, death is the common result: but if the destruc- tive action be of moderate extent and other conditions favorable, we may expect recovery through cicatrization, with perhaps some deformity by contraction of the cicatrix. When the inflammation of the connective tissue of the neck is extensive, in- volving both the lateral and anterior regions of the neck, the patient is in a perilous state. The cellulitis, when extensive and accompanied by much swelling, may pro- duce oedema of the glottis, may obstruct respiration by compressing the air-passages or the laryngeal nerves, may cause compression of the jugular veins, and thus give rise to dangerous cerebral symptoms, or may lay bare and injure important muscles and nerves, as we have seen. If the ulceration or gangrene be extensive, and death do not occur by hemorrhage from arterial or venous twigs, septic poisoning may occur, increasing still more the fatal nature of the malady. Some cases of this complication are melancholy in the extreme, as one related by Cremen, in which ulceration of the pharynx occurred, allowing the escape of food and preventing deglutition. In severe scarlatinous pharyngitis the inflamma- tion sometimes extends along the Eustachian tube, causing its occlusion. This acci- dent will be considered when we treat of otitis media, another grave complication. It often also extends into the nares, causing catarrh of the Schneiderian mucous membrane, with discharge of muco-pus from the surface. Not infrequently ulcera- tion or gangrene occurs in the faucial surface, producing more or less destruction of tissue and forming excavations, while the cutaneous surface retains its integrity and is not even reddened. The following case shows how grave the complication which we are now considering sometimes is when the external surface of the neck is not involved, and how the inflammation by extension outward from the fauces may involve the middle ear : Case 1. — Annie K , aged two and a half years, an inmate of the New York Foundling Asylum, was well, except an eczema of the scalp, until the night of April 3, 1882, when she was attacked with vomiting and diarrhoea. She was feverish and drowsy, and at 2 p. m, on the 4th the scarlatinous efflorescence appeared upon her neck, body, and lower extremities ; tongue coated ; pharynx red : temperature (axillary) 103°; pulse 160. The symptoms and aspect indicated a grave form of the malady, and the usual sustaining treatment was ordered. On April 5th the temperature was 102°, pulse 144, tongue less coated, eruption fading, less stupor, no albumen in urine. April 6th, morning temperature 102°, pulse 160; passed a restless night : stools thin and too frequent ; has grayish patches in the throat ; p. m. temperature 103.2°, pulse 150. April 7th, the diarrhoea continues, and she has a copious muco-purulent discharge from the nostrils : p. m. temperature 103.6°, pulse 160. April 10th, the temperature has continued at about 103° ; the patient is very sick, with a constant foul-smelling discharge from the nostrils ; breath very offen- SCARLET FEVER. 269 sive : temperature 103.5°, pulse about 180. April 12th, general appearance a little better, but the posterior surface of the fauces is completely covered by a thick pseudo- membrane ; had four loose stools last night ; temperature and pulse the same as at last record ; a dark, offensive, and jagged coating over the fauces, and a dark, foul discharge from the nostrils as before : examination of the chest negative. April 14th. is much prostrated ; temperature 104.5°, pulse rapid and weak ; respiration noisy : diminished resonance over lower two-thirds of left side of chest ; ulcers upon the mouth and tongue ; fauces red and ulcerated. April 17th, pulse 150, tem- perature 100.5°; general appearance somewhat better, but the diarrhoea continues, and patches of a diphtheritic character have appeared upon the lips ; moist rales in left side of chest. The symptoms continued nearly the same until April 23d, when she died. A dull percussion sound and distinct bronchial respiration were observed in the left scapular region during the last days of her life. Autopsy nine hours after death by the curator : Body well nourished ; the tis- sues have a jaundiced hue ; lips sore ; on turning the head to one side pus runs from the left ear and dirty muco-pus from the mouth. Brain normal ; on opening the petrous portion of the left temporal bone the middle ear is found full of pus, which communicated freely with the external ear through a perforated membrana tympani : the Eustachian tube cannot be traced in the sloughy tissue, and a passage filled with pus extends from the ear to the fauces ; opposite the greater cornua of the hyoid bone are two deep ulcers, each having about the diameter of a ten-cent piece, with sloughy and offensive base and sides ; the left ulcer communicates by a, ragged and wide sinus with a dark and sloughy cavity of about four drachms capacity, this cavity is located in the neck under the angle of the jaw, apparently occupying the site of a disintegrated gland, and it opens upon the surface of the fauces. The surface of the larynx has a dusky, dirty appearance, sprinkled with little cheesy-looking spots, and covered by a dirty, foul-appearing liquid, as if some of the ichorous pus had escaped into it from the neck ; about one and a half inches below the vocal cords there is an unmistakable pseudo-membrane ; below this, near the bifurcation, the trachea has a bright-red color, as if a pseudo-membrane had been peeled from it, leaving the surface raw. The detachment of a pseudo-mem- brane from this part, if it did occur, must have been ante-mortem, for the organ had been carefully handled in making the autopsy. Between the apex of the left lung and the median line the tissues of the neck, dissected upward, are found indurated, yellow, and giving an offensive odor, showing that the cervical cellulitis had extended downward farther than usual. The bronchial glands have undergone hyperplasia, being enlarged and hard. The right lung is normal : about one-half of the left lower lobe is consolidated, and when cut is found to be gangrenous and offensive. The liver is apparently somewhat enlarged ; spleen normal in size ; gastric mucous membrane has a congested appearance and is covered with mucus ; mesenteric glands enlarged, pale, and firm ; Peyer's patches swollen and pale ; at lower end of ileum some pigmentation of these glands ; in large intestine the solitary glands are enlarged, and a few of them pigmented ; kidneys pale, cortex thickened, and markings indistinct. Microscopical examination : In the pia mater perhaps a little increase of cells ; meninges of brain otherwise normal. The trachea shows well-marked diphtheritic inflammation ; it contains a film of pseudo-membrane ; evidences of inflammation occur also upon the laryngeal surface, though less marked than in the trachea. The solidified portion of the lung exhibits the ordinary lesions of broncho-pneumonia, with some interstitial change. In the kidneys we find paren- chymatous nephritis, with some cell-growth in the Malpighian bodies. The above case has been related at length, not only because it shows how severe and destructive the inflammation of the throat, extending into the tissues of the neck, sometimes is, but because four other complications or sequelae were also present — to wit, otitis media, diphtheria, nephritis, and pneumonia. We see how formidable a disease scarlet fever sometimes is when attended by the inflammations to which it so frequently gives rise, for a child older and stronger than this, if thus affected, would inevitably have perished with the best possible treatment. In localities where diphtheria is endemic, as in New York City and Paris, scarlet fever is often complicated by pseudo-membranous inflammations of the fauces and air-passages. In severe cases the Schneiderian as well as the 270 CONSTITUTIONAL DISEASES. faucial surface is covered with pseudo-membrane, so that it can be readily seen on inspecting the anterior nares. Occasionally, this exudation appears upon the laryngeal and tracheal surfaces, as in the case which I have related above and in others presently to be related, causing dangerous embarrassment of respiration. This complication sometimes begins almost at the commence- ment of scarlet fever, but in most instances it does not occur before the third or fourth day, and it sometimes does not appear till in the declining stage of the fever. When it begins it intensifies the fever and produces general aggravation of symptoms. The elaborate treatise by Sanne of Paris on diphtheria contains a chapter entitled " Secondary Diphtheria." In it the author says, what all who are familiar with diphtheria will agree to, that secondary diphtheria does not differ in nature from the primary form, and that it exhibits a tendency "to occupy the organs which are themselves the seat of the more pronounced local determinations of the primitive malady Diphtheria is seen in the course or sequel of numerous diseases. Some appear to have a special proclivity for engendering diphtheria ; these are specific maladies : measles, scarlet fever, pertussis." Sanne's statistics relating to the seat of scarlatinous diphtheritic exudation are as follows : Fauces alone attacked 15 cases. Fauces with larynx attacked 4 Fauces with nasal fossa attacked 8 Fauces with larynx and nasal fossa attacked 4 Fauces with larynx and bronchi attacked 1 Fauces with nasal fossa and lips attacked . 1 Fauces with lips and skin attacked 1 Fauces unaffected 3 Diphtheria generalized 2 Larynx only affected 2 Nasal fossa 1 The pellicular exudate upon the laryngotracheal surface is treated else- where in this book. Coryza frequently commences at or about the time of the pharyngitis. The inflammation of the Schneiderian membrane is continuous posteriorly with that of the fauces, and is announced by redness and swelling, inability to breathe freely through the nostrils, and an irritating ichorous discharge. Simple coryza in itself involves little danger, though it is an unpleasant com- plication, and in the nursing infant it may interfere with drawing the nipple. Diphtheritic coryza, on the other hand, which is frequently present when diphtheria complicates scarlet fever, involves danger, since it is apt to cause ulcerations, hemorrhages, and septic poisoning. When the local symptoms are unusually severe and the discharge abundant, it is probable that inflam- mation has in some cases extended to the antrum of Highmore. Inflammation of the Middle Ear is another unpleasant and not infrequent complication. The statistics of different aurists collated by Dr. C. H. May, and presented in a paper on scarlatinous otitis read before the Pediatric Sec- tion of the New York Academy of Medicine, March 4, 1889, show that about 5 per cent, of all aural affections result from scarlet fever, and in 10 per cent, of the cases of total deafness the loss of hearing is from this disease. It is due to extension of the catarrh from the pharynx along the Eustachian tube to the tympanum. In a considerable proportion of cases of otitis media this tube is occluded by the infiltration and swelling of its mucous membrane, so that the muco-pus escapes with difficulty or is retained. Hence severe ear- ache, an increase of the febrile movement, and outward bulging of the mem- brana tympani occur. Sometimes headache or other cerebral symptoms arise, SCARLET FEVER. 271 probably from the fact that the meningeal artery, which supplies the meninges, is connected by anastomosing branches with the tympanum. In one of the cases related above it will be recollected that the ulceration and abscess extended from the fauces to the middle ear, the entire Eustachian tube having disappeared in the ulcerative process. Frequently, the otitis escapes detection, its symptoms being masked or obscured by the general disease, until the membrana tympani is perforated and otorrhoea begins ; but by careful examination the nature of the complica- tion can usually be ascertained before the ear is injured to this extent, for a patient too young to speak will often press with the fingers against the painful ear or lie with the ear pressed upon the pillow, evidently having an increase of suffering if placed in any other position. One old enough to speak and in proper mental condition makes known the earache as soon as it occurs. In most instances the scarlet fever has continued some days when the otitis begins. The otitis may begin insidiously, but in other instances it begins with a chill and a rise of temperature to 104° or 105°. The pain referred to the ear may be paroxysmal, and it is usually worse at night. It may radiate from the ear, following the branches of the fifth nerve. The patient expe- riences pain on pressure upon and around the tragus, and when the inflamma- tion extends to the mastoid cells, pressure upon the mastoid process is also painful. The otitis may be unilateral, but in a large proportion of cases it is bilateral. The mucous membrane of the tympanum, red and swollen from inflamma- tion, secretes muco-pus abundantly, and this, pent up in the cavity, must obtain an exit before relief occurs. It is well if the secretion escape, though with difficulty, down the Eustachian tube. The destructive action of the pus upon the delicate structure of the ear is often such that within a few days irreparable harm is done and more or less deafness results. Relief can occur, if the Eustachian tube remain closed, only by perforation of the membrane and the discharge of the secretions into the external meatus. When this takes place the inflammation in the most favorable cases gradually abates, the aperture in the drum closes, and the integrity of the auditory apparatus is preserved. In severe cases the mastoid cells participating in the inflammation become filled with muco-pus and tender to the touch, and often the collateral oedema causes tumefaction and narrowing of the external ear, which subside with the discharge of pus from the tympanum. Unfortunately, there is for many a more melancholy history — a more destructive inflammation, involving permanent impairment or total loss of hearing. This most frequently takes place in strumous or feeble children. All grades of inflammation and destructive action occur in different cases. The perforation in the drum-membrane may be large or the membrane may be completely destroyed, and the detached ossicles escape one by one into the external meatus, and in a few instances, fortunately rare, this occurs in both ears, producing complete and permanent deafness. In my own practice this has never occurred, but I have met one or two adults who were totally deaf from this cause. The mucous membrane which lines the bony wall of the middle ear has the function of the periosteum, and therefore when inflamed and subjected to pressure is liable to ulcerate. As in other parts of the skeleton under similar conditions, superficial caries or necrosis of the underlying bone is liable to occur. The carious or necrotic process may extend to the mastoid cells. An offensive otorrhoea, continuing for months or years, indicates the persistence o\' this pathological state of the tympanum, which is rendered so obstinate by the presence of dead bone. A moment's survey of the anatomical relations of the middle ear shows the danger to which these patients are liable. A thin 272 CONSTITUTIONAL DISEASES. bony septum, perforated with blood-vessels, and sometimes containing con- genital apertures, separates the tympanum from the cranial cavity above. Posteriorly lie the mastoid cells, connected with the tympanum by one large and several small apertures. Anteriorly is the commencement of the Eus- tachian tube, and in close proximity to the tympanum lies the carotid canal, and at one point also the superior petrosal sinus. Virchow has shown how inflammation extending from the ear in otitis media sometimes produces such compression of the veins or sinuses by the swelling from the infiltration and exudation that the circulation is arrested, and the fibrin contained in the blood of these vessels is precipitated, forming thrombi, with the most disas- trous effect upon the individual. Pus may also burrow in the interstices of the bone, causing great pain, or the pent-up secretions, having no outlet for escape, may in time undergo caseous degeneration, producing the conditions in which tuberculosis so often originates. Death not infrequently occurs in chronic otitis media in another way. The otorrhcea, after months or years, suddenly ceases, the child complains of constant severe headache and is feverish, and the case ends in coma, preceded perhaps by convulsions. Meningitis has occurred, produced by extension of the inflammation through the thin bony septum which divides "the tympanum from the cranial cavity, and at the autopsy hyperemia of the meninges, fibrin, pus, perhaps softening of the brain and an abscess, are found in the portion of the encephalon adjacent to the tympanum. Therefore, otitis media, though it often ends favorably, is in many patients an obstinate, dangerous, and even fatal sequel of scarlet fever. The complication known as scarlatinous rheumatism is regarded by some as a synovitis, but its symptoms, especially its shifting from joint to joint, seem to ally it to the rheumatic affections. In some epidemics it is common. It usually begins toward the close of the first week or in the second week, and its common seat is in the ankle, phalangeal, and wrist joints. It is attended by very little swelling in most patients, though the joints are tender and painful on pressure. It does not seem to retard convalescence materially, but it produces suffering and involves danger as regards the heart. It sub- sides in a few days with the ordinary treatment of acute rheumatism, and even without special treatment, the chief danger being that, as in idiopathic rheumatism, endocarditis may arise, with permanent crippling of the valves. The following was a case of valvular disease having this origin. It occurred in my practice. Case 4. — Freddy M , aged four years, sickened with scarlet fever March 6, 1879. The usual vomiting occurred on the first day, and the temperature was 104°. The case progressed favorably till March 14th, when he complained of pain in both wrists, both ankles, and both knees. On March 17th the general condition was good, the urine contained no albumen and apparently few urates, but he still had pain in the joints of the upper and lower extremities and in the back ; pulse 140, tempera- ture 103° ; breathes with a slight moan; urates in the urine, but no albumen. A distinct mitral regurgitant murmur is now heard for the first time. Under the use of salicylate of sodium the pain in the joints soon ceased, but the mitral murmur is permanent. The following prescription is for a child of five years : R. 01. gaultheriae, fgj ; Sodii salicylat, giij ; Syrupi, fgij ; Aqua?, f^iv. — Misce. Sig. : Give one teaspoonful every four hours in water. Of the serous inflammations complicating scarlet fever, pericarditis has been, according to Rilliet and Barthez, most frequently observed. In this SCAB LET FEVER. 273 country it is probably more common than is usually supposed, but it is less frequently detected than pleuritis, the symptoms of which are more con- spicuous. The following case, which occurred in my practice, was an example of this complication : Case 5. — C , girl, aged five years and ten months, sickened with severe scarlet fever on April 4th. Was delirious ; pulse 158 ; had vomiting and consti- pation. April 10th, pulse varies from 124 to 153, no delirium ; a considerable quantity of urates in the urine. April 11th, has to-day, for the first time, severe pain in the epigastrium, with tenderness and moderate distention. Otherwise symptoms favorable, but severe ; pulse 140 ; respiration moderately accelerated and vesicular in every part of the chest. From this date the symptoms continued about the same till April 14th, when the dyspnoea became more marked and the action of the heart rapid and tumultuous. The epigastric pain, distention, and tenderness continued : the percussion sound was dull over the lower part of the chest : the dyspnoea became rapidly worse, although the pulse had considerable volume : and at 5 p. m. death occurred. At the autopsy about one ounce of turbid serum, with a soft deposit of fibrin, was found in the pericardium. Each pleural cavity contained from six to eight ounces of transparent serum, and both lungs were readily inflated, except a little of the posterior portions of both lower lobes : no fibrinous exudation over the lungs. The liver extended four inches below the margin of the ribs, and upon its convex surface in the epigastrium, corresponding with the seat of the pain, was a rough patch of fibrin about one and a half inches in diameter. The bronchial mucous membrane was moderately injected, as was also that of the colon, and the kidneys appeared hyperaeinic. Among the serous inflammations which complicate or follow scarlet fever, pleuritis is one of the most important. It usually begins in the desquamative stage, and is frequently suppurative, on account of the feeble state of the patient when it commences. It has, in my practice, been tedious, as all empyemas are, and it does not differ in its clinical history from the idio- pathic disease. I have met cases of scarlatinous empyema in which, from opposition of the family, or for other reasons, thoracentesis was not per- formed and death occurred ; others in which this operation effected a cure ; and one, at least, in which the patient recovered by escape of pus through a bronchial tube and its expectoration. The pleuritis is seldom latent, or so masked by the symptoms of the general disease that it is liable to be over- looked. On the other hand, the cough, embarrassment of respiration, and pain referred to the affected side render diagnosis easy. Dilatation of the heart is common in grave cases of scarlet fever, such cases as are properly termed malignant. It is indicated by a feeble and quick pulse. Acute infectious maladies, especially those of a malignant type and accompanied by a marked rise in temperature, are very liable to cause paren- chymatous degenerations in organs, prominent among which is granulo-fatty degeneration of the muscular fibres of the heart. This weakens very much the contractile power of the heart. But early in malignant cases, probably before the muscular fibres are damaged, the contractile power of the heart is feeble from impaired innervation, the result of the general weakness. Hence this organ, when weakened by structural change and insufficiently stimulated through diminished innervation, may not fully empty itself during the systole, and consequently it becomes dilated. Dilatation of the heart and imperfect contraction of its auricular and ventricular walls facilitate the formation of clots in the cavities of the heart; and this appears to be the immediate cause of death in not a few instances. An ante-mortem clot occurring in any of the cavities of the heart necessarily seriously obstructs the circulation, unless it be of small size. Hence the dyspnoea, which may occur suddenly. and the change of pulse to one of marked feebleness and frequency. Large. 18 274 CONSTITUTIONAL DISEASES. firm white clots are most frequently found in the right cavities. They inter- lace with the chordae tendineae, lie even within the auriculo-ventricular open- ing, and send prolongations into the pulmonary artery and the cavae. Asso- ciated with the white clots are dark, soft clots and fluid blood. The left cavities may be contracted and empty, or they may contain dark, soft clots or white ante-mortem clots. Clots in the left ventricle are sometimes pro- longed into the aorta as far as the brachiocephalic branches, while those in the left auricle may extend to the pulmonary veins. If dilatation of the heart be so great that clots form in its cavities, speedy death is probable. Sometimes a patient passes through scarlet fever and appears in a fair way to recover, when he succumbs to some exhausting sequel distinct from the heart, and at the autopsy the heart is found dilated and containing whitish clots, which are probably ante-mortem, and which hastened death by obstruct- ing the circulation. Under such circumstances this state of the heart is attributable in great measure to the complication which has weakened its contractile power. The following was a case in point ; it occurred in the New York Found- ling Asylum : Case 6. — R. A , aged three years, had scarlet fever, beginning March 23, 1882. The symptoms were favorable at first, but serious complications and sequelae occurred, which were fatal. The record of April 18th reads: ' ; Appears well nour- ished, but is anasniic ; has otorrhoea ; no oedema : skin desquamating ; dulness on percussion over upper third of right side of chest, anteriorly and posteriorly ; mucous rales and rude breathing over same area ; fine rales posteriorly over lower part of left side of chest; pulse 160, respiration 68, temp. 101§°." April 2.0th, is feeble and takes nutriment with difficulty ; tongue thickly coated ; pulse 160, respiration 68, temp. 101f°. April 26th, condition about the same as at last record, but he is evidently weaker ; the lips are ulcerated and fauces still swollen. May 2d, cannot speak distinctly ; a brownish, foul-smelling secretion lodges on the spoon used in depressing the tongue ; left side of face swollen. On the following night eight con- vulsions occurred, attended by orthopnoea and mucous rales in the chest from pul- monary oedema. Diarrhoea supervened and the patient died about midnight. Autopsy. — Body moderately wasted and very white ; several dark-blue spots on scalp and face from hemorrhages underneath. A careful examination showed the presence of broncho-pneumonia in each lung, with considerable infiltration of the walls of the bronchi and cylindrical dilatation of many of them ; cavities of the heart- dilated, so that this organ appears much enlarged, and its shape approaches the glob- ular ; its apex is rounded or obtuse ; transverse diameter of the right ventricle, when its walls were open and drawn apart, was three and a fourth inches ; that of the left ventricle three and a quarter inches. Similar measurements of the heart of another child of about the same age, believed to be normal, were about one inch less in each direction. All the cavities contain white firm clots along with soft dark clots. Lesions observed in other organs were carefully noted, some of which were serious : but the immediate cause of death appeared to be imperfect contraction of the heart and the formation of clots in its cavities. The nephritis which gives rise to symptoms, and therefore interests the practitioner, commonly begins in the declining period of scarlet fever or dur- ing the desquamative stage, and is in many instances plainly attributable to exposure to cold or to currents of air. It originates either during this period, or. if it has previously existed as a mild renal catarrh, it now becomes aggra- vated. Dropsy, which always attracts attention, does not occur till the nephritis has continued for some time. Why nephritis, with the subsequent dropsy, so frequently occurs after scarlet fever is not fully understood. Rilliet and Barthez attribute it to dis- turbance of the function of the skin. The fact has long been observed that the kidneys become affected nearly if not quite as frequently after mild as severe cases. Indeed, the chief danger in mild cases, when the patients are SCARLET FEVER. 275 but a short time in bed and are soon allowed to go about, is from the nephritis. Chilling the surface and checking cutaneous transpiration appear to be the immediate cause of this inflammation in a considerable proportion of cases. Therefore, severe attacks of scarlet fever with abundant rash and desquama- tion, which require the patient to be kept in bed the proper time and in a warm room two or three weeks, appear to be less frequently followed by this renal disease than are milder cases which are more carelessly treated. The following is a resume of Klein's examinations in twenty-three cases. 1. Parenchymatous Nephritis, Proliferation of Nuclei, Hyaline Degeneration of Arterioles. — The Glomerulo-nephritis of Klebs. — Klein found increase of nuclei (probably epithelial) in the glomeruli, and hyaline degeneration of the intiina of minute arteries, especially marked in the afferent arterioles of the Malpighian bodies. The intima of these vessels was in places as swollen as to resemble cylin- drical or spindle-shaped hyaline masses, and cause narrowing of the lumina of the vessels in which this degeneration occurred. Klein observed in .some specimens so great hyaline degeneration of the capillaries of the Malpighian bodies that circula- tion through them was obstructed. In the more advanced or protracted cases this hyaline substance in the glomeruli began to assume a fibrous appearance. Bowman's capsule was considerably thickened. This hyaline degeneration of the Malpighian bodies Klein discovered in the earliest cases which fell under his observation. Also in the earliest cases the multiplication or germination of the nuclei of the muscular coat of the arterioles was observed, with a corresponding increase in the thickness of the walls of these vessels. This change in the muscular element was found in the arterioles in different parts of the kidney, but it was most conspicuous in these vessels at their point of entrance into the Malpighian bodies ; and it was distinctly noticed in other arterioles, both in the cortex and in the base of the pyramids. In the glandular portion of the kidneys other anatomical alterations were ob- served, indicating parenchymatous nephritis. There were swelling of the epithelial lining of the convoluted tubes : multiplication of the nuclei of the epithelial cells, especially in ascending tubules, which lay close to the afferent arterioles of Malpig- hian corpuscles: granular matter, and even blood, in the cavity of Bowman's cap- sule and the convoluted tubes ; cloudy swelling and granular disintegration of epi- thelium in some parts of the convoluted tubes ; detachment of epithelium from the membrane of larger ducts of the pyramids in some cases. These parenchymatous changes are already known to the profession through the observations and writings of Dickinson, Fenwick, Johnson, Simon, and others. Klein, in commenting on the hyaline degeneration which he observed, states that Neelsen found the walls of the capillaries of the pia mater thickened, highly refractive, and of a lardaceous appearance in certain acute infectious maladies, as variola, typhoid fever, measles, and in one case scarlet fever. 1 Usually, only a small portion of" the capillaries were thus affected, most frequently at the point of division into branchlets. In a few instances Neelsen noticed degeneration of arterioles extending a considerable distance, with fusion of the intima, media, and adventitia, and chemical examination showed that the substance produced by this degeneration had similar properties to elastic tissue. Although the examinations by Neelsen relate to the pia mater, two of his observations are especially interesting : first, that the hyaline change affects chiefly vessels near their point of branching ; and. secondly, that the hyaline substance is of the nature of elastic tissue, for in the kidney in scarlatinous nephritis the arterioles undergo the change in question chiefly near their point of branching into the capillaries of the glomerulus : and the intima being the part which undergoes the hyaline change, it is probable, in the opinion of Klein, that the same substance is produced by the degeneration in walls of the vessels of the kidney which Neelsen observed in the pia mater, and therefore that it is of the nature of elastic tissue. This hyaline degeneration of the arterioles is also very marked in the spleen in scarlet fever ; and in studying the minute anatomy of the intestines and spleen in typhoid fever Klein has found the same degeneration of the intima of the minute vessels. He believes that this hyaline change and the proliferation of muscle-nuclei which thus occur at an early period in scarlet fever in the renal vessels when the 1 Archir d&r Heilkunde, 1876. 276 CONSTITUTIONAL DISEASES. kidneys become affected are due to an irritating cause acting similarly to that in typhoid fever. Klein calls attention to the interesting examinations of the scarlatinous kidney made by Klebs, who attributed the diminished urination and the uraemic poisoning in certain cases in which the kidneys do not exhibit any marked change to the naked eye to what he designates glomerulo-nephritis. Klebs says : "In the post- mortem examination the kidneys are found slightly or not at all enlarged, firm, .... the parenchyma very hypersernic. Only the glomeruli appear, on close inspection, pale like small white dots. The urinary tubes are often not changed at all. Occasionally the convoluted tubes are slightly cloudy. The microscopic examination shows that there are neither interstitial changes nor proliferation of epithelium, the so-called renal catarrh generally supposed to be present in these conditions on account of the absence of other perceptible derangements ; and there seems, therefore, leaving out the glomeruli, the congestion of the kidneys alone to remain to account for the symptoms during life." But that mere congestion is insufficient to produce the symptoms appears from the fact that it does not cause them under other circumstances. Klebs finds, "on microscopic examination of the glomerulus, the whole space of the capsule filled with small somewhat angular nuclei, imbedded in a finely granular mass. The vessels of the glomerulus are almost completely covered by nuclear masses." Klein, commenting on these examinations by Klebs, states that in all early cases which he examined he observed great abundance of nuclei of the glomeruli, but a condition like that described and figured by Klebs 1 he has seen in only a few glomeruli ; for a general state of these bodies as described by this observer, and such an excessive proliferation of the nuclei that the blood-vessels are completely compressed, was not seen in one of the twenty-three cases. Klein therefore ques- tions whether the diminished urination and retention of the urea in scarlet fever, when the kidneys do not exhibit any conspicuous catarrhal or other change, is due, unless in exceptional instances, to compression of the vessels of the glomeruli by nuclear germination, but believes, rather, that the obstructed circulation, and con- sequent diminished urinary excretion, are largely due to the changed state of the arterioles. Klein adds that perhaps undue contraction of the arterioles, through stimulation by the blood-irritant, may also be a factor in causing arrest of circula- tion in the Malpighian corpuscles. As regards cases that perished early, he found the parenchymatous change slight, so that a careful examination was required in order to detect cloudy swelling and granular degeneration. 2. Interstitial Nephritis. — A second set of changes Klein observed in cases that died about the ninth or tenth day. In such cases he found changes due to inter- stitial, in addition to those produced by parenchymatous, nephritis. Round cells, lymphoid cells, or whatever else they should be called, were seen in the connective tissue of the kidneys. In the kidneys of those that died at the end of the first week after the commencement of nephritis, infiltration with round cells was observed in the connective tissue around the large vascular trunks. At a later stage this infil- tration had extended into the bases of the pyramids and into the cortex. The gradual increase in extent and intensity of this infiltration was so decided in the cases which Klein observed that he has no hesitation in concluding that when interstitial nephritis occurs it begins about the end of the first week, in the man- ner already stated — to wit, as a slight infiltration of the tissues around the large vascular trunks, and gradually extends, so that portions of the cortex, and rarely portions of the base of the pyramids, are changed into firm, pale, round-cell tissue in which the original tubes of the cortex become lost. The infiltration of the cortex with round cells, beginning at the roots of the interlobular vessels, spreads rapidly toward the capsule of the kidney, and laterally among the convoluted tubes around the Malpighian bodies In the course of this process considerable parts of the peripheral cortex, occasionally of a cunei- form shape, with the base nearest the capsule of the kidney, become changed into whitish, firm, bloodless, cellular masses, in which Malpighian corpuscles and uri- nary tubes are only imperfectly recognized, being more or less degenerated. In some cases attended by this infiltration of the cortex Klein observed a more or less dense reticulation of fibres, especially around the interlobular arteries, containing in its meshes lymph-cells, chiefly uninuclear. 1 Handbuch der Pathol., p. 646, fig. 72. SCARLET FEVER. 277 In a child of five years that died after a sickness of thirteen days Klein found evidence of intense interstitial inflammation, and also emboli, consisting of fibrin with a few cells, in the arteries, both in those of large size and in the arterioles, chiefly where they enter the Malpighian corpuscles. He states that in the speci- mens which he examined the more intense the degree of interstitial change, the greater was the enlargement of the kidneys, and the more distinct also were the evidences of parenchymatous nephritis in the urinary tubes, which either contained casts or were in process of destruction. By being crowded with inflammatory prod- ucts, especially cells, the Malpighian corpuscles were obliterated, undergoing fibrous degeneration. A very curious fact observed was the deposit of lime in the urinary tubes, first of the cortex, and then also of the pyramids, at an early stage of scarlet fever, when the kidneys otherwise showed only slight change. Several observers, as Biermer, Coats, and Wagner, have each described a case of scarlet fever with interstitial nephritis, which they consider unusual ; but Klein has apparently demon- strated, as we have seen, by a large number of microscopic examinations, that this form of nephritis is common after the ninth or tenth day. Nephritis, in proportion to its extent and gravity, is accompanied by languor, febrile movement, thirst, loss of appetite and strength. At first the patient expe- riences but slight pain in the head or elsewhere, and the quantity of urine is not notably diminished : but as the disease continues urination becomes less frequent and the urine more scanty. Albuminuria occurs, while the urea is only partially excreted, and therefore it accumulates in the blood. If the nephritis be so severe or protracted that this principle accumulates to a certain extent, grave symptoms occur, as headache, vomiting, apathy or restlessness, and, more dangerous than all, eclampsia, which is not unusual in these cases. Microscopic examination of the urine shows the presence in this liquid of blood-corpuscles, granular epithelial cells, and hyaline or granular casts or both. The specific gravity of the urine is diminished. But a large quantity of albumen in the urine may render the specific gravity as high or higher than in health. The altered state of the blood soon gives rise to transudation of serum, first observed in most cases as an anasarca occurring in the feet and ankles. The oedema, if not checked by treatment or through mildness of the disease, extends over the limbs, scrotum, and sometimes upon the trunk. It is well if the dropsy remain limited to the subcutaneous connective tissue, but, unfortunately, it is apt to occur, if the nephritis continue, in and around the internal organs, producing, mentioned in the order of frequency, pulmonary oedema, effusion into the pleural and peritoneal cavities, the pericardium, the encephalon, and lastly into the con- nective tissue of the larynx, causing that very fatal complication, oedema of the glottis. Although this is the common order in which dropsies occur, exceptions are not infrequent. Even the anasarca may not be the first to appear, although in the vast majority of cases it has the precedence. Thus, Rilliet relates the case of a boy of five years who twenty days after the occurrence of scarlet fever, and six hours after the appearance of bloody and albuminous urine, had double hydro- thorax, rapidly developed. As long as the hydrothorax continued no anasarca was observed, but as it declined anasarca appeared. Legendre cites a case in which oedema of the lungs occurred without anasarca or other dropsy. Occasionally, the anasarca and internal dropsies take place nearly simultaneously. The nephritis and consequent serous effusions usually appear within three weeks after scarlet fever ends, but cases occur in which the effusions are first observed as late as the fourth and fifth weeks. The patient may be considered to possess immunity from this sequel if he have reached the close of the fifth week after the abatement of scarlet fever without its occurrence. The dropsy is usually acute, but it may assume the chronic form, since the nephritis which causes it, happily curable in most instances, may, if neglected, become chronic. Whether the dropsy in itself involve danger depends in groat part on its location. Anasarca and ascites may exist a long time with little suft'er- ing or danger, but a small amount of serum in certain other localities causes alarming symptoms and speedy death. (Edema of the lungs, hydro-pericardium, oedema of the glottis, and intracranial effusions are always dangerous, and the last two are sometimes fatal within twenty-four to forty-eight hours. (Edema of the lungs has been fatal within twelve hours from the appearance of the first symp- toms of obstructed respiration. 278 CONSTITUTIONAL DISEASES. Cerebral symptoms occurring during scarlatinous nephritis are probably sometimes due to the irritating effect of the retained urea on the nervous centre. In other cases the cause appears to be a cerebral oedema or compres- sion of the brain by effusion of serum within the ventricles and upon the surface of the brain. Headache, dull or severe, dilatation of the pupils or their oscillation in a uniform light, vomiting with little apparent nausea, are common symptoms of scarlatinous nephritis when it has continued a few days, and the excretion of urea is so diminished that this substance begins to exert its poisonous effect on the system. Such symptoms are frequently followed by somnolence threatening coma or by eclampsia, unless the patients are promptly and properly treated. In some patients that die of scarlatinous nephritis, death occurring in convulsions or coma, no appreciable lesions are observed within the cranium, unless more or less congestion, the fatal ending being attributable to the uraemia. In other instances we find an effusion of serum within the ventricles or upon the surface of the brain. Although the symptoms in scarlatinous nephritis and uraemia may appear very unfavorable, the prognosis is usually good under prompt and appropriate treatment. Thus severe convulsions and a degree of somnolence that bordered on coma may abate, and convalescence be fully established within a few days. Rilliet and Barthez announce ten recoveries in thirteen patients affected with convulsions due to this renal affection. Anatomical Characters. — Scarlet fever being, as we have seen, a con- stitutional febrile disease of an ataxic nature, and accompanied by certain inflammations, necessarily affects the composition of the blood ; but since this disease varies so greatly in type or severity, the state and appearance of this liquid also vary. At the autopsies of the more malignant cases we find the blood dark and fluid, with small, soft, and dark clots in the heart and large vessels. In other cases the clots are large, firm, and solid, as described in a preceding page. In malignant cases that end fatally Rilliet and Barthez state that both the large and small vessels of the cerebral meninges and the brain are found hyperaemic, but in a variable degree. In those who die in coma, preceded by delirium or convulsions, during the eruptive stage the intracranial congestion is usually marked, with perhaps some. transudation of serum, but without inflammatory lesions. The fibrin in scarlet fever remains in about normal proportion, except as it is increased by inflammatory com- plications. Andral found an increase in the proportion of blood-corpuscles from 127 to 136 parts in 1000. The respiratory apparatus, except the Schneiderian membrane, is usually normal when no complications exist. Samuel Fenwick 1 made post-mortem examination in sixteen cases of scarlet fever, and concludes from them that inflammation of the mucous membrane of the stomach and intestines occurs like that of the skin, followed by desquamation of the epithelial cells, like that of the epidermis. I have had the opportunity of examining the stomach and intestines of those who died of scarlet fever in the eruptive stage, and have not found any unusual hyperaemia of the gastro-intestinal surface except when gastro-intestinal inflammation, usually indicated by diarrhoea, had occurred as a complication. In some cases the abdominal organs exhibit changes which suggest a resemblance to typhoid fever. The spleen is enlarged and somewhat soft- ened, and Peyer's patches and the solitary glands are thickened and promi- nent, but less in degree than typhoid fever. The mesenteric glands also are in a state of hyperplasia. In other patients these parts appear normal. Klein made microscopic examination of the liver in eight cases, and states that he found granular opaque swelling of liver-cells, and changes in the 1 London Lancet, Julv 23, 1864. SCARLET FEVER. 279 internal and middle coats of certain arteries similar to those observed in the kidneys which have been described above. He also found evidences of inter- stitial inflammation, as an increase of round cells and connective tissue in the liver. He remarks also that he observed hyaline degeneration of the intima of arteries in the spleen. Killiet and Barthez state that swelling and soften- ing of the spleen are exceptional in scarlet fever, but are sufficiently common to merit attention. In post-mortem examinations which I have witnessed nothing noteworthy has appeared to the naked eye in the state of the liver, nor ordinarily in that of the spleen. The efflorescence, though one of the anatomical characters, has perhaps been sufficiently described in the foregoing pages. It begins over the neck, chest, and groins as numerous reddish points not larger than a pin's head, closely crowded together, but with skin of normal color between. It is esti- mated that the aggregate efflorescence and aggregate normal skin over a given area are about equal. If the cutaneous circulation be active and the rise of temperature considerable, these spots extend and coalesce, producing an efflorescence like erythema or like the hue of a boiled lobster, to which it has been likened. The efflorescence, less upon the face than upon the trunk, contrasts in this respect with that of measles, in which the rash is full in the face, often causing some swelling of the features. It is also less upon the palmar and plantar surfaces than elsewhere. It scarcely causes any percep- tible elevation of the skin, but in certain localities, as upon the backs of the hands and upon the forearms, it communicates the sensation of slight rough- ness. The seat of the efflorescence is mainly in the superficial layers of the skin, but it is said that it sometimes has occurred upon a cicatrix, as that from a burn. In the robust and in favorable cases in which the circulation is active the rash has a scarlet hue, and when the cutaneous capillaries are emptied and the skin rendered pale by pressure with the fingers, the circula- tion immediately returns when the pressure is removed. In malignant cases the color is not scarlet, but dusky red, and so sluggish is the capillary circula- tion that the skin when pressed upon recovers the blood very slowly. In grave cases also extravasation of blood in minute points or transudation of its coloring matter sometimes occurs in portions of the surface when, of course, decolorization is not fully produced by pressure. In cases ending fatally, during the eruptive stage the efflorescence may entirely disappear in the cadaver, or it remains upon parts of the surface, especially depending por- tions. Desquamation is attributable to the exaggerated proliferation of the epidermis and the loosening of its attachment by the inflammation. Diagnosis. — In the commencement of scarlet fever, prior to the eruption, no symptoms or appearances exist which enable us to make a positive diag- nosis. Positive statement in reference to the nature of the attack should be deferred, for the credit of the physician. Still, if a child with no appreciable local disease sufficient to cause the symptoms a few days after exposure to scarlet fever, or during an epidemic of this malady, be suddenly seized with fever, the pulse rising to 110, 120, or more, and the temperature to 102°. 103°, or 105°, scarlatina should be suspected. The diagnosis is rendered more certain at this early stage if vomiting occur, and especially if the fauces be red, for hyperaemia of the fauces, due to commencing pharyngitis, is one of the earliest and most constant of the local manifestations of scarlatina. When the eruption has appeared the nature of the malady is in most instances apparent. The punctate character of the eruption before it becomes confluent, its occurrence within twenty -four hours after the fever begins over almost the entire surface, its absence or scantiness upon the face. and especially around the mouth, serve to distinguish it from other diseases. Scarlet fever and measles were long considered identical by the profes- 280 CONSTITUTIONAL DISEASES. sion, and, though the ordinary forms of these maladies can be readily distin- guished from each other, cases occur in which the differential diagnosis is attended by some difficulty. But there are differences in the symptoms and course of the two diseases which aid in discriminating one from the other. Measles begins with marked catarrhal symptoms, as if from a severe cold. Mild conjunctivitis, causing weak and watery eyes, coryza, and mild laryngo- bronchitis, with accompanying cough, precede the eruption three or four days and continue during the eruptive stage. The fever during the first or initial stage of measles is remittent, the evening temperature being two or three degrees higher than that in the morning. Contrast this with the invasion of scarlet fever, in which the only catarrh is that of the buccal and faucial surfaces, and there is consequently little or no cough, and the rise in tem- perature, ordinarily high in the beginning, is nearly uniform in the different hours of the day. The scarlatinous eruption appears, as we have seen, within twelve to twenty-four hours about the neck and upper part of the chest, and spreads over the body in a shorter time than that of measles, which appears on the third day. The rash of measles begins to fade at the close of the third or in the fourth day after its appearance, that of scarlet fever not till from the sixth to the eighth day. In nearly all cases of measles, even when the rash is confluent upon the face and a considerable part of the trunk in consequence of the high fever and active cutaneous circulation, we observe the character- istic rubeolar eruption upon certain parts of the surface, as the extremities ; which, in connection with the history, renders diagnosis certain. Erythema resembles the scarlatinous eruption, but its duration is com- monly shorter. It is limited to a part of the surface, and it is accompanied by much less fever. The temperature in erythema does not usually rise above 100°, unless for a few hours, whereas in scarlet fever it continues several days considerably above 100°. The scarlatinous efflorescence has also a brighter red or more scarlet hue than that of erythema, except that in the more malig- nant cases, in which the severity of the symptoms renders the diagnosis clear. But an important aid in differentiating the one from the other of these diseases is the fact that in erythema there is, with few exceptions, no faucial inflam- mation, and in the few instances in which it is present it is slight and tran- sient, fading within a day or two. Scarlet fever is readily diagnosticated from diphtheria, although the affinity is close between these two maladies. The early appearance of the pseudo-membrane upon the fauces in diphtheria, its absence in scarlet fever, and the absence of any appearance resembling it until the fever has con- tinued some days, and the characteristic efflorescence upon the skin in scarlet fever, render diagnosis easy. If scarlet fever have continued some days when first seen by the physician, the diphtheritic pseudo-membrane may be present as a complication, or the fauces may present an appearance like diphtheria from ulceration or sloughing and the presence of foul and offen- sive secretions, which produce a dark -grayish and fetid mass over the faucial surface. Under such circumstances the character of the disease is ascer- tained by the history of the case, and especially by the occurrence of the scarlatinous eruption. An erythema transient and limited to a part of the surface sometimes appears in the commencement of diphtheria, and at a later period, as a result of the toxaemia upon the extremities. Roseoloid points and patches often occur upon the extremities. Both kinds of rash can be readily diagnosticated from that of scarlet fever, for the erythema, as has been stated, is transient and partial, and does not exhibit minute points of deeper injection, while the toxasmic rash differs in form and aspect from that of scarlet fever, and appears at a stage when the scarlatinous efflorescence has faded or begun to fade. SCARLET FEVER. 281 The efflorescence of rotheln sometimes closely resembles that of scarlet fever, though it is usually more like that of measles ; but it is ordinarily accompanied by symptoms which are much milder than those of scarlet fever, and it begins to abate as early as the third, and disappears on the fourth, day. The eyes have a suffused appearance, the temperature may reach 102° or 103°. and the efflorescence may be as general over the body as that of scarlet fever, but there is not the aspect of serious indisposition, and the speedy abatement of the symptoms shows that the disease is not scarlet fever. Prognosis. — The prognosis depends on the form of scarlet fever, whether mild or severe, the strength of the patient, and the presence or absence of complications or sequelae. The type of the disease is sometimes so mild throughout an epidemic or during a series of years that death seldom occurs, whatever the mode of treatment ; but afterward the type changes, and the percentage of deaths increases and remains high till another amelioration in the type occurs. Sydenham in the middle of the seventeenth century stated that scarlet fever, as he saw it in London, was so mild that it scarcely deserved the name of disease : " Yix nomen morbi merebatur." Morton some years later, and Huxham in the following century, had abundant reason to regret the change of type, and now throughout Great Britain scarlet fever is one of the most fatal and most dreaded of the diseases of childhood. In Dublin during the present century, prior to 1834, scarlet fever was uniformly mild, so that on one occasion of eighty patients in an institution all recovered. In 1834 the type of the disease totally changed and epidemics of unusual virulence occurred. The type frequently changes from mild to severe or severe to mild, not only in consecutive years, but in consecutive months. A few years since a distinguished physician of New York treated about fifty cases of scar- let fever in one of the institutions without a single death, but a few months later the type of the malady changed, and his own son was among those who perished from it. The prevailing type of the disease should therefore be con- sidered in giving the prognosis when in the commencement of a case we are asked the probability as regards the termination. Extensive statistics, including those collected by Murchison from various sources, show that in different epidemics the mortality may vary as much as from 3 per cent. (Eulenberg of Coblentz) to 19.3 per cent, (cases seen by myself in New York City in 1881-82, many of which were complicated by diphtheria), or even to 34 per cent, (epidemic in the Palatinate in 1868-69). The hospital statistics of Billiet and Barthez gave 46 deaths in 87 cases, or about 53 per cent. The mortality is nearly equal in the two sexes, but age has a marked influence on the percentage of deaths. The period of the greatest mortality, and also of the greatest frequency, of scarlet fever is between the ages of one and six years. The following are statistics bearing on the relation of the age to the percentage of deaths : Under 1 year. From the close of 1st till close of 5th year. From the 5th to the 12th year. Fleishman : : Cases Deaths 8 6 204 88 260 51 1st to close of 6th year. 6th to 12th year. From the 12th to 20th year. Kraus : Cases Deaths . 13 4 113 29 106 10 7th to 16th year. 40 Yoit : Cases Deaths 5 1 166 24 109 10 282 CONSTITUTIONAL DISEASES. From 1st to close Under 1 year. of 5th year. Over 5 years. Roset: Cases . 43 156 88 Deaths .16 31 3 Under 5 years. 5th to 10th year. 10th to 15th year. Over 15 years. Russinger : Cases . 101 126 47 27 Deaths .21 20 3 These statistics, which I believe correspond with the observations of others,, show that although few cases occur in the first year, the percentage of deaths is large, and that a majority of the total deaths from this malady occur under the age of six years. After the sixth year the greater the age the less the proportionate number of deaths. Observations have thus far failed to establish any connection in the atmos- pheric conditions of temperature or moisture and the type of scarlet fever. Grave as well as mild epidemics have occurred in all climates and seasons. Scarlet fever is liable to so many complications and sequelae that a phy- sician should not predict a certain favorable termination in the beginning, however mild and regular the symptoms may be. But a favorable result may be expected if the attack be mild, the efflorescence appear at the proper time and extend over the entire surface, the angina be moderate and accom- panied by little or no cellulitis or adenitis, with pulse under 140, temperature not above 103°, and no marked nervous symptoms. Whether the complications or sequelae be dangerous depends upon their character. Rheumatism has never in my practice been dangerous, nor has it materially retarded convalescence, except when it affected the heart, causing pericarditis or endocarditis, when it involves great danger. Nephritis, if it be moderate, attended by little albuminuria and serous effusion and by the occurrence of few renal casts in the urine, commonly ends favorably under judicious treatment, as we have already stated ; but severe nephritis, with abundant albuminuria and casts and serous effusions, soon gives rise to alarming symptoms, and is the cause of death in a considerable number of instances. A similar remark is applicable to the angina, which occurs in all grades of severity. If it be attended by much cellulitis, with considerable ulceration or necrosis, the state is one of danger in consequence of the diffi- culty in administering sufficient nutriment, as well as from the diminished assimilation and the loss of strength due to the prolonged inflammatory fever, the septic poisoning, and the occasional hemorrhages. Complication by pharyngeal or nasal diphtheria, now so common where diphtheria is endemic, also greatly increases the danger. Many cases, even when their course is normal and without complications, involve danger, and some are necessarily fatal, from the direct effect of scar- latinous blood-poisoning. Such are grave or malignant forms of the disease which the experienced eye recognizes at a glance. Death often occurs rapidly from the toxaemia. Such cases are characterized by high temperature (105° or 106°), rapid pulse, dusky-red hue of the surface from languid capillary circulation, pungent heat, frequent vomiting, diarrhoeal stools, a dry-brown tongue, and marked nervous symptoms, such as delirium, great restlessness, or stupor. Not a few in this form of scarlet fever take eclampsia, which is likely to be severe and repeated, and to end in fatal coma. Other inflammatory complications and sequelae, which have been described in the preceding pages, retard convalescence and jeopardize the life of the patient, such as empyema, endocarditis, pericarditis, and pneumonia. Otitis media is seldom immediately dangerous, although it may be painful and involve serious consequences, even a fatal meningitis, as has been stated SCARLET FEVER. 283 above, after months or years of otorrlioea. Anomalous cases are believed to be. as a rule, more dangerous than such as are attended by an early and full efflorescence and have the usual symptoms. Treatment. — Prophylaxis. — Since the discovery by Jenner of the pro- phvlactic power of vaccination as regards smallpox, the attention of the profession has been frequently directed to the prevention of scarlet fever. Belladonna has been employed for this purpose by a class of practitioners who believe in the theory that an agent which produces symptoms similar to those of a disease is antagonistic to that disease, and therefore tends to pre- vent it. or. if it be present, to render it milder ; and since this herb causes an efflorescence upon the skin and redness of the fauces, it was selected as the proper preventive and remedial agent for scarlet fever. Its use, however, for this purpose has been fruitless, and it is now nearly or quite discarded. It is now known, from a considerable number of observations, that scarlet fever occasionally occurs in the domestic animals during epidemics of the disease in children. It is stated that Spinola observed it in the horse ; that Heim saw a dog that occupied the same bed with a scarlatinous patient sicken with fever, which was followed by desquamation ; that Letheby saw scarlatina in swine, and Kraus in young cattle. Prominent veterinary surgeons, as Williams of Great Britain, admit the occurrence of scarlatina in animals, and the hope has arisen that since smallpox is modified in cattle so as to afford us the vaccine virus, perhaps scarlet fever may also be modified by passing through one of the lower animals, so that a milder and less fatal form of the disease might be produced in man by inoculation from the animal. Inocula- tions have been made to ascertain whether the scarlet fever of animals occurs in a modified form, but so far without result. Under the circumstances the experimenter who propagates so dangerous a disease by inoculation renders himself liable, it seems to me, to criminal proceedings in the courts. In the present state of our knowledge the most reliable and certain pro- phylaxis is the isolation of patient and nurses and the thorough and judicious employment of disinfectants upon their persons and in the apartments. All furniture and articles not absolutely required should be removed from the sick-room, and no one should be allowed to enter it except the medical attend- ant and nurses. Constant ventilation should be insisted on by lowering the upper and raising the lower sash of the window two or three inches in mild weather. Even in stormy weather sufficient ventilation can be obtained in this way without exposing the patient to currents of air, which should be avoided. The New York Board of Health enforces the following regulations to prevent the spread of scarlet fever as well as other acute infectious maladies : "Care of Patients. — The patient should be placed in a separate room, and no person except the physician, nurse, or mother allowed to enter the room or to touch the bedding or clothing used in the sick-room until they have been thoroughly disinfected. "Infected Articles. — All clothing, bedding, or other articles not absolutely necessary for the use of the patient should be removed from the sick-room. Articles used about the patient such as sheets, pillow-cases, blankets, or clothes, must not be removed from the sick-room until they have been disin- fected by placing them in a tub with the following disinfecting fluid : eight ounces of sulphate of zinc, one ounce of carbolic acid, three gallons of water. They should be soaked in this fluid for at least an hour, and then placed in boiling water for washing. " A piece of muslin one foot square should be dipped in the same solution and suspended in the sick-room constantly, and the same should be done in the hallway adjoining the sick-room. 284 CONSTITUTIONAL DISEASES. u All vessels used for receiving the discharges of patients should have some of the same disinfecting fluid constantly therein, and immediately after being used by the patient should be emptied and cleansed with boiling water. "Water-closets and privies should also be disinfected daily with the same fluid or a solution of chloride of iron, one pound to a gallon of water, adding one or two ounces of carbolic acid. ki All straw beds should be burned. : ' It is advised not to use handkerchiefs about the patient, but rather soft rags, for cleansing the nostrils and mouth, which should be immediately there- after burned. " The ceilings and side-walls of a sick-room after removal of the patient should be thoroughly cleaned and lime-washed, and the woodwork and floor thoroughly scrubbed with soap and water." By^ such measures of prevention there can be no doubt that the number of cases of scarlet fever has been reduced. But do the health boards accomplish all that they are able to do in sup- pressing scarlet fever as well as diphtheria ? The New York Health Board excludes children from the schools who live in the houses where these diseases are occurring, gives directions in reference to the care of the patient and the disposition of infected articles, and promises to disinfect the sick-room when word is sent to the board. But these measures are inadequate or are only partially successful in preventing these diseases. To my knowledge, many families in New York never send word that they are ready for the disinfection of the apartments, and many families in the tenement-houses move away as soon as possible. The vacated rooms are re-rented to families who have no knowledge of the previous sickness, and are surprised when their children immediately after are taken sick. It would be better if the health board in every instance disinfected the infected apartments after the termination of the sickness, whether the family are willing or not. Moreover, the reader is referred to our remarks on the prevention of diphtheria for evidence of the inadequacy of the sulphur fumigation. But the suppression of scarlet fever cannot be effected without the co-ope- ration of the attending physician. He can accomplish more than the health board in the way of prophylaxis. More than a quarter of a century has elapsed since the late Dr. William Budd of England recommended prophy- lactic measures, and the following is his testimony in regard to the result : " The success of this method in my own hands has been very remarkable. For a period of nearly twenty years, during which I have employed it in a very wide field, I have never known the disease to spread beyond the sick- room in a single instance, and in very few instances within it. Time after time 1 have treated this fever in houses crowded from attic to basement with children and others, who have nevertheless escaped infection. The two ele- ments in the method are separation on the one hand and disinfection on the other." x In my opinion it is quite possible to realize the experience of Dr. Budd if proper prophylactic measures be employed from the beginning of the sick- ness. The attending physician at his first visit and at each subsequent visit should consider it an imperative duty to direct the employment of adequate preventive measures. Health boards give directions that objects not required to promote the comfort of the patient should be removed from the sick-room, and no one be allowed to enter it except the physician, nurse, and mother. The floor and walls of the apartment should be bare, but I would go farther than the health board, and insist that no reading matter, especially books and primers, be allow in the room, or if allowed they should subsequently be 1 British Medical Journal, January 9, 1869. SCARLET FEVER. 285 burnt, since, as we have seen, the specific poison obtaining lodgment between the leaves is not readily reached by disinfectants, and may communicate the disease months afterward. I recommend for disinfection of the room at my first visit, and also for cases of diphtheria, the following prescription : R. Acidi carbolici, 01. eucalypti, da. 5J ; Spts. terebinth., 3VJ. — Misce. Two tablespoonfuls are added to one quart of water in a tin wash-basin or similar vessel with broad surface, and maintained in a state of constant simmering over a gas- or oil-stove during the entire sickness. The odor of this vapor is agreeable rather than unpleasant, and it appears to disinfect to a considerable extent the breath and exhalations from the body of the patient. At the same time, I order inunction of the entire surface every third hour with the following : R. Acidi carbolici, 01. eucalypti, da. gj ; 01. olivse, Ivij. Dr. Jamieson recommends disinfection of the fauces by the frequent application of a saturated solution of boric acid in glycerin. This or some other non-irritating solution should be often applied, not only to the fauces, but also in the anginose cases to the nostrils. I have recommended the application of corrosive sublimate solution, two grains to the pint, applied to the fauces by a camel-hair pencil or by cotton wadding wound around a slender stick, in the same manner in which Dr. Oatman and others employ it in diphtheria. The cautious physician in attending a case of scarlet fever will always bear in mind the possibility that his person or clothing may become infected, and be the vehicle through which the poison may be communicated to others. In examining the fauces of a patient he should stand a little to one side, so that no muco-pus, if the patient cough, be received on his clothing ; nor will he go directly from a scarlatinous patient to a child with another sickness, or to a midwifery case, without first washing his hands, hair, and face in a corrosive-sublimate solution, and changing his outer apparel ; or if he visit a child without such precautionary measures, he will not approach any nearer than is sufficient to enable him to determine its ailment and condition. Hygienic Treatment. — The room occupied by a scarlatinous patient should be commodious and sufficiently ventilated. Its temperature should be uni- form, at about 70° during the course of the fever. When the fever begins to abate and desquamation commences, a temperature of 72° to 75° is prefer- able, so that there is less danger that the surface may be chilled during unguarded moments, as at night, when the body may be accidentally uncov- ered, since sudden cooling of the surface at this time may cause nephritis or some other dangerous inflammation. Henoch does not believe in the theory that the nephritis is commonly produced by catching cold, but many observa- tions show that those who are carefully protected from vicissitudes of tem- perature, who remain during convalescence in a warm room, and are pro- tected by abundant clothing, more frequently escape this complication than such as are under no restraint of this kind and are carelessly exposed in times of changeable weather. Nevertheless, it is true that a certain proportion suffer from nephritis however judicious the after-treatment may be. The best hygienic management does not always prevent its occurrence. The patient should not, therefore, leave the house until four weeks after the 286 CONSTITUTIONAL DISEASES. beginning of the fever, and in inclement weather not till a longer time has elapsed. So long as desquamation is going on and the skin has not regained its normal function, the patient should remain indoor, and when finally he is allowed to leave the house he should be warmly clothed. Therapeutic Treatment. — In order to treat scarlet fever successfully, it is necessary to bear in mind that it is a self-limited disease, running a certain time and through certain stages, and that it is not abbreviated by any known treatment. Therapeutic measures can only moderate its symptoms and ren- der it milder. The severity of the disease is indicated by its symptoms, and the symptoms are to a certain extent under our control. Mild Cases. — A patient with a temperature under 103° and with only a moderate angina does not require active treatment, but, however light the disease, he should always be in bed and in a room of uniform temperature, as stated above. Instances have come to my notice in the poor families of New York in which scarlet fever was not diagnosticated, and the patients were allowed to go about the house, and even in the open air, in the eruptive stage, till some severe complication or an aggravation of the type created alarm and medical advice was sought, when it appeared that a grave and dan- gerous condition had, through carelessness and ignorance, resulted from a mild and favorable form of the malady. The physician when summoned to a case however mild, should never fail to take the temperature, note the pulse, inspect the fauces, and inquire in reference to the fecal and urinary evacuations, that he may detect early any unfavorable changes which may occur. Since in all cases of mild as well as severe scarlet fever more or less blood-deterioration and angina are present, the following prescription of the tincture of the chloride of iron and pineapple will be found useful : R. Tine, ferri chloridi, ^ij ; Syrupi ananassa? saliva?, ^v. — Misce. Shake bottle. Give one teaspoonful every two hours to a child of three years I have long since discarded the potassium chlorate as a local remedy for affections of the throat, but the above prescription is beneficial as a tonic and astringent. The following is also a useful prescription : R. Quinise sulphat. , gr. xyj ; Syr. pruni virginiani, Syr. verba? santa? comp., da. ^j. — Misce. Sig. One teaspoonful every fourth hour to a child of three to five years. The treatment of scarlatina by antiseptic remedies will be considered hereafter. The itching and dryness of the surface, which increase the discomfort of the patient in mild as well as severe scarlatina, are relieved by the ointment mentioned in treating of prophylaxis. The linen should be changed every day and the bed thoroughly aired. Ordinary Cases and Cases of Severe Type. — A safe temperature in scarlet fever may be considered at or below 103°. If it rise above this, measures designed to abstract heat are very important — more important even in many cases than the medicinal agents which are commonly used to combat this disease. Since a high temperature retards assimilation, promotes deleterious tissue-change, and causes rapid emaciation and loss of strength, measures designed to reduce it are urgently needed. " The production of heat depends chiefly on oxidation of the constituents of the body " (Billroth). Therefore, fever indicates an increase of the oxidation and a molecular disintegration SCAELET FEVER. 287 above the healthy standard. Hence the augmentation of urea in the urine and the progressive emaciation and loss of weight which characterize the febrile state. Fever also diminishes the secretions by which food is digested and destroys the appetite, so that repair of the waste is insufficient. More- over, a high temperature continuing for a time tends to produce degenerative changes, albuminous and fatty, in the tissues, the more rapidly the higher the temperature, so that the functions of organs are seriously impaired. Among the most dangerous of the tissue-changes is granulo-fatty degenera- tion of the muscular fibres of the heart. In dogs and rabbits that have per- ished from a high temperature artificially produced by experimenters gran- ular clouding of the elementary tissues has been found after death. 1 A high temperature, therefore, in itself involves danger, and if it occur in an ataxic disease like scarlet fever, and be protracted, it greatly diminishes the chances of a favorable issue. As an agent in reducing heat without producing depression the following prescription has given in my practice better results than any other : R. 01. cinnamomi, gtt. v ; Phenacetime, J}ij ; Sodii bromidi, ^ij ; Caffeini citrat., gr. xv ; Sacch. lactis, 3j. — Misce. Divid. in chart. No. xv. To a child of ten years give one powder every three or four hours ; give half a powder to a child of five or six years. Patients with a high temperature and impending convulsions have been rescued by this remedy. The temperature can be reduced without shock or injury to the child by the judicious use of cold water externally. The cold-water treatment is not necessary if the temperature be under 103°, though useful if judiciously ■employed by sponging when the temperature is at 102° or 103° ; but if it rise above 103° it is required, and the more urgently the higher the temperature. The external use of cold water as an antipyretic in the febrile diseases is now almost universally recommended by physicians, but it still meets with oppo- sition on the part of families, especially in the treatment of the exanthematic fevers, and the directions for its employment are therefore not likely to be fully carried out during the absence of the medical attendant. The old theory that the fevers require warmth and sweating has such a firm hold on the popular mind that some years longer will be required for its removal. The modes of applying cold water recommended by cautious and expe- rienced physicians are various. Von Ziemssen recommended that the patient be immersed in water at a temperature of 90°, and cool water be gradually added till the temperature fall to 77°. In a few minutes the patient is returned to his bed, his surface dried, and he is covered by the proper bed- clothes, when his temperature will probably be found reduced two or two and a half degrees. If the patient complain of chilliness or his pulse be feeble, he should be immediately removed from the bath and stimulants adminis- tered, either whiskey or brandy, for if the extremities remain cool and the capillary circulation sluggish, the effect may be injurious, since some internal inflammation may arise to complicate the fever. Under such circumstances increased alcoholic stimulation is required. The cold pack is also effectual for reducing the temperature. The patient is placed upon a mattress protected by oil cloth, and is covered by a sheet wrung out of water at a temperature of 70°. This is covered by one or two 1 See experiments by Mr. J. W. Legg, Lond. Path. Soc. Tnutx., vol. xxiw. and others. 288 CONSTITUTIONAL DISEASES. blankets. In half an hour he is returned to bed, and will be found to have a temperature two or three degrees less than that before the bath. Another method is to apply the sheet wrung out of water at 90°, and then reduce the temperature by adding water at a lower degree from a sprinkler. In most cases, however, I prefer to reduce the temperature by the constant applica- tion to the head of an India-rubber bag containing ice. The bag should be about one-third filled, so that it should fit over the head like a cap. At the same time, as a potent means of abstracting heat, at least when the tempera- ture is at or above 104°, a similar application should be made by an elongated rubber bag lying over the neck and extending from ear to ear. Cold applied over the great vessels of the neck promptly abstracts heat from the blood, while it diminishes the pharyngitis, adenitis, and cellulitis ; which is an import- ant gain. At the same time, it is proper to sponge frequently the hands and arms with cool water. If the temperature with this treatment be not suffi- ciently reduced, one or two thicknesses of muslin frequently wrung out of ice- water should be placed along the arms and upon either side of the face. By such local measures, which are agreeable to the patient and without shock or perturbing effect on the system, we can reduce the temperature two or three degrees. By adding alcohol or one of the alcoholic compounds to the water the popular objection to the use of cold is overcome. Trousseau, in the treatment of sthenic cases attended by a high tempera- ture, was in the habit of placing the patient naked in a bath-tub, and directing three or four pailfuls of cold water to be thrown over him in a space of time varying from one-quarter of a minute to one minute, after which he was returned to bed and covered by the bedclothes without being dried. Reaction immediately occurred, often with more or less perspiration. This treatment was repeated once or twice daily, according to the gravity of the symptoms. Trousseau, alluding to this treatment, says : " I have never administered it without deriving some benefit." But the application of cold water in a man- ner that does not excite or frighten the patient seems preferable. Henoch, having a large experience, gives the following advice in reference to the water treatment : "If the fever continue high and the apparently malignant symp- toms described above develop, the head should be covered with an ice-bag r .... and the child placed in a lukewarm bath, not under 25° R. (88.25° F.). I decidedly oppose cooler baths, because in scarlatina, which presents a tend- ency to heart-failure, cold may produce an unexpected rapid collapse more than in any other affection. But I strongly recommend washing the entire body every three hours with a sponge dipped in cool water and vinegar." l In grave cases with a high temperature the application of cold should be sufficient to produce a decided reduction of heat, otherwise the full benefit from its use is not obtained. With proper stimulation and proper precautions, prostration does not occur from the ice-bags to the head and neck and cool sponging of other parts so long as the temperature does not fall below 102° or 103°. The danger alluded to by Henoch can only occur from the use of the pack or general bath, and the water treatment can be efficiently carried out and the temperature sufficiently reduced without resorting to these. Even Currie of Edinburgh, who first drew attention to the benefit from the cold- water treatment of scarlet fever in an age when the sweating treatment, and even the exclusion of cool and fresh air from the apartment were deemed necessary, recommended cold effusion only in sthenic cases with full and strong pulse ; and he mentions as a warning two cases with quick and feeble pulse and cool extremities in which death occurred immediately after the use of the water. In severe cases with frequent and rapid pulse, in which ante-mortem heart- 1 Diseases of Children. SCARLET FEVER. 289 clots are liable to occur, the ammonium carbonate is often useful. It should be dissolved in water and given in milk in as large doses as three grains every hour or second hour to a child of five years. It aids in producing stronger contraction of the cardiac muscular fibres, and thus diminishes the danger of the formation of thrombi. Ten-drop doses of the aromatic spirits of ammo- nia may be employed instead of the carbonate, given in sweetened water. It is especially useful if the stomach be irritable. A wineglassful of milk should be employed for this purpose, so that the medicine do not cause gastritis. In severe cases attended by considerable angina and foul and offensive secretions upon the faucial surface an antiseptic, as boric acid is required. If no drink be allowed for a few minutes after the dose, so as not to wash it too soon from the fauces, the antiseptic effect is more certainly produced. Those old enough should be directed to hold the medicine for a moment like a gargle in the throat before swallowing it. I employ boric acid by preference, as in the following formula : R . Acid, boric, £ss ; Tr. ferri chloridi, f^ij ; Glvcerini, ) -- ^z- Syrupi, |««-fl.lj Aquae, f 5 ij . — Misce . Sig. Give one teaspoonful every two hours to a child of five years. More minute directions will presently be given for the treatment of the pharyngitis when we speak of the complications. Alcohol, whether administered in one of the stronger wines, as sherry, or in whiskey or brandy, is a most useful remedy in scarlet fever, and is indeed indispensable in all grave cases which are attended by feeble capillary circula- tion and evidences of prostration. Milk is also the best vehicle for this agent. The wine-whey or milk-punch should be given every hour or second hour. In scarlet fever, as well as diphtheria, comparatively large doses are required, as a teaspoonful of whiskey or brandy every hour or second hour for a child of five years. During convalescence the hygienic treatment already described is import- ant. Nutritious diet and a moderate amount of alcoholic stimulants are required, while the patient is kept indoor and protected from currents of air as long as desquamation is occurring. More or less anaemia is present in most convalescent patients, so that a mild tonic containing iron will aid in restoring the health. Elixir of calisaya-bark and iron, preparations of beef, iron, and wine, or the liquid ferri-peptonati in teaspoonful doses will be found useful under such circumstances. Inunction of the entire surface with the mixture of carbolic acid, oil of eucalyptus, and sweet oil, as recommended above, should be continued as long as the epidermis desquamates. Treatment of Complications and Sequelae. — Local measures designed to diminish or cure the pharyngitis are important in all but the mildest cases. They are more especially required in the anginose variety and in those not infrequent cases in which diphtheria complicates scarlatina. Formerly it was necessary, in making applications to the fauces, to employ the brush or pro- bang for those too young to use the gargle, but hand-anatomizers. as Richard- son's or Delano's, which are now in common use, afford a quick and easy method for making such applications. Six or eight compressions of the bulb of a good atomizer are sufficient to cover the fauces with the spray. Those hand-atomizers in the shops which have slender metallic points are likely to prick the buccal surface and cause bleeding if the child resist and toss the head. To prevent this I recommend the single-bulb atomizer with a simple 19 290 CONSTITUTIONAL DISEASES. rubber tip. The following will be found useful mixtures for the atomizer for ordinary cases : R. Creosoti, Morson's Beech wood, gtt. iij-iv ; Acid, borici, ,^ij-iij ; Glycerini, f^ij ; Aquae, f^vj. — Misce. R. Carl Seller's Tablet for the Throat, no. j ; Creosote, Morson's, gtt. ij ; Aquae destillat., 3iij. — Misce. Spray either mixture over surface of the throat every two hours. If diphtheritic exudation complicate the scarlatinous angina, or the surface of the throat in consequence of ulceration or necrosis present an appearance like that in diphtheria, when the exudation begins to soften, being foul, jagged, of a dirty-brown appearance from dead matter and fetid secretions, those mixtures for spraying the throat will be found useful which are recom- mended in our remarks relating to the local treatment of diphtheria. The following mixture is also beneficial for local treatment when the faucial surface is foul and offensive from the exudations and secretions. It should be applied by a large camel's-hair pencil every three to six hours : . Acidi carbolici, gtt. x ; Liq. ferri subsulphatis, f#j; Glycerini, ,Jj; ^iij. — Misce. Aqua?, In all cases of scarlatinous pharyngitis sufficiently severe to require special treatment, cool applications should be made over the neck from ear to ear, as by two thicknesses of muslin frequently squeezed out of cold water, or by the elongated India-rubber bag already recommended in our remarks relating to the methods to reduce temperature. In the first days of scarlet fever the coryza is slight and no discharge from the nostrils occurs, so that no local treatment is required ; but before the ter- mination of the malady, in cases of ordinary gravity, a nasal discharge usually supervenes, producing more or less redness and excoriating the upper lip. Moreover, in localities where diphtheria occurs, if this malady complicates scarlet fever, it usually affects the nostrils at the same time that the fauces are invaded. These conditions require local treatment of the nares. It should be remembered that the Schneiderian membrane is midway in sensitiveness, as it is in location, between the conjunctival and buccal surfaces, and is readily irritated by strong applications. Medicinal applications made to it must be much milder than those which the fauces tolerate. They should always be applied warm, and a teaspoonful of any mixture properly employed is sufficient for each nostril at one sitting. The applications should usually be made every two to four hours, according to the gravity of the case and the amount of the discharge. The best instrument for this purpose is a small syringe of glass with curved neck and bulbous rubber tip. The child's head should be thrown back and the piston depressed rapidly, so as thoroughly to wash out the nasal cavity. The application can also be made through an atomizer with a rounded tip or a tip covered by rubber tubing. The following is a useful prescription : R. Acidi borici, gj ; Sodii biborat., ,^ij ; Aqua? purae, Oj. — Misce. SCARLET FEVER. 291 It is evident, from what lias been stated above, that the condition of the ear should be closely observed in and after scarlet fever. If the patient have earache, considerable relief may be obtained in the commencement by drop- ping a few drops of laudanum and sweet oil into the ear and covering it by some hot application, either dry or moist, which will retain the heat. A light bag containing common table-salt, heated, or dry and hot chamomile-flowers, will also answer the purpose. Water as hot as can be well tolerated dropped into the ear or allowed to trickle from a fountain syringe, so as to fill the ear, is also very beneficial in allaying the pain. A -I per cent, solution of nitrate of cocaine, with an equal quantity of laudanum, dropped into the ear, will often give considerable relief. If the hot applications over the ear are not well borne. Dr. C. H. May, aurist, recommends applying a long and narrow ice-bag immediately behind the auricle and extending under and in front of the ear, so as to cover the temporo-maxillary region, and at the same time instilling into the ear hot salt water (^j to Oj), to which laudanum or cocaine is added. He also states that antipyrine in large doses is also useful in reliev- ing the pain. 1 If the pain be not quickly relieved, a leech should' be applied at the base of the tragus. 0. D. Pomeroy, an experienced aurist of New York, says : " Leeching employed at the right time rarely fails to subdue the pain and inflammation. The posterior face of the tragus is ordinarily the best place for applying the leech, but it may be applied in front of the ear or behind, wherever the tenderness on pressure is greatest. In my opinion, paracentesis may frequently be rendered unnecessary by the timely use of one or two leeches applied to the meatus." If the otitis continue, as shown by pain in the ear, of which children old enough to speak bitterly complain, and which causes those too young to speak to press their fingers into or against their ears, this inflammation should not be neglected, as it may involve serious consequences. Multitudes of children have had permanent impairment or even loss of hearing, with caries or necro- sis of the walls of the middle ear and of the mastoid cells, which might have been prevented by prompt and skilful management of the ear in the early stage of the inflammation. If, therefore, the otitis continue without mitiga- tion of pain after the above measures have been employed, paracentesis of the drumhead is probably required. The following directions for performing this operation, which will be useful for country practitioners who may not be able to obtain the assistance of a specialist, are furnished by Dr. Pomeroy : " The forehead mirror should be worn, in order to leave the hand free to operate by either artificial or day light. A good-sized speculum is introduced into the meatus. Then an ordinary broad needle, about one line in diameter, with a shank of about two inches, such as oculists use for puncturing the cornea, should be held between the thumb and fingers, lightly pressed, so as not to dull delicate tactile sensibility. The part being well under light, the most bulging portion of the membrane should be lightly and quickly punctured with a very slight amount of force. The posterior and superior portion of the membrane is the most likely to bulge. The chordae tympani nerve ordinarily lies too high up to be wounded. The ossicles are avoided by selecting a pos- terior portion of the membrane. After puncture the ear should be inflated by an ear-bag whose nozzle is inserted into a nostril, both nostrils being closed, so as to force the fluid from the tympanum. The puncture may need to be repeated at intervals of a day or two, provided that the pain and bulging return." Albert H. Buck of New York, in a highly instructive paper read before the International Medical Congress in 1876, writes as follows of paracentesis of the membrana tympani in scarlatinous otitis : ,: In this one slight opera- 1 Pediatric Sec. of N. Y. Acad, of Med., March 14, 1889. 292 CONSTITUTIONAL DISEASES. tion, which in itself is neither dangerous nor very painful, lies the power to prevent the whole train of disagreeable and dangerous symptoms." Buck relates an instructive example : The age of the patient was three years, and the earache had been complained of only about twenty-four hours. " Toward morning," says he, " I was sent for, as the pain had become constant An examination with the speculum and reflected light showed an oedematous and bulging membrana tympani (posterior half), the neighboring parts being very red, though as yet but little swollen. In the most prominent portion of the membrane I made an incision scarcely three millimetres (one-tenth inch) in length, and involving simply the different layers of the membrana tympani. This was almost immediately followed by a watery discharge (with- out the aid of inflation), which ran down over the child's cheek. At the end of three or four minutes the child had ceased crying, and in less than a quar- ter of an hour she was fast asleep. At first the discharge was very abun- dant and mainly watery in character, but it steadily diminished in quantity and became thicker, till finally, on the fourth day, it ceased altogether. On the tenth day the most careful examination of the ear could not detect any trace of either the inflammation or the artificial opening." The ear had prob- ably been saved from ulceration of the drum membrane, long-continued sup- purative otitis, and perhaps permanent impairment of hearing. When an opening has been made in the membrana tympani, either by incision or ulceration, it is advisable in some instances to inflate the tym- panum by Politzer's method, which has been alluded to above. The nozzle of an India-rubber bag with a flexible tube attached is introduced into the nostril on the affected side, and both nostrils are compressed against it. The patient fills his mouth with water, which he swallows at a given signal, as after the words one, two, three, spoken by the operator. During the act of swallowing, which opens the Eustachian tube, the rubber bag is forcibly com- pressed, which forces the air along the tube into the middle ear and facilitates the escape of the pent-up secretions in the tympanic cavity. Dr. May recom- mends cleansing the nostrils and pharynx with a warm solution of salt, one drachm to the pint, before the use of Politzer's bag. If the otitis have continued unchecked by treatment until the secretions within it, after days and nights of suffering, have escaped by ulceration through the drumhead, the opportunity for prompt and certain cure is passed. Still, the patient under these circumstances may quickly recover, or there may be the other alternative described above, in which the ear is badly dam- aged and chronic inflammation established in the walls of the tympanum, giving rise to an offensive otorrhcea. In this state of the ear internal rem- edies are indicated, such as surgeons employ in suppurative inflammations of bone occurring in other parts of the system. Cod-liver oil and iodide of iron are required, especially by patients of strumous diathesis, the object being to promote a more healthy state of system, so as to prevent extension of the inflammation and facilitate the healing process. Carbolized solutions, as the following, syringed warm into the ear in which otorrhoea is occurring, are useful in promoting cleanliness and increasing the comfort of the patient : R. Acidi carbolici, £ss ; Glycerini, f:fij ; Aquae, f^iv. — Misce. But recently an effectual curative agent for local treatment has been discov- ered in boric acid, by the use of which the discharge quickly diminishes and the condition of the ear more certainly and rapidly improves than by the use of carbolized lotions. SCARLET FEVER. 293 R. Acidi borici, gij ; Glycerini, Aquae, ad. Oss. Sig. Instil sufficient to till external ear several times daily. The following astringent has also been employed with good results for the otorrhoea resulting from scarlet fever as well as from other causes : R. Zinci sulphatis, Aluminis, da. gr. v ; Aquae, 15 j. — Misce. A few drops of this should be dropped into the ear, or, if the ear be sensitive and painful, five drops should be added to a teaspoonful of warm water and dropped or syringed into the ear. But in recent times aurists have discovered in iodoform a remedy, the action of which is safe and efficient for protracted otorrhoea with granula- tions. The ear should first be thoroughly cleansed by syringing with warm water and dried, and iodoform, to which a little balsam of Peru is added to mask the disagreeable odor, should be pressed down to the bottom of the auditory canal by any convenient instrument, It is anodyne, astringent, and disinfectant, and should be employed in a dry state in considerable quantity. The sequelae of otitis media, such as granulations sprouting out from the drumhead, some of which may be of large size and are known as polypi, may require treatment by the aurist. A polypus may sometimes be removed by the forceps, or, better, by the snare. Polypi not large and favorably located can sometimes be cured by an astringent powder, as iodoform, sulphate of zinc, alum, or aristol. The otitis externa produced by the irritating dis- charge which flows from the middle ear soon disappears when the flow ceases. The renal affection — which, as we have seen, so often commences in the declining period of scarlet fever or during convalescence, in mild as well as severe cases — is frequently more dangerous than the primary disease. It largely increases the percentage of deaths. A clear appreciation of its thera- peutic requirements is important, since by judicious treatment many recover who would inevitably be sacrificed by improper measures. The family should be informed that the danger from scarlet fever does not cease with the decline of the eruption, and that the kidneys may become seriously affected by too early exposure of the patient to currents of air or sudden changes of tem- perature, by which cutaneous transpiration is checked. He should therefore be kept indoor in a comfortable and uniform temperature three or four weeks after the termination of the fever, until desquamation has entirely ceased and the new epidermis is sufficiently thick and firm to protect the surface. Dur- ing the changeable temperature of the autumnal, winter, and spring months even longer confinement at home may be advisable. The nephritis and consequent albuminuria antedate by some days the occurrence of dropsy, and a physician should never discharge a scarlatinous patient without one or more examinations of his urine. When his visits cease the nurse should be in- structed to make the examinations by heat and nitric acid during the ensuing month, and if any evidence, however slight, appear that the kidneys are involved, he should be notified, in order that appropriate treatment may be immediately com- menced. Early and correct treatment of the nephritis is attended by much better results than delayed treatment, and many more patients are doubtless now saved than in former times, when little attention was given to the state of the kidneys until dropsy or other prominent symptoms appeared. I have found no mother or nurse so ignorant that she could not properly employ the test of nitric acid and heat, and if she be solicitous for the welfare of the child, she will not hesitate to carry out the directions and immediately notify the physician if the tests employed produce the least cloudiness or turbidity of the urine. 294 CONSTITUTIONAL DISEASES. The patient as soon as nephritis commences, as shown by the state of the urine, should be put to bed in a room of warm and equable temperature (72° to 75° F.). His diet should be liquid, consisting of milk, farinaceous food, and a moderate quantity of animal broths. He may drink liquids freely, especially water not too cool, to which spiritus aetheris nitrosi is added. If he be prostrated by the primary disease, alcoholic stimulants should be allowed. The indications are to relieve the hypergemic kidneys by diaphoresis and purga- tion. To produce the former the patient should be immersed in a warm bath at about the temperature of the body (98° to 100°), in which, if he be quiet and com- fortable, he should remain from fifteen to twenty minutes, but a shorter time if restless and frightened by the water, after which he should be placed in a warm bed and well covered by blankets. If perspiration result, the bath has been useful, and it may be employed in grave cases two or three times daily. If perspiration do not result, it may be produced by surrounding the body either by hot dry or moist air. Hot air may be produced by burning alcohol in a thin layer upon a plate under a chair, upon which the patient sits while he is surrounded by a blanket, or he may be covered in bed and the hot air introduced under the bed- clothes. In New York a convenient apparatus is used for this purpose, consisting of a small sheet-iron pipe enclosed in a small box of the same material. The box is in the form of a trunk, with a handle for convenience in carrying, and the lower end of the pipe, which extends nearly to the floor, contains an alcohol lamp. Hot moist air may be produced by placing against the patient bottles of hot water sur- rounded by towels wrung out of water. The steam arising from them and envelop- ing the body and limbs produces a prompt sudorific effect. There is in use in this city, in the treatment of these and similar cases requiring diaphoresis, a convenient apparatus for generating steam. It consists of a cylinder pierced with holes for the admission of air and containing a spirit lamp, over which is a pan or pail holding a little water. The patient, nearly naked, is placed in a chair with the apparatus underneath, and is covered by a blanket, so that the steam surrounds the body. This gives rise to free perspiration, which continues after the patient is placed in bed. This treatment should be repeated one or more times daily, according to the gravity of the case. The sudorific effect of the treatment by external warmth described above should be aided by employing diaphoretics. Those which have been most used are the acetates of ammonium and potassium, the bi-tartrate and citrate of potassium, and spiritus aetheris nitrosi. If employed when the surface is cool they act rather as diuretics than diaphoretics. These agents, being simple in their action and without deleterious effect, may be given frequently and in large proportionate doses for the age. But lately a diaphoretic which far surpasses these in efficiency has been discovered in pilocarpine, the active principle of jaborandi. Being soluble in water and tasteless, it is easily administered, and is retained when, on account of the uraemic poisoning present in scarlatinous nephritis, the stomach is irritable and other medicines, as digitalis, are rejected. Ether may be employed with it, or the amount of alcoholic stimulant may be increased at the time of its exhibition in order to guard against any depressing effect. To a child of two years one-fortieth to one-twentieth of a grain may be given every six hours by the mouth. It may also be employed hypodermically, as one-twentieth of a grain to a child of five years. It has both a diaphoretic and a diuretic action, while it stimulates both the salivary and mucous secre- tions. According to one observer, an adult when fully under the influence of pilocarpine secretes from one pint to one quart of saliva within two hours, and Leyden reports a case of diphtheritic nephritis in which the quantity of urine rose from half a pint to five pints daily. But its most prompt and certain action is upon the sweat-glands. Hirschfelder speaks of its beneficial action in relieving various forms of dropsy, and adds : " In one morbid con- dition of the kidney, however, jaborandi is the remedy par excellence, and that is the acute parenchymatous nephritis which frequently follows scar- SCARLET FEVER. 295 latina This disease heals spontaneously if the danger that threatens life from reduction of the urine and from the effusions of fluid into the cav- ities of the body be averted. In this disease jaborandi works wonders." I have also found it an invaluable agent when the older remedies failed and death seemed imminent. The following cases, in which the beneficial action of this agent was apparent, occurred in my practice : Case 1. — G , male, aged live years and six months, sickened with scarlet fever on June 2, 1882. It began with vomiting, and was attended by a degree of fever which indicated an attack of rather more than the average gravity. The fauces at one time exhibited a slight exudation like that of diphtheria. In the declining stage of the malady rheumatic pain and tenderness occurred in the wrist- and finger-joints, but not in those of the lower extremities. The case, however, progressed favorably, and during the convalescence my attendance ceased. On June 24th my attention was again called to the child, when the urine was found to be scanty and very albuminous. External measures, such as are described in the foregoing pages, were employed, and the infusion of digitalis with potassium acetate ordered to be given every three hours ; but this medicine was for the most part vomited. The bowels were kept open by jalap and the potassium bitartrate. The urine, however, continued scanty, and on June 28th severe convulsions occurred. At this time the quantity of urine was only f^ij in twenty-four hours. The pulse in the convulsions was quick and feeble, the skin very hot, and the axillary temp. 103°. The eclampsia continued one hour, and was controlled by large and repeated doses of bromide of potassium, aided by clysters of five grains of hydrate of chloral in water. Muriate of pilocarpine was now directed to be given in doses of one- thirty-second of a grain every three hours, dissolved in cold water. This agent was not vomited, and it must have been given by the parents in their fright and anxiety in larger or more frequent doses than were directed, for on July 1st the bottle containing one grain was empty. Free diaphoresis resulted from the pilocarpine, and the quantity of urine was increased. The mother stated that the child had taken only two doses, or one-sixteenth of a grain, of pilocarpine when the diuretic effect was apparent and free diaphoresis also occurred. She also stated subsequently that the quantity of urine was larger when the pilocarpine was ad- ministered every third hour than when given at a longer interval. A flaxseed poultice on which mustard was dusted was also applied over the kidneys. On June 20th the pulse was 96, temperature 100.5° ; occasional convulsive attacks occurred, which were readily controlled by enemata of hydrate of chloral. On June 30th the symptoms were all better ; no more attacks of eclampsia had occurred, and the urine was more abundant and less albuminous. The mother remarked that the new medicine (pilocarpine) had settled the stomach and increased the urine. The patient continued to improve, and on July 4th the record states : " Now takes the pilocarpine, gr. ^, every six hours ; passes urine freely since yesterday ; has not vomited since he began to take the pilocarpine ; pulse 106, axillary temp. 99°; is playful and takes milk freely, nearly three quarts in twenty-four hours, with some farinaceous food. Digitalis with potassium acetate is also given in occasional doses." July 6th, pulse 92, temp. 99°; perspires much, and urine nearly normal in quantity a,nd character. Case 2. — Mary S , aged five years, on Dec. 22, 1882, presented the symp- toms of severe nephritis. Her brother had scarlet fever two weeks previously, and she had sore throat at about the same time, but without efflorescence ; pulse 98, temperature 98.5°; her urine highly albuminous, and reduced to f^iv in twenty- four hours 5 bowels constipated. Ordered a single dose of R. Hydrarg. chlor. mitis, gr. iij ; Resin, podophyll., gr. \. — Misee. The muriate of pilocarpine was also ordered, gr. ^ (T , but the patient vomited soon after taking it. Another dose was retained, and was followed by considerable per- spiration. Dec. 23d, had one stool from the powder of yesterday, lias taken five doses of pilocarpine, but vomited after three of them. The last dose was adminis- tered at 10 p. m., and the mother says she " sweat fearfully *' during the night. The patient was kept warm in bed ; stimulating poultices oi' mustard and flaxseed, one 296 CONSTITUTIONAL DISEASES. to sixteen, were constantly in use over the kidneys, and the pilocarpine was admin- istered three or four times a day. The record for Dec. 26th states: "Took the pilocarpine four times since yesterday morning, and each dose is followed by per- spiration lasting from one to one and a half hours ; quantity of urine, from f^vj to f^viij daily ; vomited twice yesterday, not to-day ; pulse 104 ; temp. 97.75° ; complains of frontal headache ; bowels regular ; has considerable salivation. The patient is warm in bed, and the flaxseed and mustard poultice over the kidneys is continued. ,; Dec. 28th, specific gravity of urine 1019 ; urine still quite albuminous and containing blood-corpuscles and granular casts, also crystals of oxalate of lime. Dec. 30th, takes gr. 2V pilocarpine twice daily, and occasional doses of infusion of digitalis ; urine more abundant ; its specific gravity 1014, slightly albuminous, and containing very few granular casts and blood-corpuscles ; has lost its smoky appear- ance ; reaction alkaline ; perspiration slight ; patient convalescent. In another instance a child of five years, from three to four weeks after scarlet fever, was noticed to have anasarca of the face and extremities, with scanty and albuminous urine. One thirty-second of a grain of muriate of pilocarpine was administered every six hours without the desired sudorific effect. It was then administered every four hours, with an increase of per- spiration and urination, so that the nephritic symptoms were relieved and the patient apparently out of danger within three or four days. In a fourth patient, a girl of three years having scarlatinous nephritis, with symptoms very similar to those in the last case, the administration of one-twentieth grain doses of pilocarpine in conjunction with the hot-air bath was followed by increased perspiration and urination, and progressive and rather rapid convalescence. This child had been taking bichloride of mercury in one-fiftieth grain doses, prescribed by a homoeopathic physician, without appreciable benefit, it having been for the most part vomited. Given, as in the above cases, in moderate doses and with sufficient inter- val, pilocarpine has never in my practice had any deleterious effect, and I regard it as a very important addition to the remedies for the relief of scar- latinous nephritis. It is apparently the most useful and important diaphoretic for this disease which we possess, but .pilocarpine is a dangerous remedy if not given in the proper small doses and at proper intervals. It has pro- duced a fatal bronchorrhoea by too large a dose, of which I was a witness ; so that it must be given in small doses and its effects closely watched. Cathartics, especially those of a hydragogue nature, are also very bene- ficial. Their action is more certain than that of most diaphoretics and diu- retics, and their employment is imperatively required in severe or dangerous cases in which it is necessary to remove as soon as possible the serum or urea which endangers life. Young children or those with delicate stomachs and those much enfeebled by the primary disease may take magnesia, either the citrate or the calcined. A good cathartic for ordinary robust cases is a mix- ture of jalap and potassium bitartrate, the pulvus jalapse compositus, consist- ing of one part of jalap and two of cream of tartar. Ten grains of the mixture may be given to a child of five years, and repeated according to circum- stances. Its effect is increased by dissolving a teaspoonful of potassium bitartrate in a gobletful of water and allowing the patient to drink from it. The following cathartic also acts promptly and beneficially in the treatment of scarlatinous nephritis : R. 01. cinnamomi, gtt. v; Magnes. sulphat., Jf j ; Potass, bitartrat., gij. — Misce. Dose : One teaspoonful repeated from two to four hours until catharsis occurs. After the use of laxative agents the kidneys, being less congested on account of the diversion that has occurred, often begins to excrete urine SCARLET FEVER. 297 more freely. But if the patient be anaemic or enfeebled and the symptoms are not urgent, it is frequently better to avoid active catharsis, which more or less reduces the strength, and employ remedies of a sustaining character, as in the following case, which occurred in my practice : A little boy, pallid and scrofulous, began to have anasarca after scarlet fever, chiefly in the scro- tum, accompanied by a moderate degree of ascites. The urine, which was passed in nearly the normal quantity, contained albumen, but not in large amount. This patient gradually and fully recovered, with no treatment except the use of an oil-silk jacket over the kidneys and abdomen to pro- mote diaphoresis, and the use of iron. Such a patient, treated by the power- ful eliminatives which we employ for the more urgent and robust cases, would probably have been injured rather than benefited. No treatment can there- fore be recommended in a treatise on scarlatinous nephritis which will be strictly applicable for all cases. Variations are demanded according to the state of the patient and the form and gravity of the disease. Diuretics which do not stimulate the kidneys are proper at an early as well as late period of the renal malady. The following is a favorite diuretic in the New York City Hospital : R. Potass, acetat., 1 ' ' bicarbonat. , >- da ^ij ; " citrat., J Infus. tritici repentis, £iv. — Misce. Give one teaspoonful every two hours. One teaspoonful of the infusion may be given every third hour to a child of five years. The following formula is for one of the same age in good general condition. It should be given in water : R. Potass, acetatis, Jss ; Infus. digitalis, f^ vj. — Misce. Give one teaspoonful from two to four hours. Local treatment is important. In the majority of cases instead of depletion a poultice slightly irritating, so as to cause redness of the skin, should be applied over the kidneys, or for older children, not likely to be frightened by the process, the dry cups may be applied daily. In subacute cases, not attended by any alarming symptoms, sufficient redness may be produced by the external use of one part of turpentine and two of camphorated oil. Eclampsia, described in the preceding pages, is produced, as we have seen, during the course of scarlet fever by the irritating effect of the scarlatinous poison upon the nervous centres ; but, occurring after the decline of scarlet fever, it is ordinarily produced by the retained urea. The same remedies are required to control the convulsive movements as when they occur under other circumstances. The bromide of potassium should be immediately administered in large doses whenever eclamptic symptoms arise. During eclampsia a child of three years should take five grains of this agent every five to ten minutes till the attack ceases, and then at longer intervals. The hydrate of chloral is a more powerful agent, and if the eclampsia be not quickly controlled, I commonly employ it per rectum, dissolved in one or two teaspoonfuls of water. For a child of three to five years five grains should be thrown into the rectum by a small glass or gutta-percha syringe, and retained by pressure. Properly administered and retained, it rarely fails to control the eclampsia within ten or fifteen minutes. Subsequently, occa- sional doses of the bromide should be given to prevent the occurrence of eclampsia while the measures described above are being employed to elimi- nate the urea. 298 CONSTITUTIONAL DISEASES. Rheumatism, endocarditis, and pericarditis, arising as complications or sequelae, require the treatment which is appropriate when they occur under other circumstances, but the remedies should not be depressing, as the sys- tem is already enfeebled by the primary disease. The rheumatism, if mild, usually abates in a few days without medication, and the affected joints require only some soothing lotion and support by a bandage. The following liniment may be applied upon muslin and covered by cotton wadding : R. 01. caryophylli, ^ij ; Tine, belladonnse, fjjj ; 01. camphorati, f^iij. — Misce. If the rheumatism be severe and affect several joints, the sodium salicylate should be prescribed, as in the idiopathic disease, with an occasional opiate to procure rest. Endocarditis and pericarditis require rest in the horizontal position, avoid- ance of all excitement, the use of the tincture or infusion of digitalis or the tincture of strophanthus to procure a slow and steady action of the heart. Three drops of the tincture of digitalis or one to one and a half drops of the tincture of strophanthus may be given every four hours to a child of five years. The same external measures should be employed as in acute pleu- ritis. I prefer the application of a thin poultice of flaxseed containing one- sixteenth part of mustard and covered with oiled silk. The cardiac inflam- mations, as well as rheumatism, require opiates in sufficient doses to procure rest and sleep. In some instances strychnia, gr. t -J-q to a child of eight years, is the better heart tonic. Pleuritis, which we have stated is often suppurative, demands the same- treatment as the idiopathic disease when it occurs in cachectic patients. CHAPTER III. ROTHELN. This disease has also been designated rubella, epidemic roseola, rosalia r rubeola notha, and German measles. Some recent writers incline to the belief that it occurred in Europe in the eighteenth century, having the name rubeola. Thomas states that, according to Formey, 457 died from rubeola, 172 from scarlet fever, and 53 from measles in Berlin in the decade beginning with 1784 ; but he also states that many who observed these epidemics be- lieved that the rubeola was a species of measles. We infer that this was the correct opinion, and that the rubeola of the eighteenth century was not the rotheln of the present time, since the latter is almost never fatal, except from complications. In Great Britain, from the year 1840 onward, various writers, when treating of measles and scarlet fever, make statements which lead us to think that they may have sometimes mistaken epidemics of rotheln for modi- fied forms of measles or scarlet fever. Perhap"s it is not too much to claim that the first clear and distinct differentiation of rotheln was made in this country. Cases of rotheln occurring in and about Boston were described by Dr. Homans. Sr.. in 1845, and at a later date — to wit, in 1853 and 1871 — B. E. Cotting and Mr. D. Howard saw cases, and described them in papers read ROTHELN. 299 before local societies (Bast. Med. and Surg. Journ., March 15, 1873). In 1S74. Dr. Caleb Green of Homer, Cortland co., New York, an accurate and intelligent observer, also witnessed an epidemic of this disease. Rbtheln was not. however, noticed in American treatises, and it scarcely received recognition in America, until an epidemic of it occurred in the Xew York Foundling Asylum and in New York City in 1873-7-1, which furnished the material for a paper published in the Archives of Dermatology in 1874. This epidemic began in the latter part of 1873, and attained its maximum in March and April, 1874, after which it gradually declined. This, so far as I can learn, was the first occurrence of rbtheln in this locality. In a general practice of more than twenty years, extending over a considerable portion of this city. I had previously seen nothing like it, and other older physicians, having a large general practice, informed me that they considered it an en- tirely new disease with us. Those who believed that they had occasionally observed isolated cases of it previously to this epidemic probably referred to roseola. The first case which I observed occurred in the middle of December, 1873, in West Seventy-first street, in the northern suburbs of New York. A few weeks later cases were so numerous in the more thickly-populated section of the city as to attract the attention of many physicians. It was evident that a disease had appeared with which we were not familiar, and as the eruption occurred in points and small circumscribed patches, it was usually designated by the physicians, in want of a more accurate name, epidemic roseola, or was spoken of as a spurious measles. Physicians who were familiar with foreign medical literature saw the resemblance between these cases and those of rbtheln as described by British and continental writers, but in certain at least of the foreign cases the duration of the rash was said to be seven days (Liveing, London Lancet, March 14, 1874, and Med. Xeirs and Library, May, 1874), whereas in the cases in New York it commonly disappeared by the fourth day. This discrepancy, however, was not sufficient to invalidate the belief in the identity of the New York disease with the foreign rotheln. It was readily explained by the difference in the seasons in which the cases occurred, for Liveing observed his cases in June and July, and, as we will see, the greater the external heat the longer is the duration of the eruption. Between the middle of December, 1873, and May 1, 1874, 1 had observed and treated this malady in eighteen families. Cases occurred in three other families living in the same houses with some of those which I attended, and, as they were fully and clearly described to me, so that there could be no doubt as to their nature, I have included them in my statistics. The total number of cases in these twenty-one families was 48. During May, when the epi- demic was declining, I saw 6 additional cases, occurring singly, making a total of 54. Their ages are given in the following table : Age. Cases. From eight months to one year - 11 one year to two years 4 " two years to five years 16 " five years to ten years 23 " ten years to fifteen years 3 " fifteen years to thirty years J} Total number of cases 51 The age of the youngest patient was eight months and that of the oldest thirty years: 72 per cent, of the total number were between the ages of two and ten years, so that rotheln is pre-eminently a disease of childhood. Indi- 300 CONSTITUTIONAL DISEASES. viduals in and beyond the middle period of life seem to have nearly an immu- nity from it. The age of the oldest patient of whom I was informed in the epidemic of 1873 and 1874 was about forty years. On March 25, 1873, during my attendance in the New York Foundling Asylum, rbtheln appeared in a boy of four years ; in the following month about thirty more cases occurred in this institution, all children, while among the large number of female nurses and employes, who were chiefly between the ages of twenty and thirty years, all but three escaped. From 1874 to 1880 rotheln did not prevail in New York, unless now and then an isolated or sporadic case, the nature of which was not recognized and which was supposed to be roseola. On August 9, 1880, two cases appeared in different wards of the New York Foundling Asylum, when it was remembered that two weeks previously these children had been exposed to a patient in the hospital attached to the institution who had what the phy- sician in attendance supposed at the time to be roseola. Commencing with these two cases, an epidemic occurred in the asylum, mild in type, affecting only a few at a time, but extending over several months, until about sixty inmates, chiefly children, were attacked. Toward the close of 1880 rotheln began to appear in the northern part of the city, in which the asylum is located and over which my practice extends. Its maximum prevalence was attained in the latter part of March and April, 1881, when it particularly attracted the attention of physicians. A large proportion of the children attending certain public and private schools were attacked. It occurred in seventeen families in my practice. The ages of the patients in these families are given in the following table : Age. Cases. From one to two years 3 " two to five years 8 " five to ten years 18 " ten to fifteen years 11 There were two cases over fifteen years, aged respectively twenty-two and forty-two years _2 Total number of cases 42 Premonitory Stage. — Premonitory symptoms are in most instances absent or so mild as to attract but little attention. It not infrequently happened in the New York epidemics that the parents or the teachers in the schools were first made aware of the illness of the children by observing the eruption. In some instances children were sent from school, not because they felt too ill to remain, but on account of the unusual appearance of the skin. Sometimes, however, in those old enough to express their sensations a pre- monitory stage of some hours or a day, or even of longer duration, was present, consisting of such symptoms as usually occur when one has taken a severe cold, as languor, pain in the head, trunk, or limbs. The resident physician of the New York Foundling Asylum was so ill with rotheln that he was confined to his bed during the first day of the disease. Now and then patients experience nausea previously to the eruption and in the first and second days of the eruptive stage. In only one instance did I observe grave prodromic symptoms. A boy aged eight years was suddenly seized with clonic convulsions, and while in a warm bath for the relief of these the rash appeared upon those parts of the body which were immersed in water. Symptoms. — Tegvmentary System. — (a) The Skin. — The eruption com- monly commences upon the forehead, around the ears, and along the neck, as in measles. Occasionally it may appear upon the back or chest, as in the above-mentioned case, in which the hot water accelerated its appearance. BOTHELN. 301 Commencing above, the efflorescence travels downward, appearing after some hours upon the lower part of the trunk and on the legs, resembling in this respect the eruption of measles and scarlatina. It occurs upon all parts of the integument except the scalp and palmar and plantar surfaces. In the majority of the cases which I have seen it gradually faded away, disappear- ing by the fourth day, but in children who were kept warm in bed or in warm apartments it remained longer than on others. In many instances traces of the rash were still visible several days after recovery when the patients were heated by exercise or excitement. It reappeared at times, though indistinctly, on a girl of thirteen years for three weeks. In most of the cases in the New York epidemics the eruption commonly occurred in points and circular spots somewhat smaller than those of measles. These points and spots were numerous and thickly set, so that, in the aggregate, the}* covered at least half of the surface, while between them the skin pre- seDted nearly or quite its normal appearance. The general aspect in most cases was more like that of measles than that of scarlatina, but in exceptional instances the skin between the points and spots had a redness similar to that of erythema, and the resemblance was very like the scarlatinous efflorescence. Thus, in a boy of three years the eruption so closely resembled the scarlat- inous over the trunk that were it not that the temperature was constantly below 100°, and the fever entirely ceased within three or four days, I would probably have considered the malady a mild scarlatina. In certain patients the eruption, beginning in circumscribed spots, like that of measles, becomes in two or three days confluent, so as to resemble that of scarlatina, while over other parts the spots remain discrete. This was the character of the eruption upon the third and fourth days on the extremities of a little boy in the Foundling Asylum. The rash is attended by considerable itching, from which, indeed, many patients suffer more than from all other symptoms. The eruption disappears on pressure, produces a slight roughness of the surface, as ascertained by passing the fingers gently over it, and usually fades away without desquamation. Exceptionally, there is a slight branny exfolia- tion, and in one of my patients the exfoliation was as great over the abdomen as in cases of scarlatina. (6) The Mucous Membrane. — In connection with the cutaneous eruption a mild inflammation also occurs upon the mucous membrane covering the fauces, buccal cavity, and nostrils, and upon reflections of this membrane over the eyes and eyelids — i. e., upon the conjunctiva. In certain patients this inflammation is scarcely appreciable, but in the majority it arrests atten- tion at once. It produces a suffused, reddish, or weak appearance of the eyes, with a moderately increased lachrymation. On everting the eyelids the pal- pebral conjunctiva is seen to be injected. In certain patients a moderate puri- form secretion collects at the inner angle of the eyelids. In occasional cases the conjunctivitis causes oedema of the lids, usually slight and likely to be overlooked by the physician ; but in three instances which I now recall to mind the mothers of the children directed my attention to the swollen state of the lids. In one of these, an infant of twenty-three months, the tumefac- tion was so great, commencing about the time the eruption began to fade. that light was totally excluded from the eyes and it was impossible to ascer- tain their condition. The skin over the eyelids retained nearly its normal appearance, and a puriform secretion appeared between the lids. In three or four days the oedema of the lids and the hyperemia of the conjunctiva declined. The coryza is in most cases sufficient to cause an unpleasant sen- sation in the nostrils and provoke sneezing; but the flow from the nostrils. though present, was in no instance under my observation as abundant as in ordinary cases of scarlatina or even of measles. The fauces present an injected 302 CONSTITUTIONAL DISEASES. appearance, and in severe cases there is moderate swelling of the tonsils. The same catarrhal hyperaemia is also seen in spots or patches, more or less diffused, upon the buccal surfaces. Both the faucial and buccal catarrh are less in degree, however, than in cases of rubeola and scarlatina, which have an equal intensity of cutaneous eruption ; and this fact aids in differential diagnosis. The Respiratory System. — In both the epidemics which I have witnessed the mucous membrane of the larynx, trachea, and bronchial tubes participated only slightly in the inflammation which involved the nasal, buccal, and faucial surfaces. Many of my patients had no cough, but others had a mild cough, lasting a few days, but with normal respiration. It was due apparently to a very mild catarrh of the respiratory tract at the time when the nasal and conjunctival surfaces were the most affected. It subsided in a few days without treatment. In no case do I recollect that there was any hoarseness. The Digestive System. — The tongue in roth el n is moist and of normal appearance or covered by a slight fur. The appetite may be impaired, but is not wanting in uncomplicated cases. The patients sometimes say that it is nearly the same as in health ; the thirst is slight, and the bowels are regular. Nausea is not infrequent, and vomiting was, in several cases in my prac- tice, one of the initial symptoms. In certain patients it also occurred on the first or second day of the eruption. In others there was no nausea, so far as I could learn, either immediately before or during the prevalence of the disease. This symptom is less frequent in rotheln than in scarlet fever, but is as common apparently as in measles. I have never found albumen in the urine, though I have examined that passed by several patients. This secre- tion did not appear to be abnormal except as it contained urates, so common in febrile states. The Pulse and Temperature. — The largest number of accurate daily obser- vations relating to the temperature was, I think, that of Dr. Reid in the New York Foundling Asylum during the month of March, 1874. He has kindly furnished me with his statistics relating to this symptom, as follows : c ' The number of closely-observed cases in which the temperature was taken was 24. In 17 of the cases the temperature ranged from 97° to 99° ; in 6 it reached 100°, 100£°, and lOOf ° ; in 1 it reached 103i° on the second day of the eruption, but remained so elevated only one day." In certain patients Dr. Eeid observed what he designates " a tendency to the development of an ephemeral fever." These observations correspond closely with those made by myself during the same epidemic. Thus, in 16 cases I found the axillary temperature taken each day to be constantly between 98° and 100°, with a pulse under 110, except in 1 case, in which it numbered 124. In certain other patients a more decided rise in temperature from one to two or three days occurred, usually in the commencement of the malady. Thus, a girl aged three and a half years had a temperature of 101 f° and a pulse of 128. In another instance the pulse was 124 and the temperature 102°. In another, a girl of three and a half years, considerable fever occurred without apparent cause on Saturday night, but it abated on the subsequent day. She seemed well until the following Tuesday, when the fever returned and the eruption appeared. On Thursday the temperature from 102° to 103° fell to 99*°, and within a day or two she was convalescent. In two other patients from two to four days after the disappearance of the eruption an accession of fever occurred, lasting about one day, and attended by pain and distress in the epigastric region, but without vomiting or diarrhoea. In one of these the temperature was 103f °, the pulse 130 per minute. In the other case the tem- perature and pulse did not seem to be under these figures, but were not accurately ascertained. Occasionally the fever is due more to complications than to the primary disease. Thus, in two of my patients the rise of tern- ROTHELN. 303 perature was mainly attributable to diphtheritic inflammation which had attacked the fauces. But while the fever in rotheln is ordinarily of short duration, in certain patients temporary exacerbations may occur in which the temperature is as high as in scarlet fever or measles. Complications ; Prognosis. — The only complications which occurred in cases in my practice have already been alluded to — to wit, diphtheria, which, when prevalent, usually attacks surfaces already inflamed. In the Foundling Asylum varicella complicated one case and pneumonia another. In a third pneumonia occurred about three days after the disappearance of the eruption. The prognosis in uncomplicated cases is always very favorable, and there is no liability to sequelae more than in mild catarrhal inflammations of a non- specific character. The duration of rotheln is short, not ordinarily extending beyond three to five days. Nature ; Incubative Period ; Contagiousness. — Is rotheln a distinct malady, or one with which we are familiar, but the form and character of which are modified by unusual meteorological conditions? Is it roseola assuming at certain periods an epidemic character and appearing to be con- tagious ? Or is it at all times infectious, possessing a specific principle, and, like other infectious diseases, self-propagating ? Should it in nosological classification be placed among the non-contagious and local or among the constitutional and infectious maladies ? Let us consider the facts observed in the New York epidemics. The first cases of rotheln in this city were often designated roseola by the physicians called to treat them, since they seemed to resemble more closely this disease than any other with which they were familiar. But rotheln differs widely from the peculiar form of dermatitis known as roseola. The successive occurrence of the eruption over the upper and then the lower parts of the body, but covering the whole surface, and the definite duration of three to five days, are points of difference. Moreover, roseola would not, without so great a change in its character as to become virtually a distinct disease, occur in the cool months, without any appreciable dietetic cause, as an epidemic over a certain area and for a limited time, affecting whole house- holds and sparing other households as well as individuals of a certain age. We therefore consider it distinct from roseola. Most of the cases of the New York epidemics bore considerable resem- blance to measles, both as regards the appearance and duration of the erup- tion and the catarrh of the mucous surfaces. Parents often diagnosticated measles before the arrival of the physician, and the physician himself, at first glance, sometimes made the same diagnosis. But in rotheln the shortness and mildness of the stage of invasion, the absence of cough or the presence of one trivial and scarcely noticed, appetite good or but slightly impaired — in fine, symptoms that are transient or slight — afford a striking contrast to the graver symptoms of measles. But the decisive proof that rotheln is not a modified measles is found in the fact that one does not prevent the other. Of the 48 cases observed by myself prior to May 1st in the epidemic of 1874, 19 at least had had measles, and 1 who had rotheln took measles sub- sequently. I have already stated that in the New York Foundling Asylum rotheln in 1873 and 1874 closely followed an epidemic of measles. A con- siderable number of the children attacked by the former disease had recently recovered from the latter. During the epidemic of 1880 and 1881 the same fact was observed — namely, that a previous attack of measles as well as scarlet fever afforded no protection from rotheln. Dr. Chadbourne, the resi- dent physician, writes of the cases in the Foundling Asylum in 1880 ami 1881 : " Eight children had rotheln who had had both scarlet fever and measles within six months under my observation, while certain others had 304 CONSTITUTIONAL DISEASES. had these diseases at some previous time." Of the cases observed by myself in family practice in the same epidemic, it is stated in my notes that ten had had measles. These statistics are sufficient to show that rotheln is a distinct disease from measles, however close the kinship. That rotheln is not a form of scarlet fever is evident from the fact that as regards at least the New York epidemics the rash was in most instances quite distinct from the scarlatinous efflorescence, occurring, as we have said, in small more or less circular points and patches. Moreover, as we have remarked above, there is in rotheln a slight febrile movement and general mildness of symptoms which contrast with the high fever and other pro- nounced symptoms of scarlatina, or if there be considerable febrile move- ment its duration is brief. But the conclusive proof of an essential differ- ence between these two diseases is found in the fact already stated in refer- ence to measles, that the attack of the one malady does not prevent the occurrence of the other. There are, it is true, cases in which it is difficult at first to make the differential diagnosis between rotheln and mild measles or mild scarlet fever, but when the course of the malady has been closely observed for three or four days, it will rarely happen, I think, that we will be unable to make out its character. Those cases of an epidemic which arise when the causes or conditions from which it has developed are most strongly operative, and which at this time are likely to be typical, obviously afford the best data for studying its nature. Such were the 48 cases which I saw in the epidemic of 1873 and 1874, and the 42 in that of 1880 and 1881. As regards the former epi- demic, in thirteen of the twenty-one families embraced in my statistics the first cases were children who up to the time of the seizure were attending public and private schools, and in certain instances those who were nearly simultaneously attacked, living perhaps in streets widely separated, were attending the same school. During the epidemic of 1880 and 1881 the first patients in thirteen of the eighteen families in which rotheln occurred in my practice were school-children between the ages of six and twelve years, and in most, if not all, the different schools which they attended rotheln was at the time prevailing as an epidemic, as I ascertained on inquiry. It therefore seemed probable that these children whom I attended had contracted it from others in the schools. In both the New York epidemics during the time that rotheln was at its maximum prevalence, in most of the families containing two or more chil- dren the cases were multiple, not occurring simultaneously, but in succes- sion, as if the malady were contracted from those first affected. This is what we daily witness in the spread of exanthematic fevers. Thus in Mr. E 's family a girl attending one of the public schools took rotheln in the middle of December, 1873 ; the two remaining children sickened with it one week and two weeks later. A niece visiting in the family at the time when the first child was sick, but returning home to another street, also had the erup- tion on December 27th. Alice II , aged ten years, a frequent visitor at Mr. E 's, living in the same street, and several times exposed to his children during their illness, also took rotheln about January 4th. West Seventy-first street, where these cases occurred, was thinly settled and subur- ban, and I could learn of no other cases in the vicinity. A child of Mr. P , aged five and a half years, had been in the habit of playing with two children two doors away, who became affected with rotheln in the beginning of April, 1881. On April 14th he was supposed to have a mild coryza from taking cold, as he sneezed often, but in a few hours the efflorescence appeared. Four days subsequently, on the 18th, an infant was affected in the same way, and thirteen days later another child in the family, aged twelve years. In a ROTHELN. 305 similar manner rotheln occurred in the families of two brothers living in adjoining houses in West Fifty-first street. The first patient was a boy of twelve years. It appeared successively in the children of these two families until ten had been affected. In a family in West Forty-sixth street the first case was a boy attending a school in which rotheln was prevalent. Within twenty days — namely, between March 31st and April 20th— four other chil- dren were attacked in succession. These facts and cases seem to demonstrate the contagiousness of rotheln, at least during the time in which the conditions are most favorable for its development or during the time in which the epidemic influence is most pro- nounced. In the declining period of both the New York epidemics the cases which I observed occurred for the most part singly, although there was no attempt to isolate the patients, so that the contagiousness of the disease must be slight. Kotheln is, in my opinion, an exanthematic fever feebly contagious. It resembles varicella in general mildness of symptoms, in the absence of dangerous complications or sequelae, and in the uniformly favorable prognosis, while its symptoms show a resemblance to measles and scarlet fever. If the above view be correct, rotheln must possess an incubative period which, in the cases observed in both epidemics, apparently varied between seven, or perhaps less than seven, and twenty-one days. Its incubation, therefore, like that of scarlet fever and diphtheria, apparently varies in different patients. In the cases which came under my notice the incubative period, when it could be accurately ascertained, was more frequently about two weeks than a longer or shorter period. The resident physician of the New York Foundling Asylum, when the epidemic was prevailing in that institution, returned to his home in the State of Maine to a locality where rotheln was unknown. Fourteen days from the date of his departure he was himself affected with the disease in its typical form. No other case occurred at his home, where probably the atmospheric conditions were unfavorable. Minnie B , attending a school in which there were many cases, had the rash on April 5th. On the 23d of the same month, eighteen days afterward, it appeared upon the servant who was frequently in Minnie's room. Elizabeth C , attending a school in which rotheln was prevailing, had the eruption on April 17th. It commenced upon her sister thirteen days, and upon her mother fourteen days, subsequently. Other cases might be cited of an apparently shorter as well as longer incubative period. The following note from Dr. Chadbourne of the New York Foundling Asylum, bearing upon the subject, is interesting: "I am led to believe from my observations that the period of incubation was, in the majority of cases, from twelve to fifteen days. The disease has been very feebly contagious. In some cases one child would have rotheln, while the other, nursed by the same woman, escaped. In two instances women had the disease, and though each suckled two infants, the latter escaped." Osborn states that enlargement of the small glands at the edge of the hair on the postero-lateral sides of the neck has been present in all the cases which he has observed, and he therefore considers it an important diagnostic sign ( Weekly Med. Rev., Dec. 24, 1887). Several other writers have also observed this glandular enlargement, and some have stated that it occasionally pre- cedes the efflorescence. Swelling of the lymphatic glands in other parts of the system has also been recorded by different observers, and it rarely goes on to suppuration. It usually subsides with the disappearance of the rash, but Golson has observed the occurrence of abscesses in the site of the sub- maxillary lymphatic glands. Curtman has also observed the formation of abscesses in various parts of the body. 20 306 CONSTITUTIONAL DISEASES. Complications. — Recent writers have recorded a considerable number of complications and sequelae, the more important of which we will briefly enumerate as follows, but the occurrence of some of them was a coincidence : Severe bronchitis, pneumonia, pleurisy, enteritis, entero-colitis, colitis, icterus, stomatitis, rheumatism, meningitis, abscesses, miliaria, pemphigus, erysipelas, oedema, enlargement of the thyroid, otorrhoea, earache, and keratitis. Some of these complications are such as frequently occur in measles, to which, as we have seen, rotheln bears considerable resemblance. Diagnosis.— Roth eln might readily be mistaken for roseola if only a few and isolated cases occur, but the longer continuance of the eruption, the catarrhal symptoms, though slight, and in most instances the evidence of contagion, enable us to make the diagnosis. From measles this disease is distinguished by the absence of, or slight and transient character of, the prodromal stage. The fever with evening exacerbations, the cough, and pro- nounced catarrhal symptoms, which precede the rash in measles three or four days, do not occur in rotheln. The diagnosis from mild scarlet fever in the commencement of an epidemic, when only a few cases are observed, may be difficult, but no epidemics of scarlet fever occur in which the type remains so mild as in rotheln. The shorter duration of the rash, the absence of the initial vomiting and of the strawberry tongue, the usual roseolar rather than erythematous character of the rash, the mildness, sometimes scarcely appre- ciable, of the stomatitis and pharyngitis, the slight indisposition, so that the child, if it followed its inclination, would not be under restraint, and the absence, with few exceptions, of complications and sequelae, usually render the diagnosis from scarlet fever clear and unmistakable. Prognosis. — Death does not occur except from some complication or intercurrent disease. When Forney stated that in Berlin during the decade ending with 1794, 457 died from rubeola, 172 from scarlet fever, and 53 from measles, he could not by the term " rubeola " have referred to rotheln, as some have supposed, or the nature of the disease has totally changed. More- over, in the literature of rotheln the assigned causes of death have been, in my opinion, in some instances, concurrent or accidental maladies which did not result from this disease. Treatment. — In the majority of cases the medicinal treatment should be of the mildest kind or none at all. As death has occurred from bronchitis and pneumonia supervening upon rotheln, the patient should remain in a room of equable temperature, and not be exposed to currents of air. Any local ailment which may arise or any intercurrent disease should of course be promptly treated, since death may occur from them, while the primary disease is not fatal and is even trivial. CHAPTEE IV. VARIOLA— VARIOLOID. Variola, or smallpox, is a specific febrile affection, accompanied by a vesiculo-pustular eruption upon the skin. Since the discovery of the pro- tective power of vaccination it has been shorn of much of its terror, but it is still the most loathsome and most dreaded of all the fevers. Two forms of this disease are recognized, depending on the fact whether there have been previous vaccination. If the patient have been vaccinated at some period in VARIOLA — VABIOL OID. 307 his life, the disease, which is rendered milder in consequence, is designated varioloid. If there have been no vaccination, it is called variola or smallpox. Both forms are identical in nature, the one communicating the other ; they differ only in gravity. From accounts still extant — which, however, are vague — this disease appears to have prevailed at a remote period in China and Hindostan. It was carried across the Asiatic continent by caravans engaged in the silk-trade, reaching Europe in the sixth century. Its extension to countries previously free from it has been mainly through commerce and invading armies. It is stated that it reached England in the thirteenth century and Germany and Sweden in the fifteenth century. It was introduced into Mexico by the invading army of Cortez, where for years afterward heaps of skeletons of those who had perished by it were found in shaded localities. Etiology. — Although pathologists do not doubt the microbic origin of variola, the microbe which causes it has not yet been clearly ascertained. Smallpox presents four stages : the initial, or that of invasion ; the erup- tive ; that of desiccation ; and, lastly, that of desquamation. It is termed discrete when the pustules remain separated from each other ; confluent when they unite. This division is made according to the charactor of the eruption upon the face and hands. There are parts of the surface, as the abdomen, where the pustules are always discrete, even in the confluent form. Incubative Period. — During the last half of the last century inocula- tion with variolous matter was extensively practised in Great Britain and on the Continent, as it was found that smallpox thus communicated was milder than when received by infection. This operation enabled physicians to deter- mine the period of incubation, which was found to be from eight to eleven days. When variola is communicated through the air the incubative period is somewhat longer — to wit, from twelve to fourteen days. Stage of Invasion. — Smallpox begins abruptly with chilliness. In children of an advanced age there is often, as in the adult, a distinct chill. This is followed by fever and such symptoms as usually accompany a high temperature — to wit, lassitude, anorexia, and thirst. In addition, certain symptoms arise which, though not peculiar to smallpox, are so marked in the commencement of this disease that they possess considerable diagnostic value. These symptoms, which pertain to the nervous system and occur in the initial stage of varioloid as well as variola, are severe frontal headache, pain in the small of the back, and great drowsiness, sometimes with delirium. In many children convulsions occur, preceded and followed by a degree of stupor which is almost as profound as coma. Trousseau suggests the name rachialgia for the pain in the back, since he believes that it is located in or around the spinal cord. This belief is based on the fact which he, and other observers have noticed, namely, that there is sometimes in connection with this symptom an incomplete paraplegia, indicated by numbness of the legs or even inability to use them, and sometimes more or less paralysis of the bladder. These paraplegic symptoms pass off in a few days. Vomiting is also a com- mon symptom in this stage, and one also of diagnostic value. It occurs at short intervals for twenty-four to thirty-six hours, The same symptom is common in scarlet fever, and not infrequent in measles, but in both these maladies irritability of stomach is much less persistent than in smallpox : vomiting does not occur in normal rubeolous and scarlatinous cases more than once or twice. The tongue is covered with a moist fur. If the disease is to be discrete, constipation is commonly present in the stage of invasion ; if confluent, diar- rhoea is a common symptom, continuing till the fourth or fifth day. or even longer. Roseola or erythema sometimes occurs in this stage, and this may 308 COXSTITUTIOXAL DISEASES. lead to error of diagnosis, the disease being mistaken for one of these cutane- ous affections or even for scarlet fever. The symptoms in the stage of inva- sion are usually more violent in confluent than in discrete variola, but there are exceptions. Stage of Eruption. — The eruption commences about the third day, earlier in some cases, later in others. The average duration, therefore, of the first stage is somewhat shorter than in measles, but considerably longer than in scarlet fever. Sydenham has stated — and observations show the truth of the remark — that the shorter the first stage the more severe the dis- ease will prove to be ; and, conversely, the longer the period the milder will be its form. Therefore, if the eruption begin on the second day, it will, as a rule, be confluent : if not till the fifth or sixth day, it will be scanty and the disease light. The eruption commences in minute red spots, somewhat like those of lichen, which gradually enlarge. It is first observed around the lips and upon the neck, then upon the face, scalp, upper part of chest, arms, and finally upon the lower part of the chest, the abdomen, and legs. It is some- times, especially in young children, first observed in the folds of the skin, as about the genitals or in the groin. If the cuticle be irritated, as by a sina- pism, the eruption often appears first upon this part of the surface and in greater abundance than elsewhere. Commencing in a minute reddish point, as stated above, it rapidly enlarges, and soon its central part begins to be indurated and raised. It feels round and hard to the finger, is tender, and its diameter does not ordinarily exceed two lines. This is the papular stage. The papulae increase and become more elevated, and in twenty-four to forty- eight hours from the commencement of the eruptive stage they become vesic- ular. On the fifth day of the eruption, or eighth of the disease, the vesicle has attained its full size. Its diameter is then about one-fourth of an inch and its elevation is two or three lines. Its base is circular and indurated, and it is surrounded by a narrow zone of inflammation, indicated by redness and tenderness of the skin. The pock commonly, as it passes from the papu- lar to the vesicular stage, loses its acuminate form, and becomes depressed in the centre, but in most cases mixed with the umbilicated vesicles are some which remain acuminate. In proportion as the eruption becomes developed in discrete variola and in varioloid, the symptoms which accompanied the stage of invasion abate ; the fever, headache, pain in the back, and thirst cease, and the appetite returns. In the confluent form the fever continues with little abatement. Simultaneously with the eruption upon the skin an eruption also occurs upon the buccal and faucial surfaces, and often upon that of the air-passages. It occurs sometimes, also, upon the conjunctiva, producing dangerous oph- thalmia, and even ulceration with loss of sight, and upon the mucous sur- face of the genital organs. The form which it presents upon mucous sur- faces is somewhat different from that upon the skin. There is at first a deposit of fibrin, producing a small, round, grayish spot at the point of erup- tion — firm, slightly elevated, and covered, if not by the entire mucous mem- brane, at least by its epithelial layer. Ulceration soon occurs, as in ulcerous stomatitis, and if the patient live the reparative process succeeds, as in simple ulcers. The eruption upon mucous surfaces increases considerably the suffer- ing of the patient, in consequence of the tenderness of the ulcers ; and if its seat be the surface of the larynx or trachea, it may be the immediate cause of death, especially in young children, by obstructing respiration. The cutaneous eruption has been traced to the vesicular stage. On or about the fifth day of the eruptive period, or eighth of smallpox, the ves- icles gradually change their character, their contents becoming thicker and VARIOLA— VARIOL OID. 309 turbid. At the same time they increase still more in size and the central depression disappears. This is designated the stage of maturation or of sup- puration, though it is known that the turbidity is due chiefly to another substance than pus. The pock, having undergone these changes, is termed the pustule. In discrete variola and in varioloid the fever returns during the pustular stage, or if the form of the disease be confluent and the fever have continued, it now becomes more intense. The return of the fever or its increase is denoted by increased frequency of pulse, elevation of temperature, dryness of skin, anorexia, and thirst. A tendency to constipation remains throughout in varioloid and discrete variola ; in the confluent form diarrhoea more fre- quently occurs, which, if it continue, is an unfavorable prognostic sign. Other changes occur. The pustules increase somewhat in size and become more globular. Some of them, when most distended, break through friction of the clothes or scratching of the child, and their contents, escaping, add to the loathsomeness of the disease. There is in the pustular stage more or less redness of the surface between the eruptions, and, except in the mildest cases, tumefaction from subcutaneous infiltration occurs. In the confluent form at this period the features are often so swollen that the friends would not recog- nize the patient. The eyelids may be so cedematous that the eyes are for a time concealed from view. This oedema of the surface is not altogether absent in the vesicular stage, but it increases during the time of maturation, after which it subsides. Stage of Desiccation. — This immediately succeeds the full development of the pustules. The liquid portion of the contents of the pustules which are broken evaporates, leaving a crust. If there be no rupture, the liquid is absorbed and a scab results, which, though smaller, preserves in a measure the form of the pustule. While the pustule desiccates the surrounding inflam- mation rapidly abates. The crusts occur first upon the face, and on other parts in the order in which the eruption appeared. The odor from the patient at this time is peculiar. In the confluent form especially it is very offensive, and can be noticed at a distance from the bedside. Rilliet and Barthez call it nauseous and fetid. As desiccation progresses the symptoms, local and general, abate. The pulse and temperature, if the case be favorable, return to the normal ; the cough, hoarseness, and thirst disappear, while the appetite returns ; the sleep is more tranquil, and the functions generally are more regularly performed. The last stage is that of desquamation ; it commences between the eleventh and sixteenth days. The scabs, which present a dark or brownish appearance, are successively detached. This period lasts several days ; some- times two or three weeks even elapse before all the crusts separate. In the meantime, the patient gradually recovers his health and former strength. After the fall of the crust the cicatrix underneath presents a reddish appear- ance. The color gradually fades, and there remains an irregular depression, or pit, of a lighter color than the surrounding surface, and, if there have been a full development of the eruption, it disfigures the patient for life. Such is the clinical history of variola when it is favorable and its course is regular. The disease is sometimes irregular. In rare instances the erup- tion occurs almost at the commencement of the attack. The form is then likely to be confluent. There are irregularities also in consequence of diarrhoea, hemorrhages, or other complications. I have known the eruption appear first on the limbs, and last on the trunk and face, and the appearance of the erup- tion is not always the same. In the anaemic and feeble child it often presents a pale color, with some induration at its base, but without the red areola around it or with this quite indistinct. In rare instances the vesicles have a 310 CONSTITUTIONAL DISEASES. reddish color, their contents being tinged with blood. This form of variola is designated hemorrhagic. It indicates a profoundly altered state of the blood. The eruption in this form is of small size, and if the pock is broken blood oozes from it. I have met one case, perhaps two, of malignant hemorrhagic smallpox, as described by Hebra, among the rare forms of this malady. The second case died so soon that we were undecided whether he had smallpox or scarlatina. A man aged thirty-six years, previously healthy, became suddenly and severely sick in June, 1881, with fever, intense headache and backache, great depres- sion of the vital powers, sleeplessness, and a sensation of sinking or depression in the epigastrium. He had a marked foreboding of coming evil, and begged almost constantly for relief. Within forty-eight hours a heavy and continuous dusky scarlatiniform eruption covered the whole surface, except below the knees, disappearing on pressure ; fauces at first but moderately injected. On the following day, the third of his sickness, with a temperature of 104.5°, the efflorescence became a dark red, numerous small extravasations of blood had occurred under the skin, the urine contained blood, and finally it seemed to consist almost entirely of dark blood ; a large effusion of blood under the entire conjunctiva of either eye prevented closure of the eyelids, and probably hemorrhages had occurred within the eyes, as the sight was nearly lost. Death took place on the following day. In Hebra's article on smallpox is the descrip- tion of precisely such cases, but the death of my patient was too early for exact diagnosis. Varioloid. — The course of varioloid is similar to that of variola, but it is somewhat shorter. It commences with rigors, followed by fever, headache, pain in the back, vomiting, drowsiness, and sometimes delirium, or even con- vulsions. The symptoms in the stage of invasion are, indeed, the same in character, and often nearly as severe as in variola. With the initial symp- toms there is also sometimes a scarlatiniform eruption, so that the disease may at first be mistaken for scarlatina. On the third or fourth day the vario- lous eruption commences. The number of pocks is commonly few, often not more than twelve to twenty. In the mildest form of varioloid, if the phy- sician be not summoned in the stage of invasion, he may not be called at all, so that the patient passes through the disease in ignorance of its nature. The true character of the malady is not ascertained till others are affected either with variola or varioloid. The eruption pursues a more rapid course in varioloid than in the unmod- ified disease. By the fifth or sixth day the pustules are fully developed, though often smaller and less likely to be ruptured than in variola. Often in varioloid the eruption aborts. It remains papular two or three days, and then declines, or it may reach the vesicular stage and decline without pustu- lation. The constitutional symptoms in varioloid abate with the commencement of the eruptive stage. The secondary fever is slight or absent. Such is the usual mild course of varioloid, but not always. If several years have elapsed since the vaccination, its protective power is greatly impaired, and varioloid may then exhibit as severe a form as ordinary small- pox. In some instances it is fatal. The term varioloid is, as has been stated, applied to cases of variolous disease if there have been previous vaccination. It is also applied by writers to second attacks, whether the first occurred from infection or from variolous inoculation, but such cases are rare. Mode of Death. — Death in smallpox occurs in several different ways. The most fatal period is the pustular. Feeble children not infrequently die from exhaustion at or about the time that the pustules attain their greatest VARIOLA— VARIOL OID. 311 size. The eruption appears and becomes developed as usual, but there are evidences of weakness in the patient, and suddenly the progress of the vesicle or pustule ceases. It begins to subside and its walls shrivel. There is evi- dently absorption, in part, of the liquid contents. These phenomena are of the gravest character. Death is the common result, and within twenty-four hours. In other cases death occurs from apnoea. The pock, increasing in size in the larynx and trachea, obstructs inspiration, or there may be the formation of a pseudo-membrane, as in true croup. This is not an unusual mode of death in young children, in whom the calibre of the larynx and trachea is small. Sometimes convulsions and coma occur in the last hours of life. In other cases the stage of desquamation is reached, but convales- cence does not occur. The patient each day becomes more anaemic and feeble, and finally death results from failure of the vital powers. Again, after smallpox has run its course purpura hemorrhagica may be developed. Hemorrhages occur from the gums, throat, nostrils. Blood is vomited, and evacuated in the stools. I have known death to occur in all these ways, but that from purpura is least frequent. Sometimes, as in scarlet fever, death occurs suddenly and unexpectedly in confluent, and even in discrete, variola, when the previous symptoms had apparently been favorable. The patient is overpowered by the intensity of the virus. Anatomical Characters. — In those who have died of variola without inflammatory or other complication the heart-clots have been found small, dark, and soft. The blood is dark and thin. The vessels of the brain and its membranes are injected, so that numerous red points appear on the cut surface of this organ. The vessels of the lungs and the abdominal organs are congested, while the muscles present a deep-red color. The variolous eruption penetrates more deeply than that of any other exanthematic fever. It has been stated elsewhere that it occurs not only on the skin, but often on the surface of the mouth, fauces, and air-passages. The mucous mem- brane in these situations is frequently also the seat of catarrhal inflammation, being thickened and softened, and in some parts, as the larynx, a pseudo- membrane is occasionally produced, as in croup. The eruption very seldom, perhaps never, appears upon the gastro-intes- tinal surface, but the solitary follicles and patches of Peyer are often enlarged, as in some other zymotic affections. The liver, spleen, and kidneys are commonly congested in those who have died of variola. The spleen especially is increased in volume and softened ; the kidneys are enlarged, as from commencing nephritis, and sometimes softened. The minute structure of the pock is described by Rilliet and Barthez and others. The vesicle is multilocular, consisting of at least five or six compart- ments with distinct partitions. Its centre is united by fibrous bands to the derm beneath, which union gives rise to the umbilicated appearance. The giving way of these minute bands in the pustular stage occurs when the form changes from the umbilicated to the convex. In the pustular stage also, according to some, a fibrous formation occurs within the pustule ; according to others, this substance is of the nature of the epidermis, presenting the appearance of the cuticle when macerated. Mixed with this epidermic or fibrinous formation are pus-cells. Complications. — There are several different complications of variola. One is salivation. This is common in the adult, but rare in the child. When it occurs in the child it is slight, commencing with or about the time of the eruption, and disappearing in from one to four or five days. Oph- thalmia is another complication. Simple conjunctivitis, often quite intense, may occur in consequence of pustules developed under the lids. This inflam- mation subsides without injury to the eye as the primary disease abates. A 312 CONSTITUTIONAL DISEASES. more serious inflammation occurs at an advanced stage of variola, commen- cing in or near the desquamative period. This produces more or less chemosis, and sometimes opacity or ulceration of the cornea. A similar inflammation may occur in the ear, giving rise to otorrhoea, and even, in some patients, to rupture of the drum of the ear. Abscesses in the subcutaneous connective tissue have been occasionally observed, especially in the confluent form. Subcutaneous infiltration and feebleness of constitution favor their occur- rence. Suppuration within the joints is a somewhat rare complication or sequel, rendering convalescence protracted, if, indeed, the case be not fatal. M. Beraud has published a memoir to show that orchitis in the male and ovaritis in the female may complicate variola. These inflammations are believed to be accompanied by a small and imperfect variolous eruption upon the tunica vaginalis and the peritoneal covering of the ovary. Trous- seau states that he has often met this complication in the male since his attention was called to it. It is mild, and subsides with the disappearance of the eruption. Laryngitis, simple or diphtheritic, bronchitis, pneumonia, pharyngitis, purpuric hemorrhages, gangrene of the mouth or other parts, oedema pulmonum, and oedema glottidis are occasional complications, some of which are frequent, others rare. Prognosis. — This depends on the age, vigor of system, form of the disease, and the presence or absence of complications. The younger the child the greater the danger. Trousseau says : " Confluent variola, and even discrete variola, are almost always fatal in individuals less than two years old." Above the age of three or four years discrete variola usually ends favorably, but the confluent form is still, as a rule, fatal. Varioloid in the child is a mild disease, terminating favorably in a large proportion of cases. It is milder at this age than in the adult, on account of the more recent period of vaccination. If varioloid be severe and the eruption abundant in a child who has been vaccinated, it is probable that the vaccination was spurious. It is not necessary, from what has been said, to specify the favorable prognostic signs. The unfavorable prognostics are — great violence of the initial symptoms ; early appearance of the eruption ; an abundant eruption, especially if pale and without swelling of the surface ; rapid decline of the eruption in the vesicular or pustular stage ; hemorrhagic eruption or hemor- rhages from the surfaces ; fever continuing after the appearance of the erup- tion ; diarrhoea persisting beyond the third or fourth day; delirium or great drowsiness; a frequent and feeble pulse; and, finally, obstructed respiration — if slow, indicating a pseudo-membrane or variolous eruption in the larynx or trachea ; if rapid, indicating bronchitis or pneumonia. Diagnosis. — The diagnosis cannot be made with certainty prior to the eruptive stage. If, however, smallpox be prevalent, if the patient have not been vaccinated, and the symptoms which pertain to the period of invasion be present, as headache, pain in small of back, repeated vomiting, drowsiness, and perhaps convulsions, there is ground for the gravest suspicion. If in addition to these symptoms reddish points begin to appear on the second or third day, the diagnosis may be made with confidence. At this early period, even before there is any distinct cutaneous eruption, ash-colored spots may sometimes be observed on the buccal or faucial surface, the commencement of the variolous eruption ; these possess considerable diagnostic value. The scarlatiniform efflorescence in the first stage of variola sometimes leads to the belief that the disease is scarlet fever. The absence of the pharyngitis and the appearance of the variolous eruption soon after the efflorescence correct the diagnosis. Smallpox has, in the beginning of the eruptive period, sometimes been mistaken for measles. The points involved VARIOLA— VABIOL OID. 313 in the differential diagnosis have been presented in treating of that disease. After the development of the eruption it may be mistaken for varicella. The eruption of varicella is, however, preceded by symptoms which are milder and of shorter duration, and its appearance is different. It is irregular, instead of round, is not umbilicated. and it does not have the round, inflamed, Fig. 42. W V \ I \k, m Variola : first and second days of the eruption. Fig. 43. A Variola : fifth day of the eruption. Fig. 44. v^;«^> Variola : eleventh day of the eruption. and indurated base which characterizes the variolous eruption. The erup- tion of ecthyma is sometimes umbilicated, but the symptoms of ecthyma and variola and the progress of the eruptions in the two diseases are very different. There is no disease in which it is more imperatively the duty to make an early and correct diagnosis than in variola and its modified form, varioloid. 314 CONSTITUTIONAL DISEASES. Smallpox seldom occurs in the eastern part of the United States, notwith- standing the very great immigration. Therefore when it does occur and comes under observation it is more likely to be overlooked or wrongly diagnosticated than if it were more common. Thus in a prominent medical college the mis- take was recently made of not diagnosticating varioloid, and several of the physicians not fully protected suffered the consequence of infection by this loathsome disease, and, while others received cicatrices for life, one died. I trust that no one who examines the illustrations kindly furnished me by N. E. Vaccine Co. will ever make such a sad error. Treatment. — Smallpox, like the other essential fevers, is self-limited, and therefore the constitutional treatment should be sustaining and pallia- tive. In the first stages of the disease the diet should be simple ; gentle laxatives and refrigerant drinks are required if there be much febrile excite- ment. Lemonade is a grateful drink, and may be given in moderate quantity. Spiritus mindereri in carbonic-acid water may be allowed. As the disease advances more nutritious food should be recommended, and in severe cases carbonate of ammonium, and even alcoholic stimulants, are required. As confluent smallpox is nearly always, and the discrete form often, fatal in infancy, the physician should carefully watch the progress of the case in the infant. By judicious treatment some in this period of life may be saved who otherwise would perish. In the infant depressing measures should be avoided. A laxative may be given at first if there be much fever and the bowels are constipated ; but the diet should be nutritious, and many soon require tonics and stimulants. If the pulse become more frequent and feeble, or if, with frequency of the pulse, the face and extremities become cool, or in the vesicular or pustular stage the eruption suddenly subside, alcoholic stimulants must be immediately employed or the patient dies. Such is an outline of the constitutional treatment required in smallpox. Sydenham inculcated a mode of treatment which experience has shown to be injurious in infancy and childhood. He had observed that the severity of the disease was ordinarily proportionate to the amount of eruption, and concluded from this fact that measures which retarded the development of the eruption were salutary : cold drinks, a cold apartment, scanty covering of the body, cathartics that caused derivation of the blood from the surface, even sometimes the abstraction of blood, were considered, according to Syden- ham's theory, to be useful as means of preventing full development of the eruption. Sydenham's treatment, however appropriate it might sometimes be in the case of robust adults, is unsuitable for children, because they do not, as a rule, tolerate in this disease measures which reduce the strength. Moreover, small- pox is rendered more dangerous by what Rilliet and Barthez designate per- turbating treatment — treatment which renders it abnormal. The regular appearance and development of the eruption are requisite in order that the case may progress favorably. On the other hand, the opposite plan of treat- ment, which families, if left to themselves, frequently adopt — to wit, the employment of measures to promote perspiration, as hot drinks and confine- ment in a heated room — is also injurious. The patient should be kept in a temperature such as he has been accus- tomed to and such as is agreeable to him — a temperature at 66° to 70° ; his diet should be simple and nutritious ; laxative medicine should only be given to procure the natural evacuations. In smallpox, as in all infectious diseases, free ventilation of the apartment is required. The room should be dark, for a strong light perhaps increases the pitting. While the general eruption should not, as a rule, be interfered with, it is proper to endeavor to diminish, so far as possible, the size of the pocks on VARIOLA— VARIOLOID. 315 parts exposed to view, so as to prevent disfigurement. Professor Flint, in his Treatise on the Practice of Medicine, has published an excellent summary of the various measures which have been recommended for accomplishing this end. First : The opening and breaking up of the vesicle by means of a fine needle. This is tedious practice in confluent variola, but it can readily be performed in the discrete form — at least as regards the vesicles upon the face. This treatment was proposed by Rayer, and it is recommended by many who have tried it. Secondly : After the evacuation of the liquid the cauterization of the vesicle by a pointed stick of nitrate of silver. Rilliet and Barthez say, in reference to this mode of treatment, " Individual cauterization of the pustules is, on the other hand, an almost infallible means of causing them to abort. To be successful, it is necessary to penetrate into the interior of the pustule with a pointed crayon of nitrate of silver in order to cauterize the derm .... It is only the first or second day of the eruption that it (cau- terization) has certain success ; nevertheless, we have often seen it succeed the third or the fourth day, or even the fifth." Thirdly : The application of tincture of iodine once or twice daily over the eruption when in the papular stage. Some writers who have employed iodine state that it does not prevent pitting, but diminishes it. Its favorable effects are produced by coagulating the contents of the papule. Fourthly : The exclusion of light and air by means of a plaster. A mixture containing tannate of iron has been employed for this purpose in one of our hospitals. This produces a black mask. Light and air may be excluded by smearing the face with sweet oil and dusting twice daily upon the oiled surface a powder containing equal parts of sub- nitrate of bismuth and prepared chalk. Fifthly : The application of mild mercurial ointment upon the face or other parts of the surface where it is desirable to render the eruption abortive. This mode of treatment does diminish the size of the vesicles and the pitting, but I should not recom- mend it for children. I have known in the adult severe mercurialization from its employment for four or five days, and, though young children do not exhibit so readily the effects of mercury, the use of the ointment, unless for a very limited period, increases, in my opinion, their feebleness and dimin- ishes the chance of their recovery. Calamine made into a paste with sweet oil is said to be equally effectual with mercurial ointment, and it produces no constitutional effect. Its effect is obviously similar to that of bismuth and chalk employed with sweet oil as stated above. Also, I have employed pul- verized charcoal made into a thin paste with sweet oil or glycerin, and applied daily or twice daily to the face. It effectually excludes the light, and the result appeared to be good as regards pitting, but it is a disagreeable application. Curschmann recommends as preferable to any of these methods the use of iced compresses to the face and hands. The pain, redness, and swelling are diminished by their use, but without change in the copiousness of the eruption (Ziemssens Encyclop.). If fissures or excoriations occur, an application may be made of oxide or carbonate of zinc in glycerin, one drachm to the ounce. Dr. Tomkyns of the Fever Hospital, Manchester, England, states that he has used with good results the following mixture, applied from time to time over the surface : R. Glycerini, ^ss ; Tine, iodini, sjij ; Mucil. amyli, Oss. — Misce. The intense itching and the fetid odor are, according to my observations, best relieved by frequent bathing with the following wash : 316 CONSTITUTIONAL DISEASES. R. Acidi carbolic, ,^j ; Tine, camphor., ^ij ; Aqua?, Oj. — Misce. Shake bottle before using. The prevention of smallpox, so far as practicable, is one of the important incidental duties of the physician. Isolation of the patient and precautions in reference to his clothes and bedding are imperatively required, so great is the contagiousness of this disease. The only certain means of prevention is vaccination, and providentially the incubative period of the vaccine disease is less than that of variola. Therefore, smallpox may be prevented after the virus is received in the system by timely and successful vaccination. Vac- cination, at any period between the time of exposure and the commencement of the symptoms of invasion, will either prevent the occurrence of smallpox or modify it. If the symptoms of invasion have already commenced, it is uncertain whether it produces any modifying effect. Variola is so very contagious that there is danger that the physician and attendants may communicate it through their persons or clothing. The virus adheres tenaciously to objects, and may be conveyed by them long distances. Therefore the room occupied by the patient should contain no unnecessary articles, as books or writing material, and the physician attending a case should bathe and change his clothing before going elsewhere. A disinfectant should also be constantly used in the room, as the following, which I have recommended in the treatment of diphtheria and scarlet fever : R. 01. eucalypti, Acidi carbolic, da. Jfj ; Spts. terebinth., ,^ v iij- — Misce. Two teaspoonfuls in a quart of water, placed in a tin vessel, shallow and with broad surface, and maintained in a state of constant simmering. CHAPTER V. VACCINIA. Vaccinia is a mild eruptive disease which occasionally occurs among cattle and has been propagated from them to man. It is characterized by the appearance upon the surface of one or more papules, which soon become vesicular and then pustular. It is communicable by contact, but, unlike the other eruptive fevers, it is not contagious through the air. It is inoculable, both by the liquid contained in the vesicle, which is designated vaccine lymph, and by the scab which results from the desiccation of the pustule. To Gloucestershire, England, the honor belongs of discovering and utiliz- ing the fact that vaccinia, a mild and comparatively harmless disease, is trans- missible from the cow to man, and that it affords protection from smallpox. It appears that a vague opinion prevailed among the farmers of this dairying section that a disease which has since been designated vaccinia was occasion- ally received from the cow in milking, the virus passing from a pustule on the teat to a sore or chap on the hand of the milker, and that those who thus contracted the disease received immunity from smallpox. As usually happens with important discoveries, so slow of apprehension is the human intellect, these people, to whom Providence had revealed a most important fact, were VACCINIA. 317 blind to its real value. Finally, in the year 1724, Benjamin Jesty, whom the world has not sufficiently honored, " an honest and upright man," according to his epitaph, a farmer of Gloucestershire, had the courage to vaccinate his wife and two children. His excellent moral character did not shield him. He was regarded by his neighbors as an inhuman brute, who had performed an experiment on his own family the tendency of which might be to trans- form them into beasts with horns. This first essay in vaccination appears to have been entirely successful, but the prejudice against the operation continued. A fifth of a century passed, during which there was no extension of the benefits of this great discovery. At last, toward the close of the last century, Dr. Edward Jenner, a physician of Gloucestershire, an inoculator of his district, began to investigate this dis- ease of the cow, about which little was known, and the grounds for the belief that it afforded protection from smallpox. Fortunately for the world, Jenner had been educated under John Hunter, and had learned from his great mas- ter to study nature rather than books — to be guided by experience and obser- vation rather than by the dogmas of his predecessors or of the schools. Jenner performed his first vaccination on the 11th of May, 1796, twenty- two years after Benjamin Jesty had lost his good name among his neighbors by vaccinating his own family. The popularizing of vaccination, mainly through Jenner's perseverance, affords one of the most interesting and in- structive chapters in the discovery of medical science — how he went to London full of the importance of the discovery, and was there advised by his medical friends to desist from his wild schemes, lest he should injure the reputation which he had gained from a creditable paper on the habits of the cuckoo ; how he was finally allowed to vaccinate in hospital wards, and gained some adherents to the new faith among the leading physicians of the metropolis ; and, finally, how, as the claims of vaccination began to be recognized at the close of the last century and commencement of the present, a most acrimo- nious discussion arose which filled all the medical journals of that period. The opponents of vaccination resorted to every device to prevent the accept- ance of Jenner's views. They attempted to prejudice the people against them by specious arguments, by ridicule, and even by caricatures. One of the leading journals contained the picture of a cow covered with sores and devouring children, and it was urged that vaccination was a bestial operation, degrading man to the level of the brute. But the truth had gained a firm hold and the practice of vaccination extended. The discovery of vaccinia and of its protective power cannot be too highly appreciated. It has probably done more to relieve human suffering than any other discovery of the last one hundred years, unless we except that of anes- thetics, and more to save human life than any other instrumentality of a purely physical kind. The fact was established in the time of Jenner that the virus of small- pox inoculated in the cow produces vaccinia, which in its propagation back to man never returns to its original form, but always remains vaccinia. Moreover, Jenner believed that the disease known in the horse as the grease was identical in nature with vaccinia in the cow. He failed, however, in his experiment to communicate vaccinia from the horse, but other experiments have been more successful. In 1801 a Dr. Loy of the county of York, Eng- land, met two cases of vaccinia in persons who had taken care of a horse affected with the grease, and from the lymph which he obtained was able to produce vaccinia in the cow. In 1805, Viborg, a Danish veterinary surgeon. after many failures, succeeded also in communicating vaccinia to the cow by means of the virus taken from a horse. From this time little light was thrown on this subject till within the last 318 CONSTITUTIONAL DISEASES. twenty, years. Although Loy and Viborg, and perhaps a few others, had recorded their success, other experimenters had failed to communicate vac- cinia from the horse. In the absence of additional cases the profession began to question whether there might not have been some error in the observations of the gentlemen whose names I have mentioned, and whether a disease iden- tical with vaccinia, or a disease which may communicate vaccinia to the cow or to man, occurs in the horse. Observations confirmatory of those of Loy and Viborg were at length, however, made, which must be regarded as conclusive. In 1856. in the department of L'Eure-et-Loir, France, M. Pichot was consulted by a boy who had on the back of his hands vaccine pustules which had apparently reached the eighth or ninth day. He had not taken care of nor been in con- tact with a cow, but had a few days before taken care of a horse affected with the grease. Vaccination was performed by means of the lymph taken from the pustules, and genuine vaccinia was produced. Again, in 1860 an epidemic prevailed among the horses in Kiemes and Toulouse, France. A mare sickened with the disease, and there was swelling of the hough, with discharge of sanious matter. M. Delafosse vaccinated two cows with this matter and communicated genuine vaccinia. This epidemic was believed by the veterinary surgeons to be an eruptive fever, differing in its nature somewhat from the disease or diseases which have ordinarily been designated the grease. It has been conjectured that two or more distinct affections of the horse have the same appellation — one of which, it is now admitted, is identical with vaccinia of the cow and may communicate it ; and the reason why so many experimenters have failed to vaccinate the cow from the horse is that they have used the virus of the wrong disease, or have taken virus from horses which had been affected with the true disease, but from ulcers which had lost their specific character. Prior to the time of Jenner variolous inoculation was practised in most civilized countries, since variola produced in this way was found to be milder than when arising from infection. This practice is now obsolete, forbidden in some places by legislative enactments. It is superseded by vaccination. Vaccination, or the introduction of vaccine lymph into the system, is quickly and conveniently performed by scarifying with a lancet and rubbing into the incisions the lymph or a little of the scab pulverized and dissolved in a drop of cold water. It may also be performed by scraping off the epidermis with the edge of the instrument till the blood begins to ooze ; and also, though with less certainty of success, by puncturing the skin with the point of the lancet or by an instrument called the vaccinator. The scab should never be employed when it is possible to obtain pure lymph, since it contains animal matter apart from the virus, and may be the medium through which other diseases may be communicated. Besides, it is much less active than pure lymph. If the child have a vascular nsevus, this may be selected as the point of vaccination. Unless of large size, it can usually be cured by the inflamma- tion which vaccinia produces. Statistics collected by Simon, as well as Marson, show that in those who contract varioloid the larger the number of vaccine cicatrices the milder the disease and the less the proportionate number of deaths. In Simon's statistics of those who stated that they had been vaccinated, but who presented no cicatrix, 21f per cent, died ; of those who had one cicatrix, 71 per cent, died ; of those who had two, 4^ per cent, died ; of those who had three, If per cent, died ; while of those who had four or more cicatrices, only f per cent. died. These statistics would seem to indi- cate the propriety of vaccinating in several places. But. so far as appears, when two or more cicatrices were observed the patients may have been vac- VACCINIA. 319 ciliated at different times, at intervals of several years ; and if so the inference would not follow that more complete protection is produced by vaccinating in several places than in one. Moreover, if vaccination be performed in the usual manner by several incisions on the arm, and the virus be fresh and active, usually two or more distinct vesicles arise, which unite in their devel- opment and probably protect the system as much as if they were separated by a wider space. Appearances ; Symptoms. — In genuine vaccination no effect is observed, except the slight inflammation due to the operation, till the close of the third day. Then the specific inflammation commences. This is indicated by a small red point, at first scarcely visible, indurated and slightly elevated, as deter- mined by the touch rather than by the eye. This increases, and on the fifth day the cuticle over the inflamed part begins to be raised by a transparent and thin liquid. The vesicle increases in diameter, and by the sixth day presents an umbilicated appearance and is surrounded by a faint and narrow red zone. At the close of the eighth day the vesicle is fully developed. Its size varies considerably. It is usually from a sixth to a third of an inch in diameter, and oval or circular. If the vaccination have been performed by incisions, the size of the matured vesicle may be considerably larger and its shape irregular, in consequence of the union of two or more vesicles. The eruption now presents a whitish or pearl-colored appearance, due to the whiteness of the cuticle and the transparence of the liquid underneath. If the vaccination be performed by incisions, it is not unusual to observe over the centre of the vesicle, and adhering to it, a small yellowish scab, which has resulted from the scarifica- tion and which contains none of the virus. The vaccine vesicle, like that of variola, consists of compartments, com- monly eight or ten, with complete partitions, so that there is no intercom- munication. On the ninth day the inflamed areola becomes more distinct and its diameter rapidly increases. Its color is deep red, its temperature is considerably elevated, and it is accompanied by more or less induration of the subcutaneous tissue, and it is tender to the touch. On the tenth day the pock has reached its full development. The areola extends from one to two inches away from the vesicle, becoming fainter at its outer circumference and grad- ually disappearing in the healthy skin. The shape of the outer circumference of the areola is irregular, projecting farther at one point than another, though its general form is circular. On the tenth day, when the inflammation has reached its maximum, the heat, itching, and tenderness in and around the pock are such that the child is often feverish and restless. Occasionally the glands of the axilla become swollen and tender. In other cases, in which there is but a moderate amount of inflammation, the constitutional disturbance is slight. At the close of the tenth day or on the eleventh the inflammation begins to decline ; the areola becomes narrower and then disappears ; the induration and tenderness abate ; and with this change the pustule desiccates, its liquid is absorbed, and there results a brownish or dark mahogany-colored scab, which is detached, ordinarily, between the fourteenth and twenty-first days. The cicatrix, at first reddish like all recent cicatrices, gradually becomes paler. and remains whiter than the surrounding integument. It presents several minute depressions or pits, which indicate the genuineness of the vaccination. The theory that smallpox becomes vaccinia by passing through the heifer, as we have given it above, has for many years been undisputed. But recently the theory has been promulgated that vaccinia and variola, instead of being- forms of the same disease, are essentially distinct — that when the heifer is inoculated with the virus of smallpox, the disease which is produced is a modified smallpox, but not vaccinia, which occurs as a spontaneous disease 320 CONSTITUTIONAL DISEASES. among cattle. It may be that the old theory, which no one doubted until recently, is wrong, but that vaccination prevents smallpox just as a mild attack of scarlet fever prevents a severe attack of the same disease, shows, in my opinion, a close relationship between vaccinia and the severe malady which it prevents. We wait for more conclusive facts in support of the new theory before accepting it. Anomalies, Complications, and Sequels. — The vesicle is often broken accidentally or by the nails of the child. If the top of the vesicle be destroyed or most of the compartments be opened, the inflammation is commonly in- creased, considerable suppuration occurs, and there results a large, irregular, yellowish scab consisting of the virus mixed with desiccated pus. The scab is entirely unreliable and unfit for the purpose of vaccination, though the protective power of the disease is not diminished by injury of the vesicle even if it be totally destroyed. The cicatrix which results from extensive injury to the vesicle is usually large and without the indented points which characterize the normal cicatrix. In rare cases, when the inflammation which surrounds the vesicle is intense and deep-seated, suppuration occurs in the subjacent connective tissue, giving rise to an abscess. This abscess is commonly of small size, but it increases the fretfulness and constitutional disturbance which attend vaccinia. This subcutaneous suppuration occurs most frequently in those who have a scrofulous or vitiated state of system. Inflammation of the lymphatic glands of the axilla I have spoken of as not infrequent in vaccinia. This sometimes proceeds to suppuration, producing an unpleasant though not serious complication. It sometimes happens that vesicles appear in other parts besides the points where the virus was inserted. These supernumerary vesicles commonly occur where the cuticle has been removed by scalds or injuries. Trousseau relates the case of an infant whom he had vaccinated. On the eleventh day he was astonished to find twenty-seven vaccine pustules on the face, trunk, and limbs. This infant had, however, before the vaccination a simple non-specific eruption over the whole body, and it was believed that it had produced these vaccinations by transferring the lymph with its nails to the various parts where the cuticle was denuded. It is not unusual, also, to observe minute papules appearing on parts of the surface simultaneously with or soon after the vesicle, and in a few days declining. These seem to be abortive vaccine eruptions. One of the most serious complications is erysipelas. This may occur directly from the operation or from the inflammation caused by the vesicle when the virus possesses no deleterious property ; and, again, it may result from some unknown element in the virus. It may occur immediately after the operation, when it commonly prevents the working of the virus, or during the vesicular or pustular stage, or, again, after desiccation and separation of the scab. I have observed it at all these periods. Erysipelas, occurring as a complication of vaccinia, is invariably referred by the friends to the virus employed, and the physician who has had the mis- fortune to vaccinate is often unjustly blamed. In many of these cases there is a strong predisposition to erysipelas at the time of the vaccination, and the operation or the inflammation which accompanies the normal develop- ment of the vesicle serves simply as an exciting cause. Erysipelas would occur as soon from a non-specific sore ; indeed, we not infrequently are called to cases of this disease In young children which commence from non-specific sores upon the genitals or on one of the limbs. That the fault is not in the virus employed is evident from the fact that other children, vaccinated with the same, have simple uncomplicated vaccinia. VACCINIA. 321 Septicemia is a very serious complication of vaccinia. On one occasion since the publication of the last edition, 450 infants were vaccinated in the Foundling Asylum. This institution being under the charge of a large sister- hood, all the inmates are clean, and all the 450 did well with one exception. This infant, in its second year, is believed by the physicians who examined it to have poisoned the vaccine sore by scratching it with dirty finger nails. It had sores and a dusky red discoloration of parts of the surface, and a deep ulcer over its right leg denuding the tibia nearly half its length. We were taught the important lesson which surgeons practise, of disinfecting the skin before the operation and to protect it subsequently by some dressing. Sometimes, on the other hand, the cause of erysipelas, whatever it may be, exists in the virus. (For further facts in reference to this subject the reader is referred to our remarks on erysipelas.) The fact is established by many observations that syphilis is communi- cable by vaccination. The symptoms of it may not appear till vaccinia has terminated or for a little time subsequently, but it then constitutes a very serious sequel. A physician of this city, well known in this community as skilful in the diagnosis and treatment of skin diseases, and therefore not Fig. 45. BPSi^ Vaccine vesicles. Normal shape and size on tenth day. likely to be mistaken as regards the nature of the diseases, states that he communicated syphilis to two infants by vaccinating with the same scab. Both had the characteristic syphilitic eruption. In January, 1868, an infant 21 322 COXSTITUTIOXAL DISEASES. was brought to Prof. Alonzo Clark's clinic in this city having syphilitic rupia, which in the opinion of the physicians present was undoubtedly the result of vaccination. Trousseau relates the case of a young woman eighteen years old who was vaccinated with virus taken from an infant apparently in perfect health. The vaccination was unsuccessful, but twenty-three days subsequently his atten- tion was called to an eruption which had appeared in two places on the woman's arm corresponding with the points where the virus had been inserted. The eruption was that of ecthyma, which by the next examination, which was five days subsequently, had been transformed into rupia. The axillary lym- phatic glands were tumefied and indolent : finally roseola appeared, which removed all doubts as to the syphilitic character of the disease. There was syphilitic infection, which first manifested itself in the points where vaccina- tion had been performed (Article de la Vaccine'). It is not ascertained in Professor Clark's case, nor is it stated in Trousseau's, whether the lymph or scab was employed for vaccination. There can be little doubt that the pure lymph never communicates anything but vaccinia, and if by vaccination any other disease be imparted, a little blood has mingled with the lymph or the scab has been employed. The vesicle in genuine vaccinia is sometimes very small, not having a diameter of more than two lines. Occasionally the development of the vesicle is retarded. It does not appear till two or three days later than the usual time, or even a longer period. Vaccinia is modified by certain diseases. It is arrested by measles and scarlet fever, pursuing its course after the subsidence of the exanthem. On the other hand, it sometimes modifies the paroxysmal cough of pertussis, but only during the time when the pock is maturing. Eczematous eruptions occasionally occur after vaccinia, as they often do after the other eruptive fevers, or if already present they may be aggravated. Subsequent Vaccinations. A second vaccination, performed prior to the ninth day after the first vaccination, is successful. A genuine vaccine eruption results, which is smaller the more advanced the primary disease. This second eruption over- takes the first. On the ninth day the susceptibility to vaccinia is, in most cases, lost, so that vaccination performed on the tenth or subsequent days is unsuccessful. As a rule, an acute contagious disease occurs only once in the same individual. Vaccinia is an exception. In most people, after a few years it can be produced a second time, and cases of a third or fourth successful vaccination at intervals of a few years are not uncommon. Xow, subsequent cases of vaccinia differ from the first, which has been described above. The period of incubation is shorter, and the vesicular, pustular, and desiccative stages succeed each other more rapidly, so that the whole period of the disease is less. The variation from the appearance and course of the first vesicle is proportionate to the degree of protection which the first vaccination still affords both as regards smallpox and vaccinia. If several years have elapsed since the first vaccination, and the protective power which it affords is nearly lost, the second vaccinia differs but little from the first. If. on the other hand, the first vaccination still affords nearly complete protection, the result of the second is slight ; the eruption is insignificant, lacking the characteristic appear- ance of the vaccine vesicle, resembling a common sore, and disappearing within a week. It is not accompanied by the inflamed areola or any appreciable con- stitutional disturbance. VACCINIA. 323 Vaccination often produces no result. This is sometimes due to the fact that the lymph or scab employed is useless. It has spoiled by keeping or never has been good. In other cases it is due to a lack of susceptibility in the person. Some take vaccinia with difficulty and only after several vacci- nations ; just as children, though fully exposed, often fail to take measles or scarlet fever, on account of a condition of the system which prevents the reception of the virus or antagonizes and controls its action. In some instances after vaccination an eruption is produced which may or may not be genuine, but it immediately becomes purulent and is soon broken. A large yellow, uneven scab results, having none of the appearance and containing none of the vaccine virus. This scab, as well as the liquid matter which preceded the formation of the scab, is utterly useless for the purpose of vaccination, and if so employed will probably cause a sore from its irritating effect, but not of a specific character. If, in place of the true vaccine vesicle, the erup- tion presents the appearance which I have described — namely, that of a pus- tule, soon breaking and forming a large irregular, yellowish scab — the vaccinia (if it be correct so to designate it) must be considered spurious. A sore has been produced by the animal matter which was employed in the vaccination along with the virus, which has modified the action of the virus, and probably has rendered it useless as a means of protection ; or there may have been no virus inserted with this animal matter. The physician should in such cases insist on a second vaccination. Cases like the above are of frequent occurrence, and the parents of the child are often satisfied with the result. They see an eruption following vac- cination, accompanied by considerable inflammation and leaving a cicatrix. Unless undeceived by the physician, they probably remain in the belief of the child's security until, perhaps, it takes smallpox. Such cases obviously tend to diminish the confidence which the public should have in vaccination as a means of protection from smallpox, and on account of their frequent occurrence it is important in every case that the physician should see the result of his vaccination. It has been proposed, as a means of determining the genuineness of vaccinia, to revaccinate when the eruption begins, and if the first be genuine the second will overtake it. This is called Brice's test, but it is not necessary, since the physician, familiar with the appearance of the true vesicle, can determine at once its genuineness by the sight. Protection from Vaccination— Re vaccination. It was believed by the early advocates of vaccination that the general performance of this operation would soon eradicate smallpox from the com- munity, so that it would be interesting only to the medical historian as a scourge of past ages. This result, however, is only partially achieved. As a rule, the greater the benefit of any measure designed to ameliorate the condition of mankind, the greater and more numerous are the obstacles which diminish its effectiveness. Science is full of examples like this. Fortunately, these obstacles as regards vaccination are not such as to impair the confidence of physicians in its protective power, and it is not too much to expect that this simple operation will yet be the means of rendering smallpox a disease almost unknown, unless in its modified form. Vaccination should be performed in the first year of life. In rural dis- tricts, where there is little danger of exposure to smallpox, it may be deferred till the age of ten or twelve months. In the city, on the other hand, where there is constant intercourse of people and where contagious diseases are often contracted in ignorance of the time and place of exposure, an earlier vaccina- tion is advisable. Some physicians recommend performance of the operation 324 CONSTITUTIONAL DISEASES. as early as the age of four or six weeks. The objection to this is that if erysipelas occur so young an infant is likely to perish from it, whereas an infant three or four months old ordinarily recovers. For this reason I believe that the most suitable age is about four months for the city infant in ordinary times ; but if smallpox be epidemic, vaccination should be performed at an earlier age. I have vaccinated even the new-born infant when smallpox had broken out in adjoining apartments. Vaccinia usually extinguishes, for a time, the susceptibility to smallpox. According to Mr. Gintrac, varioloid does not occur within two years in those who have been vaccinated. It may, however, in exceptional instances, occur in a mild form within a few months after vaccination. The protection afforded by vaccination gradually diminishes by time, but it does not probably, as a rule, entirely cease. Varioloid, however, occurring thirty or forty years after a successful vaccination is likely to be severe, and it may even be fatal, show- ing that it has been but slightly modified. In other cases, even after so long an interval, the symptoms present a degree of mildness which indicates that the protective power of the vaccination is not entirely lost. If a second vaccination be practised soon after the scab from the first vac- cination has fallen, it will usually produce no result, but in other cases it gives rise to a little redness, swelling, and induration, which show that vaccinia has been reproduced, though in a very mild and insignificant form. It is probable that in these cases varioloid might also occur by exposure, though with a mildness corresponding with that of the vaccinia. The longer the period after the first vaccination, the greater the number of those in whom a second vaccination is effective, and, as has already been stated, the greater also the liability to the variolous disease until the system is protected by a second vaccination. A second vaccination should be performed about the sixth or eighth year, and a third between the fifteenth and twentieth years. If small- pox be epidemic, it is proper to vaccinate all who have not been vaccinated within three or four years. Selection of Virus. The lymph is preferable to the scab for vaccination, provided that it can be obtained fresh. The scab is more easily preserved, and therefore, if the lymph and the scab be old, the latter is to be preferred. The lymph should be taken on the fifth day if the vesicle be sufficiently developed. It may also be taken on the sixth, seventh, or even eighth day, provided that the areola has not formed. The lymph of the fifth day acts with greater energy, though that of the sixth or seventh day is not much inferior. Lymph obtained after the formation of the areola is less efficient, though it may communicate the genuine disease. There is no mode of vaccination so reliable as the use of lymph taken directly from the arm and immediately inserted — the arm-to-arm vaccination. Lymph can be preserved for a few days on a flattened surface of whalebone or the segment of a quill, and if employed within a week it will usually com- municate vaccinia. Lymph may be preserved a longer period between two surfaces of glass, but the best way of preserving it is in capillary glass tubes. The end of the tube is placed within the vesicle, and the lymph ascends by capillary attraction. When a sufficient quantity is received, the ends are sealed by holding them for a moment in a flame. Care is requisite in doing this so as not to heat the lymph, as it is spoiled by a temperature much above that of the body. When the lymph is used, the ends of the tube are broken, and by blowing gently through it a sufficient quantity is received on the point of a lancet. VACCINIA. 325 If the scab be genuine, it presents a dark-brown or mahogany color, and has a circular, oval, or at least a rounded form ; it is firm or compact, and has a lustre. Soft, yellowish, and irregular scabs are not genuine, and those of a dull appearance or without lustre have usually spoiled in the keeping. The scab is best preserved in soft beeswax, which excludes the air, and it should be kept in a cool place. It is the belief of many that the vaccine virus grad- ually becomes weaker by passing successively through the human system (Condie. American Journal of the Medical Sciences, April, 1865), and that therefore different specimens of virus work with different energy according to the degree of removal from the cow. To what extent this view is correct is not fully ascertained, but certainly if the virus employed continue to pro- duce a small vesicle attended only by a little inflammation, there is reason to believe that the protection which it imparts is less than that from virus which works with greater energy, and it should be exchanged for such. In New York we are able to obtain at any time lymph directly from the heifer. It has never passed through human blood, for the original lymph came from cattle in one of the provinces of France, where vaccinia was prevailing epi- demically. The popular objection to vaccination is obviated by the use of this lymph, but it works with great energy, producing a large pock and a sore which is often a month in healing. I have found it very reliable, and prefer to use it in ordinary cases. In the Boston Medical and Surgical Journal of October 12, 1882, appeared a sketch of the following remarkable case. It shows a new and unusual phase of vaccinia : •• The case about to be reported is entirely unique ; the record of a similar one I have been unable to find anywhere. Mrs. B., a healthy woman, the mother of two children, was vaccinated February 13th, with bovine virus, by her family physician, Dr. Harris of Roxbury, through whose kindness I Fig. 46. Vaccinia communicated by the mother's milk. saw the case, and to whom I am indebted for the following notes. On the fifth day after vaccination the patient complained of headache, was feverish, and in fact had the usual amount of discomfort that attends a successful revaccination. Mrs. B. was at this time nursing her infant, a child about 326 CONSTITUTIONAL DISEASES. six months old. The child had not been vaccinated on account of eczema from which it was suffering at that time. On March 9th, as nearly as the mother can remember, an eruption appeared on the head, thorax, and the legs of the child, who had been feverish and irritable for two or three days previous. On some portions of the body the eruption was confluent, but on the arms and thighs it presented the characteristic appearance of cow-pox. It was not an instance of accidental inoculation, for there was no possible way by which the child could have introduced the virus at so many different points. The disease must have been contracted from the mother through the medium of her milk." CHAPTER VI. VARICELLA. Varicella, chickenpox, or swinepox is the shortest and mildest of the eruptive fevers. It is highly contagious, so that few children escape who are exposed to it. Its period of incubation is from fifteen to seventeen days. Hutchinson (Brit. Med. Jo-urn., 1881) and Le Gendre (JDe Concours Med., 1887) state that varicella is inoculable, but some years ago inoculations which I performed with the lymph of the varicellar vesicle were without result. It attacks the same individual but once, and it occurs as an epidemic. It has been thought by some to prevail most immediately before, during, or after epidemics of smallpox, and it has been conjectured that it is a modified form of variola, and hence its name, which signifies little variola. This idea is, however, entertained by few, and it is opposed by the following facts: Vari- cella may occur after variola or variola after varicella without any modifica- tion, and the two diseases are very dissimilar as regards gravity of symptoms and duration. The variolous disease, whether smallpox or varioloid, often occurs in the adult ; varicella, on the other hand, is a disease of infancy and childhood. I have seen one adult case, which I recall to mind, and Professor Flint states that he has also observed varicella in the adult, but its occurrence at this period of life is rare. Senator relates a case that occurred at the age of eleven days. In 584 cases observed by Baader the ages were as follows : Cases. Age. 382 1-5 years. 191 6-10 " 7 11-15 " 2 16-20 " 2 ...... . 21-40 " Moreover, varicella and variola have been known to occur simultaneously in the same individual. Such a case was reported by M. Delpech in a memoir published in 1845. Symptoms. — Varicella usually commences with such symptoms as usher in ordinary mild febrile attacks — namely, headache, languor, chilliness, and sometimes aching in the back and limbs. Fever supervenes, which is usually moderate, the pulse rising perhaps to 100 or 112, and the thermometer show- ing an increase of temperature, but less than occurs in the other eruptive fevers. These symptoms which precede the eruption are sometimes absent or are so mild as to escape notice. The fever usually ceases on the second VARICELLA. 327 day. but it may return on the following night. The appetite is rarely lost, and most children continue more or less at their amusements. When the above symptoms have continued about twenty-four hours the eruption appears first over the trunk, and soon afterward over the face and limbs. It consists of minute disseminated papules which become vesicular in the course of a few hours. The occurrence of the vesicular stage is nearly simultaneous on all parts of the surface, and commonly fresh vesicles appear during the first three or four days. The vesicles lack the hard, indurated base of the variolous eruption, though they are sometimes surrounded by a faint zone of redness. They differ also from the variolous eruption in the absence of umbilication and in irregularity of shape. Some are small and acuminate, some hemispherical and of medium size, and others oval or elon- gated and of large size. The inflammation is quite superficial, not involving the subcutaneous tissue and scarcely affecting the deepest layer of the skin. The- vesicles vary in size from the diameter of half a line to that of even three lines. They occasionally give rise to slight itching. On the second day of the eruption or third day of the disease they are still fully developed, their liquid contents being nearly transparent. At the close of this day the liquid begins to be somewhat cloudy and its absorption commences. On the fourth day of the disease desiccation progresses rapidly, and by the fifth the liquid has for the most part disappeared, and a scab results, small, thin, and of a yellowish-brown color. The scabs are soon detached, the redness which indicated their seat disappears, the epiderm which had been raised and removed by the eruption is reproduced in its normal state, and in a few days all evidence of varicella is effaced. A cicatrix occasionally results, but it is due not to the simple varicellar eruption, but to a sore produced from the eruption by the scratching of the child. The number of vesicles varies considerably in different cases. They are never, so far as I have observed, confluent ; but they are sometimes so abun- dant in young children that if the disease were variola it would be called severe discrete. They occur also on the buccal and faucial surfaces, where they soon break, forming small ulcers. . The duration of the disease from the first symptoms until the disappearance of the crusts is eight or ten days. Mr. J. Hutchinson of London has described a rare form of varicella in which the eruption becomes gangrenous. It occurs most frequently in feeble, ill-conditioned children, but sometimes in those who are well nourished. Only a portion of the vesicles become gangrenous. Where the gangrene occurs a deep and unhealthy ulcer forms underneath the scab, which does not heal or heals slowly. This rare form of varicella is very fatal, death sometimes occurring from pyaemia and secondary abscesses. Crocker states (London Lancet, May 30, 1885) that the gangrene sometimes occurs upon a part of the surface which is not the seat of the eruption. Complications ; Sequels. — Complicating maladies which sometimes supervene in varicella do not, for the most part, occur in consequence of this disease, but are independent of it. Erysipelas has in rare instances super- vened on the varicellar eruption, but its occurrence is attributable to the ordinary causes, of this disease, rather than to varicella. Various sequela? of varicella have been mentioned by writers, among which we may mention 'anaemia, pemphigus, urticaria, bronchitis or bronchi-pneumonia (Meigs and Pepper), ulcers leading to glandular enlargements and tuberculosis, and nephritis (Henoch, Janssen, Oppenheim). Diagnosis. — Obviously, the only diseases with which varicella is liable to be confounded are such as present vesicles at some stage of their course. From the local vesicular eruptions this disease is diagnosticated by the fact that the vesicles appear on all parts of the surface. It is sometimes mistaken 328 CONSTITUTIONAL DISEASES. for variola or varioloid, or vice versa — a mistake very damaging to the reputa- tion of the physician. The points of differential diagnosis are the symptoms of invasion — severe and lasting three or four days in the one, mild and con- tinuing only one day in the other ; an eruption passing slowly through its stages from the papular to the pustular, umbilicated, with circular, raised and inflamed base, appearing first on the face and neck, and not till a day later on the legs, in the one disease ; while in the other the evolution, shape, and course of the eruption, as described above, are materially different. By proper attention to these distinctive features it is rarely difficult to diagnosti- cate varicella. Prognosis. — In ordinary uncomplicated varicella this disease is always favorable. Gangrenous varicella, which is very rarely seen in America, may be fatal, and complications may render a case grave. Treatment. — On account of the general mildness of varicella, prophy- lactic measures, as isolation of the patient, are seldom enforced in America, and the disease, when not complicated or gangrenous, requires little treat- ment ; but the patient should be quiet and indoor during its continuance. Large vesicles upon the face should be punctured early and irritation by rubbing should be avoided. Complications and gangrenous varicella require appropiate treatment, especially supporting remedies. Anaemia or glandular swellings remaining after varicella require tonics, especially cod-liver oil and syrup of the iodide of iron. CHAPTER VII. DIPHTHERIA. Diphtheria is one of the most dreaded, one of the most fatal, and unfortunately one of the most common, maladies of childhood. It is pro- duced by a micro-organism. It is characterized by the occurrence of a grayish-white pellicle upon the mucous surface or the skin deprived of its protecting epithelium. The specific principle is ordinarily received by the inspiration of infected air, but it is sometimes received by direct contact of infected matter with one of the surfaces not lying in the respiratory tract. Diphtheria is a disease of antiquity. M. Sanne mentions the following names by which it has been known in different countries and at different periods: Ulcus Syriacum, ulcus iEgyptiacum, garrotillo, morbus suffocans, affectus strangulatorius, pestilentis gutturis affecto, pedancho maligna, angina maligna, anginosa passio, mal de gorge gangreneux, ulcere gangreneux, angina polyposa, angine maligna, croup, diphtheritis, diphtheria. These terms express the prominent characteristics of diphtheria. It is impossible to state or form a probable conjecture in regard to the time when diphtheria originated, but its origin antedated the Christian era. According to Aurelianus, Asclepiades, who lived one hundred years before Christ, scarified the tonsils and performed laryngotomy for the relief of res- piration, and it is supposed that he treated cases of membranous croup, and probably diphtheria. Aretseus, a Greek physician of Cappadocia at the com- mencement of the Christian era, gives in writings still extant a clear and accurate description of mild and severe diphtheria. After describing what he designates ulcers upon the tonsils, " covered with a white, livid, or black con- crete product," he adds : " If the malady invades the chest by the trachea, it DIPHTHERIA. 329 causes suffocation on the same day. Children up to the age of puberty are most exposed to this disease." He gives also a graphic and truthful descrip- tion of the suffering of the child when the disease extends to the larynx, and croup results. Galen, in the second century of the Christian era, apparently alludes to diphtheria when he describes a fatal disease prevalent in his time in which fragments of " membranous tunic " are expelled. He states that he is able to determine by the manner in which the fragments are expelled, by coughing or spitting (hawking), whether they are detached from the larynx or the pharynx. Ccelius Aurelianus, a Latin physician who is supposed by some to have lived in the second century, and by others as late as the fifth century, describes a grave angina in which the symptoms which sometimes arise correspond with those in diphtheritic croup and diphtheritic paralysis as observed at the present time. In the fifth century Aetius of Amida described a disease accompanied by ;i crusty and pestilential ulcers," sometimes having a whitish and in other instances an ashy or rusty color, and not preceded by a discharge. Aetius alludes to the hoarseness which he says sometimes super- venes and is a source of danger up to the seventh day. From the close of the fifth century until the sixteenth the record of diphtheria is broken. It is probable that during the long period embraced in the Dark Ages every decade witnessed epidemics of this fatal malady, but if they were observed and recorded the records were lost, the literature of diphtheria sharing the fate of general literature during this time of intel- lectual darkness. On the revival of learning many epidemics of diphtheria were recorded in the medical literature of Europe, and this disease has since been a common topic of discussion in the civilized portions of the Eastern hemisphere. Those who have made special study of diphtheria believe that its first occurrence in North America was in New England. It is stated that Samuel Danforth of Roxbury, a graduate of Harvard, lost three of his children in 1659. within two weeks, from a disease which was designated " malady of bladders in the windpipe." Again, John Josselyn made two voyages to New England in 1638 and 1663, and in his memoranda he states that the English in New England " are troubled with a disease in the mouth and throat, which hath proved mortal to some in a very short time. This disease is designated quinsies and imposthumations of the almonds with great distempers of colds." Whether these early New Englanders had diphtheria or not I am unable to say, but nearly a century had elapsed from the time of Danforth and Josselyn when the much wider and more fatal epidemic, more clearly one of diphtheria, occurred. On March 20, 1635, at Kingston, a town fifty miles northeast of Boston, occurred the first case of the disease, which was destined to overrun the British possessions in North America. The first forty attacked by it died ; the first patient survived three days ; the three next attacked lived four miles from the first patient. When the epidemic reached Boston, Dr. William Douglass made a full and accurate clinical examination of it, and wrote a monograph containing the result of his observations. Douglass, not knowing that Bos- ton was soon to be the " Athens of America," states in his exordium that in plantation life neither honor nor credit are to be acquired by writing. His sole object in publishing his monograph was to induce others to investigate the disease more fully. Death, he states, usually occurred from the fauces or neck, which was greatly swollen. J. Dickinson, A. M., of Cambridge, a clergyman, published what he designated " Observations on that terrible Disease vulgarly called ' Throat Distemper.' " He writes : " Some expecto- rated incredible quantities of a tough whitish slough from their lungs I have seen several pieces of this crust several inches long, and near an inch 330 CONSTITUTIONAL DISEASES. broad, torn from the lungs by the vehemence of the cough.'' Dickinson also remarks that one attack of the epidemic disease does not protect from a sec- ond. One patient had at intervals four distinct attacks, the last being fatal. The fact of the recurrence of the throat affection is sufficient proof of its diphtheritic rather than scarlatinous nature, as is also the fact that the cha- racteristic pellicular inflammation sometimes occurred upon abraded or wounded surfaces at a distance from the fauces, while the latter was but slightly or not at all affected. This widespread and gradually extending epidemic of diphtheria was the first occurring within historic times in North America and probably in the Western hemisphere. The Hon. Cadwallader Colden, Esq., His Majesty's Lieutenant-Governor of the State of New York, wrote a letter to Dr. Fothergill in 1753, printed in the London Medical Observations and Inquiries, vol. i. He writes that this new throat disease extended gradually westward from Kingston, tra- versing New England, but it did not reach the Hudson river until two years had elapsed. Colden said that it remained for some time on the east side of the Hudson, but finally crossed to the west side, and he believed that it spread over all the British colonies in America. As might be expected, in due time it reached New York, and it was described by Dr. Samuel Bard in a paper published in 1771 and having the following title : " An Inquiry into the Nature, Cause, and Cure of the Angina Suffocativa, or Sore-throat Dis- temper." Bard wrote as follows : " Upon the whole, therefore, I am led to conclude that the disease called by the Italians morbus strangulatorius ; the croup of Dr. Home ; the sore throat of Huxham and Fothergill ; this disease, and that described by Dr. Douglass of Boston, however they may differ in the symptoms of putrescence and malignancy, do all bear an essential affin- ity and relationship to each other, and in fact arise from the same leaven." Dr. Jacob Ogden of Jamaica, Long Island, described this widespread throat distemper as he observed it in the townships of Long Island. His last paper on this malady was published in 1774, thirty-nine years after the first case in Kingston, and just before the breaking out of the Revolutionary war. I am not aware that any outbreak of diphtheria occurred in this country during the eighteenth century after the commencement of the war. The fact that families deserted their homes and fled to a distance for safety, especially from the cities along the Atlantic coast, may aid in explaining the disappear- ance of this disease. After the disappearance of this widespread epidemic we hear little or nothing of the occurrence of diphtheria upon this continent until nearly a century had elapsed, except that occasional isolated cases of pseudo-membranous laryngitis, popularly designated membranous croup r occurred now and then with little evidence of contagiousness. It may have been produced by the streptococcus and have been a croup of the pseudo-diphtheritic nature. In the first half of the present century diphtheria was regarded as a very important disease in Europe, and was made the subject of investigation by the most renowned clinical teachers, among whom we may mention Jurine (1807), Bretonneau (1821), Bourgeoise (1823), Gendron (1825). Billard (1826), Deslandes (1827), Blanquin (1828), Broussais (1829), Trousseau (1830), Cheyne (1833), Fricout and Burley (1836), Boudet (1842), Guersant and Blache (1844), Moland (1845), Damot (1846), and Heine (1849). During this half century, ending with 1850, which witnessed such an augmentation of the literature of diphtheria in Europe, this disease attracted but little attention in America. It appears to have been much less prevalent on this continent than in the Old World. It may have occurred in small epidemics in various localities from the time of Dr. Bard until 1850, but they attracted so little notice from American physicians that no monograph or communica- DIPHTHERIA. 331 tion to medical journals relating to diphtheria, which was worthy of preserva- tion, appeared during this long period. Etiology. — Diphtheria is caused by a bacillus, which alights upon the faucial or other mucous surface, or the skin denuded of its epidermis, and obtains there a nidus favorable for its development and propagation. It is designated the Klebs-Loeffler bacillus, having been discovered by Klebs in 1883, and subsequently more fully investigated by Loeffler. It is a small linear microbe, having nearly the length of the tubercle bacillus, but ordi- narily more than double its thickness. It often exhibits a granular appear- ance, and is stained in two minutes by the violet of methyl. It presents aspects which under the microscope are characteristic. It often exhibits a more intense coloration of its extremities than of its central parts. Both its extremities are sometimes swollen, so that its shape approximates that of the dumb-bell, or only one is swollen, so that its shape resembles that of the pear or gourd. According to all bacteriologists this bacillus does not enter the internal organs except in rare instances. It does not ordinarily extend more deeply than the mucosa, the parts below being protected by a layer of fibrinous lymph. Since the specific bacillus ordinarily acts only on superficial parts, it does not in itself produce systemic or blood poisoning, but it generates a toxine which is readily taken up by the lymphatics or blood-vessels and is conveyed to every part of the system, causing the systemic infection from which so many of the victims of diphtheria perish. L. Brieger and Karl Fraenkel say of this toxine that it is destroyed by a heat above 140° F. (60 C), and may be evaporated at 122° F. (50 C). It is soluble in water, but insoluble in alcohol. It is not precipitated by ebul- lition, nor by the following medicinal agents : sulphate of sodium, nitric acid, and acetate of lead, but is precipitated by concentrated carbolic acid, the ferrocyanide of potassium, acetic acid, carbolic acid, and nitrate of silver. It has the following composition : Carbon 45.35 Hydrogen . '. 7.13 Azote 16.33 Sulphur 1.39 Oxygen . 29.80 The investigations of Boux, Yersin, and others have shown that the diphtheria bacillus separated by passing through the Pasteur-Chamberland porcelain filter, and becoming separated from its toxine, loses its virulent property, while the clear filtered fluid, free from microbes, contains the toxine without diminution of its poisonous character. Grandmaison says that although the Klebs-Loeffler bacillus appears only on superficial inflamed parts, the poison generated by it entering the system causes paralysis, gan- glionic engorgement, albuminuria, patches of sphacelus, and visceral lesions. which, although they may be latent during life, are discovered by micro- scopic examination of the diseased viscera in the cadaver. Although the Klebs-Loeffler bacillus is the recognized cause of true diphtheria, certain accessory germs, mainly cocci, occur during the course of the attack, in the pseudo-membrane, upon and in the inflamed surface, and also in internal organs, if the disease be severe, having obtained a nidus favorable for their development in and upon the diseased parts. It appears, from examinations made, that these accessory germs are, in some eases, taken up by the lymphatics and blood-vessels, and conveyed to the lymph-nodes and the connective tissue of the neck, causing inflammatory tumefaction, and 332 COXSTITUTIOXAL DISEASES. to internal organs which are not reached by the Loeffler bacillus. These acces- sory germs increase the severity and mortality of true diphtheria. Their presence as a complication is an interesting fact, because, as we will see, the streptococcus and. in a less degree, other forms of cocci, unaided by the diphtheria bacillus, sometimes cause so severe an inflammation of the mucous surface that fibrin exudes, producing a pseudo-membrane. Klebs-Loeffler Bacillus in Healthy Individuals. — Roux and Yersin have found in the mouths of healthy children and adults a bacillus which, in a morphological point of view, is identical with the Klebs-Loeffler bacillus. They found it not only in Paris, but also at a distant village situated near the sea where diphtheria had not occurred within the memory of man. In this village Roux and Yersin examined 50 children and found this benign bacillus in 26. It does not differ from the Klebs-Loeffler either in its indi- vidual form or in the form of a colony, but only in the number of its colonies. Instead of producing a considerable culture in the bouillon, it only produces a slight culture. Hence Roux and Yersin believe that this harmless bacillus is none other than the Klebs-Loeffler, deprived of its viru- lence. They have been unable to produce its transformation into the genuine diphtheritic bacillus or the reverse, but do not doubt that this transformation is possible. This innocuous bacillus has been found most frequently in benign diphtheria and in persons recently cured of diphtheria. Dr. W. H. Park writes as follows upon this subject: ' : In 1888 Hofmann states that besides finding the diphtheria bacilli in cases of true diphtheria. he had found them in twenty-six out of forty-five throats in which no diph- theria had existed. Some of these bacilli were shorter, thicker, and more regular in form than the Loeffler bacilli, and grew more readily on agar, the growth being more luxuriant and whiter. Others, however, were in all respects identical with the Loeffler bacillus, except that those from healthy throats were not virulent. He did not feel able to state whether or not these two forms were identical with the virulent diphtheria bacilli of Loeffler or a different form of bacteria. Loeffler himself and most German writers have considered them to be altogether a different form of diphtheria, while Roux and Yersin. most French, and some German bacteriologists, look upon them as identical. Roux and Yersin, in their studies on diphtheria, gave careful attention to the relationship of the so-called pseudo-diphtheria bacillus to the true one. The majority of the bacilli they experimented with were identical with the Loeffler bacilli in growth, size, and form, and differed simply in not possessing virulence/' It is well known that the bacillus having its full vitality and virulence may remain a long time in the throats of convalescent patients. Escherich expresses {Berlin. kUn. Wochen., 1893, Nos. 21-23) the belief that the growth of the virulent bacillus sometimes continues for a time in the throats of con- valescent patients, who no longer exhibit symptoms of the disease, and is the source of infection to others. Thus the nurse in a hospital had the bacilli in her throat, and without being diseased herself, gave diphtheria to the children intrusted to her care. I have seen recently a malignant case of diphtheria, which was apparently contracted by embracing a schoolmate in the street, who had to all appearance entirely recovered from a diphtheritic attack, and had gone into the street for the first time. As in that other microbic disease, erysipelas, one attack does not afford protection against a second seizure. The belief has even been expressed by certain clinical observers that patients during convalescence are sometimes reinfected, by receiving the bacillus from the bedding, curtains or furniture, which they themselves have infected. (Plate I.) For the excellent representations of cultures of the bacillus of diphtheria PLATE I. •- - Colonies of Diphtheria Bacilli x 124 diam. : **»f b. r Col. Luxuriant Growth. Pseudo-diphth. Col. x 124 diam. - Colonies B. D. x 240 dim / x \ -/ #^ srj; \ <^- *v/^ Diphtheria Bacilli x 1000 diam. >* •&\ v VfVx*^, ,' Characteristic Diphtheria Bacilli x 1000. K \ Characteristic Diphtheria Bacilli x 1000. PLATE II. Even-stained short Diphth. Bacilli x 1000. Same as last but grown on Agar x 1000. «fti Diphtheria Bacilli. Agar culture x 1000. Pseudo-diphtheria Bacilli with a few Cocci. ■ .-. Pseudo-diphtheria Bacilli x 1000. Pseudo-diph. Bacilli. Agar Culture x 1000. Pseudo-diphtheria Bacilli x 1000. Vt Steptococci. Broth Culture x 1000. Steptococci smeared directly upon cover gh from Throat Exudate x 1000. Same from Serum Culture x 1000. DIPHTHERIA. 333 (Plates I and II) I am indebted to the kindness of the New York Board of Health. Vitality of the Klebs-Loejfler bacillus. — D'Espine and E. de Mariqual state that cultures kept sixteen months have retained their primary virulence. M. Sevestre quotes instances in which the contagion of diphtheria, after being latent for long periods, communicated the disease. Thus a girl in a locality where there was no diphtheria, examined the clothes worn by her mother, who had died of this disease two years previously, the clothes having been in a chest during this time. After about the usual time she was attacked by diphtheria. A brush used for swabbing the throat of a child having diphtheria was wrapped in paper and laid aside. Four years subsequently, a man having simple sore throat made an application to it with the brush, and his fauces soon after became the seat of a diphtheritic exudate. A severe and fatal epidemic of diphtheria occurred in a Norman village. Twenty- three years had elapsed and no recent case of diphtheria had occurred at or near the place, when excavations were made in the graveyard, and the bodies of those who died of diphtheria, nearly a quarter of a century previously were disturbed. The son of the grave-digger, who had collected the bones of the victims of diphtheria and had piled them together, was immediately afterward attacked with this disease. He was the first patient in the epi- demic which followed. Sevestre relates other cases showing the remarkable vitality of the Klebs-Loeffler bacillus, which it is probable from authentic observations, remains latent, not only for months but years, and subsequently becomes active under favorable circumstances. Pseudo-diphtheria or Diphtheroid, a pseudo-membranous inflammation caused by the streptococcus and to a less extent by other forms of cocci. In a paper read before the Berlin Medical Society by Baginsky, and dis- cussed by Virchow, Henoch, Guttmann, Fraenkel, Bitter and others, Bagin- sky stated that he had made tube-cultures from the false membrane of all the cases of sick children admitted into the hospital during the preceding year with the diagnosis of diphtheria. He obtained cultures of the Klebs- Loeffler bacillus in 118 out of 154 cases. In most of these cultures the microbes associated with the bacillus disappeared during the cultivation, while the bacillus multiplied, was typical, and was easily recognized. In the remaining 36 cases cultivation yielded no bacillus, but only cocci ; and 32 of these recovered in a few days without any complication. Of the four who died two had empyema, one pneumonia complicating measles, and the remain- ing one had severe paralysis at the time of admission. True Pseudo-diphtheria Diphtheria. (due to cocci). Baginsky 118 cases. 36 cases. T. M. Pruden " 24 " M. Martin 128 " 72 " Wm. H. Park 127 " 114 " CarlJanson 63 " 37 " The distinguished bacteriologists and clinical observers present at the Berlin Medical Society as stated above, and who expressed their views. agreed in the main that it is proper to recognize a true diphtheria produced only by the Klebs-Loeffler bacillus, and another form of pseudo-membranous inflammation, presenting similar gross anatomical characters to those in true diphtheria, but caused by cocci (mainly the streptococcus and staphylococcus). The latter is designated pseudo-diphtheria, in order to distinguish it from true diphtheria or that caused by the Klebs-Loeffler bacillus, and this nomen- clature or distinction is commonly accepted by bacteriologists in both hemi- 334 CONSTITUTIONAL DISEASES. speres. Pseudo-diphtheria like true diphtheria is accompanied by fever, tumefaction of the lymphatic glands, and is much less fatal than genuine diphtheria. The preceding table shows the relative frequency of true and pseudo-diphtheria, as ascertained in different laboratories by the examinations of specimens. Mixed Infection. — Although the term true diphtheria is applied to that form of pseudo-membranous inflammation which is caused by the Klebs- Loeffler bacillus, and pseudo-diphtheria to that which is caused by other microbes, the two having different toxines must be entirely distinct from each other in their essential nature however close their resemblance. Never- theless, an accurate diagnosis is often rendered more difficult by the fact, which is more and more recognized, that in a large proportion of cases there is a mixed infection, that is the coexistence of the Klebs-Loeffler bacillus and forms of cocci which are pathogenic. Of course a patient who is sick from the combined action of the diphtheria bacillus and of cocci which penetrate the system is less amenable to treatment than one in whom only one form of microbe is present. Dr. I. L. Morse has published the following statistics relating to the etiology and pathology of diphtheria and pseudo-diphtheria : Percentage of Mortality. Klebs-Loeffler alone in 46 cases of which 20 died 43 per cent. " " with streptococci in 21 cases of which 6 died .28 " " with staphylococci in 93 cases of which 43 died, 46 " " with streptococci and staphylococci in 77 cases of which 29 died . . 38 " " " with others in 3 of which 1 died 33 " Streptococci alone in 18 of which 1 died 5 " Staphylococci alone in 27 of which 15 died 40 " Staphylococci and streptococci 99 of which 19 died 19 " Others in 5 of which 2 died 40 " Although the toxine generated by the Klebs-Loeffler bacillus is more fatal than any of the cocci or than any toxine generated by cocci, the com- bined action of the two evidently produces the highest mortality, and the least amenable form of diphtheritic disease. The internal inflammations, as broncho-pneumonia, which are so liable to occur in cases of mixed infection, are believed to be mostly due to cocci, since these organisms penetrate the system. The opinions of distinguished bacteriologists confirmatory of this statement might be mentioned. (Plate II.) Age. — Most of the published statistics relating to the ages of diphtheritic patients evidently embrace all cases of pseudo-membranous inflammation, whether the cause be the Klebs-Loeffler bacillus or streptococcus and staph- ylococcus — in other words, whether the disease be diphtheria or pseudo-diph- theria. Trousseau has said that diphtheria does not spare any age, but is most common between the ages of two and five or six years. Guersant believes that the age of greatest frequency is between the second and seventh years, and Barthez and Rilliet agree with him. Buillon-Lagrange in 73 cases occurring in one epidemic treated — Under 2 years 14 cases. From 2 to 6 years 18 " " 6 to 12 " " 10 " " 12 to 18 " 9 " " 18 to 20 " 15 " " 20 to 40 " 4 " " 40 to 50 " 1 " Above 50 " -. . 2 " DIPHTHERIA. 335 According to M. Barthez, in Sainte-Eugenie Hospital during twenty years the ages of the diphtheritic patients were as follows, adults being excluded from this institution : Under 1 year 81 cases. From 1 to 2 years 314 " • 2 to 3 " 319 " " 3 to 4 " 292 " " 4 to 5 " 200 " " 5 to 6 " 103 " " 6 to 7 " 59 " " 7 to 8 " 36 " " 8to 9 " 24 " " 9 to 15 " 82 " " 15 to 17 " 2 " Louis has observed that diphtheria may occur at an advanced age, but that it is infrequent after the age of forty years, and rare after sixty years. As in scarlet fever, so in diphtheria, cases are infrequent under the age of six months. Oertel says : " In the first half year the infant organism seems to be not at all susceptible to the disease." Nevertheless, cases are on record showing that pseudo-membranous inflammation due to microbes does occur even in the newly-born. Dr. Abraham Jacobi says : " I have met with three cases of diphtheria of the pharynx and larynx myself. One of these became sick on the ninth day after birth, and died on the thirteenth day ; the other died on the sixteenth day after birth ; the third was taken when seven days old, and died on the ninth day" (Treatise on Diphtheria, 1880). The following cases of diphtheria in the newly-born have also been reported : Number. Age. Author. 1 14 days Ligri. 1 15 " Bretonneau. 1 17 " Bednar. 1 8 " Bouchut. 1 7 " Weikert. Several cases . Parrot. 18 Eiredey. A disease of the newly-born has occasionally been observed in maternity wards which seems to be of diphtheritic origin, but which presents unusual features. Thus, Dr. W. S. Bigelow reports in the Boston Medical and Surgical Journal, for March 11, 1875, ten cases occurring in the latter part of 1873 in the Boston Lying-in Asylum, all fatal but two. The prominent symptoms and anatomical characters were a dark hue of the skin, hasmaturia, pseudo- membranous exudation upon certain mucous surfaces, dark-green stools, enlarged and dark spleen, engorged kidneys ; in some of the cases effusion of blood into the pelves of the kidneys and along the urinary tract. A case similar to those observed by Dr. Bigelow came under my notice. Malignant diphtheria occurred in a family in West Fifty-third Street in 1880. The patient, a boy of ten years, died, and the remaining two children, as soon as the nature of the malady was apparent, were sent from the house. Never- theless, one of them, seven days after the removal, was attacked with diph- theria of the hemorrhagic form, and died in less than one week. Blood escaped from the nostrils, from the fauces, from the vessels under the skin in numerous places, causing hemorrhagic spots, and from the kidneys or urinary tract, causing hematuria. The mother suffered great mental depres- sion, although her general health seemed good. Her infant, born three months subsequently to the occurrence of diphtheria in her family, was well 336 CONSTITUTIONAL DISEASES. developed, but it presented also a similar hemorrhagic cachexia. Blood escaped from the vessels under the skin, causing blotches and prominences, and from the mucous surfaces. The bleeding was persistent and copious from the umbilicus, so that death occurred in less than a week. The poison elaborated by microbes is subtle and penetrating, causing the specific inflam- mation in the uterine walls of the parturient woman, even when her fauces are not affected ; but the exact causal relation of diphtheria or pseudo-diph- theria to cases like the above must be determined by future observations. It is certain that pseudo-membranous inflammations of a microbic cha- racter sometimes appear in newly-born infants. An epidemic of this occurred in the New York Infant Asylum in 1887. Five infants under the age of thirty-seven days had the pseudo-membranous exudate upon the surfaces which are usually affected, but this was before the distinction was made between true diphtheria and pseudo-diphtheria based upon different microbic causes. Prof. Prudden, who conducted one of the post-mortem examinations, made the following record : " The anatomical diagnosis, then, is diphtheria of pharynx, larynx, and trachea, with double broncho-pneumonia, localized septic inflammation of the umbilical vein and hypogastric arteries and the abdominal wall surrounding them." This epidemic in the infant asylum, so far as could be determined by laboratory cultures and investigations, was produced, not by the agency of the Klebs-Loeffler bacillus, but by the strep- tococcus. Probably, therefore, the epidemic was one of pseudo-diphtheria, and not of diphtheria. Incubative Period. — In inoculated animals this is from twelve hours to three days. In Trendelenberg's experiments the incubative period was mostly from one to three days ; in Lagrave's about twenty hours. In Duchamp's inoculations the animals died after forty-eight hours, with the larynx and trachea, upon which the infectious material was applied, covered with pseudo-membrane. Oertel says that the rabbits upon which he experi- mented by inoculation of the muscles perished in from thirty to thirty-six hours, rarely after forty-two hours, the disease-process extending rapidly to neighboring tissues. When diphtheria is contracted by a child upon a wounded surface the incubative period, although short, may extend four days. The history of such a case was contributed by Mr. Phillips to the British Medical Journal. Instruments which had been employed in performing tracheotomy in a case of diphtheritic croup were in a few hours used for circumcision. Four days later the wounded prepuce was covered with a pseudo-membrane which extended over the glans, causing much oedema of the prepuce and retention of urine. When diphtheria is contracted in the usual manner — that is, by the inspi- ration of air containing the specific principle — the period of incubation appears to be somewhat longer than when it is communicated by direct contact. My observations lead me to believe that when the incubative period is short the disease is likely to be severe, and when the incubative period is long the attack is mild. I was enabled to ascertain very nearly the incubative period in the following cases : A boy of nine years was in the same room about one hour on Saturday with a child who had fatal diphtheria. On the following Tuesday, without any other exposure, he sickened with a fatal form of the malady. Mrs. E. assisted in nursing a severe case of diphtheria from Novem- ber 11 to 13, 1874, after which she returned home, several blocks away. On the evening of the 15th she complained of sore-throat, and on the following day the diphtheritic exudate was observed upon her tonsils. On the 19th, the pellicular formation had disappeared and she was convalescent. On the 20th, her sister, who resided with her, and who had not been elsewhere exposed, was also attacked. In three other cases which came under my DIPHTHERIA. 337 observation the incubative period seemed to be accurately fixed at six to seven days. Sarini says that the incubation, so far as could be determined, was as follows : From 1 to 2 days 7 cases. " 2 to 8 " 48 " " 8 to 13 " 23 " " 13 to 15 " 6 " " 15 to 20 " 14 " Modes of Propagation. — No fact is better established than that diphtheria does not originate de novo whatever may be the insanitary conditions. It is produced by the reception in or upon some parts of the system of the pre- existing specific germ. Its extreme contagiousness from person to person is well known. A moment's exposure to the breath of a patient, or in the infected room where he is under treatment or has been perhaps weeks or months previously, has in numberless instances communicated the disease. The virus adheres tenaciously to objects on which it happens to. alight. The clothing of a patient, even when the disease has been in its mildest form, his bedding, the furniture of his room, and the objects which he handles, may for weeks afterward communicate the disease even when transported to a distance. A child was for a brief period in a room where diphtheria had occurred two months previously, and, after the usual incubative period, sickened with the disease. The diphtheritic poison may remain in an active state for months between the leaves of a book handled by a patient having a mild attack or during convalescence. Most of the contagious diseases of children are quickly detected by cha- racteristic symptoms or appearances with which the most ignorant families are to a certain extent familiar ; but mild diphtheria possesses so few subjective symptoms that it is often not suspected or detected even in intelligent families who are watchful of their children. Children with mild diphtheria sit among other children in the schools, the city conveyances, in the churches and dis- pensaries, and frequently communicate to those who are near them a malig- nant form of the disease from which the unfortunate victims quickly perish. The diphtheritic microbes are so subtle, and their vitality and power of propa- gation so great that it is difficult to prevent the extension of diphtheria in the schools and places of public resort. Many instances are related in which diphtheria is communicated by direct contact with some infected solid substance, as a particle of the diphtheritic exudate, muco-purulent secretion from an infected surface or the blood of a patient. In a considerable number of instances recorded in the literature over-anxious and self-sacrificing young surgeons have sucked the obstruction from the tracheotomy-tube in cases of diphtheritic croup with perhaps relief to the patients, but with the occurrence of fatal diphtheria in themselves from the exposure. A diphtheritic conjunctivitis, severe and dangerous to the eye, has sometimes occurred in the attending physician or nurse after examination of the fauces of the diphtheritic patient, produced probably by a particle of pseudo-membrane or muco-pus thrown into the eye by the expulsive cough. In these instances of communication by direct contact the poison is received either upon one of the mucous surfaces or upon the skin denuded of its protecting epidermis. It is well known that filthy accumula- tions of all kinds afford a nidus which is favorable for the development of the Loefner bacillus. Hence the theory seemed plausible that poisonous gases escaping into the nurseries through broken waste-pipes or from decaying refuse matter in and around domiciles conveyed the Loeffler bacillus and was the source of diphtheria. City physicians who were called to treat diphtheria in the 22 338 CONSTITUTIONAL DISEASES. small, damp, dark, and dirty apartments of the tenement-houses and inhaled the foul gases were led to the irresistible conviction that these gases were the vehicle of the fatal bacillus. But investigations relating to the nature of sewer-gas have shown that this belief that sewer-gas is the carrier of the Loeffler bacillus is probably untenable. Mr. L. Parry Laws presented to the Main Drainage Committee of London the results of his investigations relating to the composition of sewer-gas, undertaken at their request. His examina- tions, as well as those previously made by Connolly and Haldane, showed that the air of sewers contained about twice the quantity of carbonic acid and about three times the quantity of organic matter above that found in the external air at the same time. Moreover, the sewer-air contained a smaller number of micro- organisms than the air which they examined in domiciles. Mr. Laws found that the micro-organisms of the sewer-gas were related to those of the air outside, and the forms present were almost wholly moulds and micrococci. Investigations like those related above have led to the belief on the part of many bacteriologists that sewer-gas does not convey the Loeffler bacillus into domiciles through untrapped or defective waste-pipes, as was formerly believed ; but the causal relation of this gas to diphtheria is like other foul exhalations which cause deterioration of the system, weaken the powers of resistance, and render the action of the diphtheritic bacillus which happens to be present more virulent and fatal. Probably the sewer and other fetid gases increase the virulence of the Loeffler bacillus, and perhaps, under cer- tain circumstances, it renders the benign bacilli virulent, but this, however plausible, has not been proven. Diphtheria contracted from Animals. — Observations are accumulating which show that diphtheria occurs in certain domestic animals and is some- times communicated from them to man. That certain animals are liable to it has been shown by inoculations in many laboratories, made for experimental purposes. The feathered tribe especially appear to be susceptible to this disease. On the island of Skiathos, off the north-eastern coast of Greece, no diphtheria had occurred during at least thirty years previously to 1884, according to Dr. Bild, the physician of the island. In that year a dozen turkeys were introduced from Salonica. Two of them were sick at the time and died soon afterward ; the others became affected subsequently, and of the whole number seven died, three recovered, and two were sick at the time of the inquiry. These two had laryngeal obstruction with difficult breathing and swelling of the glands of the neck. As further evidence that the disease was true diphtheria, one of the turkeys that survived had paralysis of the feet. The turkeys were in a garden on the north side of the town, and the pre- vailing winds from the island are from the north. When this sickness was occurring among the turkeys an epidemic of diphtheria commenced in the houses nearest to the garden and spread through the town. It lasted five months, and, of one hundred and twenty-five cases in a population of four thousand, thirty-six died. Diphtheria was from this time established on the island, and frequent epidemics of it have occurred since. 1 M. Menzies 2 states that diphtheria is common among the poultry in Italy, in which country the flat roofs of the houses afford a resting-place for turkeys, fowls, pigeons, and rabbits, and their evacuations are carried by the rain into the cisterns and wells. A physician at Posilippo, near Naples, had directed his servant not to obtain drinking-water from the well next to his house, but from a well at a distance. So long as he obeyed the instruction his family was well, but, yielding to his indolence, he finally disobeyed the command and obtained water from the infected well. Four of the children who drank this water took diphtheria and died, while the fifth child, who did not drink it, escaped. 1 Bulletin Medicale, Jan. 22. 1888. 2 Thesis, Paris, 1881. DIPHTHERIA. 339 Dr. F. F. Wheeler 1 states that while in a nesting of wild pigeons he found many sick with a pseudo-membranous sore throat. He dissected many with his pocket-knife, which he was obliged to throw away on account of its offen- sive odor. There were millions of pigeons in the nesting, and they were hunted and eaten by the inhabitants. In the same year diphtheria broke out in a most malignant form among the people, causing many deaths. Several years previously pigeons nested in the same locality or near by, and fully half of the children in the vicinity had diphtheria. Dr. Geo. Turner 2 states that a pigeon was brought to him for dissection. The whole of its windpipe was covered by a pseudo-membrane, as in the croup of a child. Pigeons were inoculated in the fauces with this mem- brane, and a similar disease was produced, which extended to their eyes through the nostrils. Dr. Turner also related several other epidemics of diphtheria in different localities, accompanied by a fatal pseudo-membranous inflammation in the feathered tribe, the poultry, turkeys, pigeons, and in one locality the pheasants. At Tougham a man bought a chicken at a low price, as it was affected with the prevailing disease, and cared for it at his home. Soon after diphtheria broke out in his family and this case was the first in the village. Bilhaut 3 states that a pigeon-fancier had lost several birds by disease. He endeavored to save one of them that was sick by allowing it to pick food from his tongue. The pigeon died and an examination showed that it died of diphtheria. Before its death the man sickened with diph- theria and pseudo-membranes formed underneath his tongue on either side of the fraenum, where the bird had picked its food, and also upon his tonsils. Recently also M. Cagny has related cases showing the propagation of diph- theria from the feathered tribe to man. 4 Did time permit other similar cases might be related published in American medical journals. Bacteriologists in their experiments have demonstrated the fact that certain quadrupeds used for experimental purposes contract diphtheria. Trendelenberg inoculated sixty-eight rabbits introducing diphtheritic pseudo- membrane through an artificial opening. Eleven of the rabbits died with the symptoms and appearance of diphtheria. In control experiments he intro- duced various foreign bodies into the larynx of rabbits, and was unable to produce results or lesions resembling those in diphtheria. Oertel performed twelve similar experiments, and five of the rabbits died after the production of pseudo-membranes. Zahn, Gerhardt, Labadie-Lagrave, Francotte, Bates- Klein, and Yulpian may be mentioned among those who have obtained similar results from their inoculations. Bruce Low, in his report to the Local Gov- ernment Board, 5 states that a little boy at Enfield had fatal diphtheria, and vomited on the first day of his illness. A cat licked the vomited matter from the floor, and soon after the boy's death it was noticed to be ill, and its suffering and symptoms so closely resembled those of the dead boy's that it was destroyed by the owner. During the first part of its sickness the ani- mal was allowed to go out in the back yard, and a few days subsequently the cat of a near neighbor became ill. This cat had frequented the back yard. It was nursed during its sickness by three little girls, all of whom took diphtheria. Lawrence 6 reports two cases in which diphtheria seems to have been communicated by cats. In the first case, that of a little girl, a careful inquiry showed that the child had not been exposed to any case. although diphtheria was prevailing within a mile of the patient's residence. but she had fondled a sick cat a few days before. The cat died some time 1 American Practitioner and News. 2 Journal of Laryngology and Bhinology. 3 Journal de Medicine de Paris, July 13, 1890. 4 Journ. de Medicine, July, 1890. ' 5 British Med. Journ,, May 10, 1S90. 6 Med. Press and Circular, London, June 4, 1890. 340 CONSTITUTIONAL DISEASES. afterward, and a second cat became sick and was killed. Inquiry disclosed the fact, that a neighboring farmer had lost seventeen cats and* another fifteen cats, from a throat distemper, and one of the farmers stated that he had examined the throats of some of the cats and found them covered with a white membrane. S. C. Coleman 1 of Colorado, Texas, states that after a residence of five years in Colorado he saw the first case of diphtheria. A child of five years, living thirty miles distant in the country, with no neigh- bor within six miles, had diphtheria followed by paralysis. Being far from any source of human contagion, this child had rarely seen other children. The father stated that two kittens had recently died of what seemed to be the same disease as that of the child, who had nursed them and frequently kissed them. The risk of fondling diseased cats, which are pets of the nursery, cannot be too strongly stated. Many observations have shown during the last few years that milk affords a favorable nidus for the propagation of the Klebs-Loeffler bacillus, and that occasionally epidemics are produced by an infected milk-supply. In 1879, Mr. Wm. H. Power, health inspector, investigated an outbreak of diphtheria, and believed that he traced it to the milk. The cows that furnished the milk that apparently caused the diphtheria, had what the veterinary surgeons designated " garget " or " infectious mammites." Gooch has described an out- break of diphtheritic tonsilitis in Eton College which he traced to the milk supplied. The cows furnishing milk drank water which contained sewage from a neighboring farm. The investigation showed that the milk when boiled was harmless, since the boiling destroyed the germs, but when used unboiled the disease was communicated. The cows were removed to another pasturage, where the water used by them was different, and the epidemic ceased. The disease was in all instances propagated by the milk supply. Observations therefore show that milk, which is the culture medium of vari- ous pathogenic microbes, is sometimes the medium of the communication of diphtheria, as it is known to be of scarlet fever. Diagnosis. — No more important duty devolves upon the physician than that of making an early and correct diagnosis of diphtheria and of those mal- adies of the throat which resemble diphtheria in appearance, but are in their nature distinct from it. If the case be one of diphtheria, its nature should be recognized at the beginning, so that proper remedial measures be employed as well as measures designed to prevent propagation. If the disease be not diphtheria, a correct diagnosis is required so that needless treatment and alarm be prevented. In many cases the diagnosis is easy or highly prob- able after diphtheria has continued twenty-four hours, since in addition to the fever and pain in swallowing, the characteristic whitish-gray pellicle has begun to form on one or both tonsils. If the exudate be not limited to the tonsils, but extend to the fauces, and cover more or less the pillars and arch of the palate and the uvula, the disease is probably diphtheria. Still cer- tainty in regard to the nature of the disease in many instances requires a microscopic examination. Prof. H. M. Biggs 2 of the New York Health Board states that within a certain time of the large number of suspected cases of diphtheria removed from the tenement houses and slums of New York to the Willard Parker Hospital, 30 to 50 per cent, of them did not have true diph- theria, but pseudo-diphtheria or pellicular inflammation, caused by forms of cocci, especially by the streptococcus. The result of treatment corresponded with that observed elsewhere, for of those shown by the microscope to have true diphtheria, 20 to nearly 50 per cent, perished ; while of those that had pseudo-diphtheria, the mortality was from 1 to nearly 5 per cent. Like other well-known bacteriologists, those doing the bacteriological 1 New York Medical Record, Nov., 1890. 2 Journ. of Laryngology, Sept., 1894. DIPHTHERIA. 341 work of the Xew York Health Board have been able to produce cultures and make returns, indicating the nature of the disease in from twelve to twenty- four hours. The following is extracted from the report of Dr. Biggs : " During the past three'months four hundred and five cases of true diphtheria have been subjected to repeated bacteriological examinations, performed at short intervals during the course of the disease, and during convalescence. In all of these cases cultures were made at the beginning of the disease, again after the lapse of three or four days, and finally at short periods after the complete disappearance of the false membrane, until the throat was found to be free from the diphtheria bacillus. In two hundred and forty-five of these four hundred and five cases the diphtheria bacilli disappeared within three days after the complete separation of the false membrane ; in one hundred and sixty cases the diphtheria bacilli persisted for a longer time — namely, in one hundred and three cases for seven days ; in thirty-four cases for twelve days ; in sixteen cases for fifteen days ; in four for three weeks, and in three for five weeks after the time when the exudation had completely disappeared from the upper air-passages. " In many of these cases the patients were apparently well many days before the infectious agent had disappeared from the throat. These results show that in a considerable proportion of cases persons, who have had diphtheria, continue to carry the germs of the disease in their throats for many days after all signs and symptoms of the disease have disappeared. No doubt the disease is largely disseminated by these persons, who are appar- ently well, and who mingle with others while their throat secretions still con- tain the diphtheria bacilli. u These experiments have led the Health Department to adopt the rule that no person who has suffered from diphtheria shall be considered free from contagion until it has been shown by bacteriological examination, made after the disappearance of the membrane from the throat, that the throat secre- tions no longer contain the diphtheria bacilli, and that until such examina- tions have shown such absence all cases in boarding houses, hotels, and tene- ment houses must remain isolated and under observation. Disinfection of the premises, therefore, will not be performed by the department until exam- ination has shown the absence of the organisms." Let us more closely compare the diagnostic characters of diphtheria with those of other and distinct diseases from which it is very important that diphtheria should be differentiated in practice. Pseudo-diphtheria or Diphtheroid.— Perhaps, I have already sufficiently stated the diagnostic characters of this disease. Pseudo-diphtheria is pro- duced by the streptococcus, sometimes associated with other forms of cocci. The streptococcus does not generate so deadly a poison as that of the Klebs- Loeffler bacillus. Consequently, the systemic infection in true diphtheria is much more fatal than in pseudo-diphtheria. While the Klebs-Loeffler bacil- lus does not enter the system, or rarely does so ; the forms of cocci do, and there is frequently a mixed infection, the Loeffler bacillus being present with the streptococcus and staphylococcus. But diphtheria and pseudo-diphtheria, although their differential diagnosis is, in many instances, difficult or impos- sible without bacteriological examination, require essentially the same treat- ment. Follicular Pharyngitis or Tonsillitis. — This is a common disease, most likely of microbic origin. It frequently extends through families, all or most of the children being affected by it. It is attended by fever, dysphagia, and an inflammatory hyperemia, not only of the tonsils, but of the pharyngeal surface generally. It commences suddenly like diphtheria, with headaches, chilliness, heat of surface, the temperature often rising to 103° Fall., languor 342 CONSTITUTIONAL DISEASES. and frequently pain in the back and extremities. The dysphagia attracts attention to the fauces, the surface of which is seen to be hypersemic, espe- cially its tonsilar portion. In a few hours a whitish material exudes from the crypts of the tonsils, forming rounded masses of the size of a small pin's head. This secretion, occurring as small rounded salient masses, distinct from one another is distinguished by its appearance from the diphtheritic pseudo- membrane, which, at first, is a thin pellucid exudate, becoming thicker subse- quently. Consisting simply of epithelial cells, held together by the secretion, these small rounded masses are quickly detached by the swab or brush, when they are found to be friable, readily crushed between the thumb and fingers, and having a fetid odor. If two or more of them happen to unite, forming an appearance like that of the diphtheritic membrane, they still present the same physical characters, and are readily detached from the tonsilar surface without hemorrhage. This peculiar secretion of follicular tonsilitis is usually limited to the tonsilar portion of the pharynx, and is of short duration, no new secretion occurring after two or three days. Pultaceous Pharyngitis ; Confluent Muguet. — This form of pharyngitis occurs in low or debilitated states of the system. It occurs in protracted and exhausting diseases, attended by malnutrition and faulty digestion. As the term " pultaceous " indicates, the inflammatory product is soft and friable, coming away in fragments when touched by the brush or sponge without bleeding or injury to the mucous membrane. Under the microscope it is found to consist of epithelial cells, often in fragments, but no fibrin. In cer- tain cases to which the term cryptogamic is properly applied, a cryptogam, the oidium albicans, is also present. When the substance forming this soft and pultaceous pellicle is removed, the mucous membrane underneath is entire, hypersemic, and sometimes covered with a newly-formed epithelial layer. The appearance of the pultaceous product to the naked eye may closely re- semble that in diphtheria, but its friable character, its epithelial nature and the absence of fibrin, which the microscope reveals, renders the diagnosis certain. Scarlatinous Pharyngitis ; often with more or less Gangrene and Con- tiguous Inflammations as Adenitis and Cellulitis of the Neck. — As a rule, the microbe, which causes the destructive inflammation in the fauces and adja- cent parts in scarlet fever is the coccus in its various forms, especially the streptococcus (Booker and others). Gangrene of the fauces may supervene at any time, and it bears a close resemblance to the destructive action caused by the Loeffler bacillus. This bacillus may occur, constituting a true diph- theritic complication, but its advent is usually after the scarlet fever has con- tinued a few days, when it is announced by an aggravation of symptoms. An exact diagnosis must be made by the microscope. Herpetic Pharyngitis. — Small vesicular eruptions of short duration some- times attend the initial stage, after which small white or grayish-white ulcers remain. Their small size and history serve for diagnosis. After ablation of the tonsils or injury of the fauces by highly-irritating applications as ammonia the appearance, in some cases, closely resembles diphtheria, but it is differentiated by the history. Anatomical Characters. — Within a day, and usually within a few hours, from the commencement of the inflammation a small, slightly-raised, whitish or grayish spot or patch is observed, usually upon the tonsilar por- tion of the inflamed surface — very significant as a diagnostic sign and as a forerunner of what is to happen. This patch, termed the pseudo-membrane, gradually becomes firmer, and at the same time thicker and broader from fresh exudations underneath. It retains for a time its grayish- white color, but it becomes brownish-white from age. In mild cases the pseudo-membrane DIPHTHERIA. 343 is usually limited to the tonsilar surface, but in severe cases it covers the uvula, portions of the velum, the isthmus, and the walls of the pharynx, both lateral and posterior. It does not ordinarily attain a greater thickness than one-eighth to one-sixth of an inch. I have seen it, however, not far from one-third of an inch thick. The inflamed mucous membrane is not only hyperaemic and infiltrated with serum, but it also contains numerous round white corpuscles (leu- cocytes), which may result in part from proliferation of connective-tissue corpuscles, but are believed by most pathologists, since Cohnheinrs well- known discovery, to be in great part wandering white corpuscles of the blood which have escaped through the walls of the blood-vessels along with the fibrin. In the commencement of the diphtheritic inflammation, before the pseudo-membrane forms, we often observe a grayish tinge of the mucous surface, which is due to the crowding of the cellular elements in and under- neath the mucous membrane ; for these newly-formed cells not only infiltrate the mucous membrane, but can also be traced into the submucous con- nective tissue. Even where the inflammation remains catarrhal, as it does over certain areas in all cases of diphtheria, this infiltration of the mucous and submucous tissues with cells is common. During the active period of diphtheria it is often astonishing to see with what rapidity the pseudo-membrane returns when removed by force. A few hours suffice to restore it as firm and extensive as before the interference. In the most favorable cases the membrane is detached in a few days, and is not reproduced. Its separation is promoted by the secretions underneath, espe- cially by pus, which is secreted in abundance between it and the tissues underneath, which have preserved their integrity. In most instances it does not separate in mass, but disappears by progressive liquefaction. Occasion- ally, even in cases which do not present a severe type, the diphtheritic patch does not disappear until the lapse of four or five or even six weeks, or if it softens and is detached another appears in its place. In these instances of an unusual prolongation diphtheria has been designated chronic. Such are the appearances, character, and history of the pseudo-membrane in this malady. Although its common seat is upon the fauces, and in mild cases it is limited to them, nevertheless all the mucous surfaces are liable to be attacked by the inflammation in consequence of the infection of the blood, and therefore in severe cases, and even in cases of moderate severity, we often find the product elsewhere as well as upon the fauces, and in localities where from its mechanical effect it greatly increases the danger and even compro- mises life. The mucous membrane of the nostrils, mouth, larnyx, trachea, bronchial tubes, Eustachian tubes, conjunctiva, oesophagus, stomach, intestines, vagina, prepuce, and even the delicate lining membrane of the middle ear, are at times the seat of diphtheritic inflammation with the characteristic product. In a case which occurred in the Nursery and Child's Hospital of New York the surface of the stomach was almost completely lined by the diphtheritic formation, so as apparently to abolish the function of this important organ. The occurrence of the pseudo-membrane in the nares is common, and is attended by the discharge from the nose of thin mucus and pus. Nasal diphtheria involves great danger from the fact that it is likely to give rise to systemic infection of a grave type. In the nursing infant it is also dan- gerous, since by its mechanical effect it interferes with lactation. The thin, irritating discharge produces excoriations around the nostrils and upon the upper lip. I have met only one case of diphtheritic inflammation of the intestines in which the diagnosis was certain. A physician in whose family diphtheria was occurring became seriously sick with symptoms which closely resembled those of typhoid fever. After a long sickness he expelled per 344 CONSTITUTIONAL DISEASES. rectum about one foot of pseudo-membrane of a cylindrical form, evidently derived from the surface of the intestines. In the subsequent months the patient suffered from constipation and severe abdominal pains, apparently due to contraction in healing of the large intestinal ulcer. Death finally occurred from this state of the intestines. The formation of the diphtheritic pellicle upon the vulva and vaginal walls is not infrequent, and in parturient women exposed to diphtheria . it sometimes occurs upon the uterine walls, usually with a fatal result. A considerable number of cases are on record in which diphtheritic inflammation occurred upon the prepuce after circumcision, pro- ducing the usual pseudo-membrane, and in one instance in my practice, referred to above, it attacked the prepuce the day after I had dilated it with an instrument clean and free from infection. The Blood. — The blood in cases of a severe type is usually darker than in health and the clots soft. After death from diphtheritic croup it is also dark from the excess of carbonic acid in it. The chemical changes which the blood undergoes in diphtheria are partially known. MM. Andral and Gavarret found a notable diminu- tion of fibrin in grave infectious diseases, as typhoid fever, puerperal fever, etc., and it is not improbable that the same is true of diphtheritic blood, although the exuda- tion of fibrin is so abundant. M. Bouchut and others have noticed an excess of the white corpuscles in the blood in diphtheritic patients, so that, instead of three or four in the field of the microscope, as many as sixty have been counted. M. Sanne writes of diphtheria : " It is necessary to recognize in the dark-brown blood an abnormal accumulation of the debris of the red corpuscles, debris of little abun- dance in the normal state, augmented considerably under the noxious influence of the diphtheritic poison, which has rapidly produced destruction of a great number of globules." ] Small extravasations of blood in the various organs are among the most constant lesions. They have been most frequently observed in the brain and its meninges, the lungs, spleen, and kidneys. In one case which I examined after death in the Xew York Foundling Asylum the extravasations in and under the gastric mucous membrane produced mottling as great as that of the skin in measles. The most minute examinations of the organs in diphtheria yet published are those recently made by Oertel, and we will present a summary of them in the following pages. Brain and Spinal Cord. — The anatomical changes occurring in these organs are in a measure described in our remarks on diphtheritic paralysis. Oertel dis- covered, as the earliest anatomical change in the brain and spinal cord as well as in the membranes, a venous hyperaemia, with small extravasations of blood, "not larger than a pea,"' in the white medullary matter of the brain, while in the corti- cal layer and in the central parts no extravasation was found. In the most severe forms of the disease small hemorrhages not larger than a pea were found not only in the cerebral meninges, but also in various parts of the brain. These produced some softening in their immediate neighborhood. These small hemorrhages have been found also in or upon the medulla oblongata and spinal cord, but with less softening. Buhl, in addition to the extravasations in and upon the brain and spinal cord, discovered in one case great enlargement of the anterior and posterior roots and the ganglionary swellings of the spinal nerves. The swelling was found to be due to the accumulation of cells and nuclei in the sheaths of the nerves and to extravasations of blood. These anatomical changes were most marked at the roots of the lumbar nerves. (For further particulars relating to the pathology of the nervous system in diphtheria the reader is referred to our remarks* on Paralysis.) Tonsils. — Covering these organs is the pseudo-membrane, consisting of the usual fibrillar meshwork, enclosing leucocytes, changed epithelial cells, and amor- phous matter : the older the exudation the coarser is the network. The adenoid tissue and the septa have undergone hyperplasia. The follicles are crowded with cells which have undergone necrobiosis. As a result of the necrobiosis masses are formed of various shapes and sizes, staining deeply. In consequence of the necro- biosis and degenerative changes the follicles become a hyaline network infiltrated 1 Trade de la Diphtherie, p. 107, Paris, 1877. DIPHTHERIA. 345 with leucocytes and granules. In advanced cases the adenoid and connective tissues undergo a similar necrobiotic change, and are so blended with the pseudo-membrane that it is difficult to determine where the latter ends and the tonsilar tissue begins. The vessels of the tonsils undergo a hyaline thickening of their walls, and if this occur chiefly in the intima total occlusion may result. In the tissues immediately surrounding the tonsils hyaline degeneration of the muscular fibres occurs (Zenker's degeneration), and the connective tissue between the muscular fibres is infiltrated with leucocytes. Fancied Surface and Uvula. — These parts are often also covered with pseudo- membrane, and are more or less changed by the application of remedies. The line of separation of the exudate and underlying tissues cannot be readily distinguished. The upper portion of the diphtheritic pellicle is filled with bacteria and with leu- cocytes and other cells which have undergone necrobiosis. In the mucosa next to the pseudo-membrane hyaline degeneration of the connective tissue occurs, and the mucosa is infiltrated with cells which have undergone marked changes. The nuclei of the connective-tissue cells exhibit various stages of degeneration and decay, though the cells may retain their form. The deeper layers of the mucosa, like the upper, are infiltrated with leucocytes. The uvula in severe cases is usually swollen and oedematous, and sometimes entirely covered by the diphtheritic pellicle. When the uvula is involved in the general faucial inflammation, necrobiosis of the cells and nuclei occurs in every part of it. The cells in the arterial adventitia and in the perivascular tissue exhibit necrobiotic change, their nuclei being disintegrated. In the uvula, also, hyaline degeneration occurs in the walls of the vessels. Epiglottis. — The epithelial cells covering the epiglottis undergo marked prolif- eration early in the disease, and are infiltrated with leucocytes. They soon begin to undergo degeneration, forming granular masses. Areas of necrobiosis occur, and finally hyaline degeneration of the network takes place. The leucocytes ex- tend deeply into the mucous membrane, followed by degenerative and necrobiotic changes. In places the epithelium is thrown off, and a pseudo-membrane forms of exuded fibrin and necrobiotic leucocytes and epithelium. Bacteria, along with leu- cocytes and degenerated epithelial cells, occupy the meshes of the pseudo-mem- brane. Lungs. — The anatomical characters of the air-passages are fully treated of in the article on Diphtheritic Croup. Catarrhal bronchitis is common in diphtheria. It is not often absent in croup, and one of the chief sources of danger in this dis- ease is the extension of pseudo-membrane from the laryngo-tracheal surface to the bronchial, and the transformation of the catarrhal into a croupous inflammation. "When bronchitis occurs the inflammation creeps downward gradually from the laryngo-tracheal surface, and its severity is proportionate to the degree of extension. When there is a general bronchitis and it is very liable to become croupous, the muco-purulent exudation is abundant. When . pseudo-membranous bronchitis occurs, there are usually portions of the bronchial tree in which the inflammation remains catarrhal. One of the chief sources of danger in diphtheritic croup is the extension of the inflammation to the bronchial tubes and the abundant secretion of muco-pus, which clogs the tubes and prevents proper decarbonization of the blood. W^hen the bronchitis becomes croupous, a thin, easily-detached film appears upon the intensely-red, hypereemic, and swollen bronchial surface. It increases in thick- ness and firmness, and is of a brownish-gray color. Whatever the stage of the inflam- mation, the pseudo-membrane can always be readily detached from the bronchial surface, since its relation to it is one of apposition, and not of integral connection, as upon the pharyngeal surface. In the large tubes and those of medium size hollow cylinders, more or less complete, form 5 but in the smaller tubes, if the pseudo-membrane extend to them, solid cylinders are produced. Frequently, in the bronchial croup of diphtheria, while the entire bronchial surface is intensely red and swollen, the pseudo-membrane is absent in certain parts ; in other parts it forms cylinders, in other parts still longitudinal bands of a ribbon shape are pro- duced, and in more or fewer of the minuter tubes, plugs which entirely fill the lumina and prevent the entrance of air exist. The alveoli beyond these plugs gradually col- lapse, and more or fewer of them return to the unexpanded foetal state. From the tubes which are still pervious the muco-pus is with difficulty expectorated on account of its viscidity, and this thick secretion contains floating particles of pseudo-membrane. Pseudo-membranous bronchitis in diphtheria is in nearly all 346 CONSTITUTIONAL DISEASES instances an extension of a laryngotracheal croup. It occurs, according to Sanne, most frequently between the second and sixth days. Various forms of pulmonary disease occur in diphtheria, usually as a complica- tion and often as a final result of the downward extension of inflammation from the larynx, trachea, and bronchial tubes. Splenization, atelectasis, and broncho- pneumonia are common complications of diphtheritic croup. Broncho-pneumonia, like pseudo-membranous laryngo-tracheitis and pseudo-membranous bronchitis, upon which it largely depends, occurs usually in the first week of diphtheria. In 121 cases of broncho-pneumonia complicating diphtheria, observed by Sann Acidi muriat., dilut., ,^ij ; Glycerini, Jj ; Aquae purse, ^iv. — Misce. Dose : One teaspoonful before each feeding. In cases of feeble digestion the predigested foods are often very useful, as the beef peptonoids of Reed and Carnrick, the sarco-peptones of the Rudisch Company, and peptonized milk. Failure of the appetite and refusal to take food are justly regarded as very unfavorable signs. Trousseau says : " Alimentation occupies the first place in the general treatment ; and I have observed that the severer the attack the more imperative is the necessity to sustain the patients with nourishing food. Loss of appetite — that is, disgust for every kind of food — is one of the most alarming prognostic signs. We must try to overcome the loathing of food by every possible means ; and to get nourishment taken I sometimes do not hesitate, in the case of children, to threaten punishment. When the patient retains his appetite for food, there is good hope of recovery." l Occasionally, when great dysphagia is present, whether from the severity of the pharyngitis or from palatal paralysis, it is necessary to resort to rectal alimentation. The rectum absorbs, but does not digest, and it is capable of absorbing peptonized food to such an extent that life may be sustained without stomach digestion and solely by rectal alimen- tation. For the purpose of rectal alimentation I have usually employed peptonized milk containing in solution peptonized beef, as the sarco-peptones of the Rudisch Company. If this is administered through a No. 12 to No. 14 elastic catheter introduced far enough to reach the sigmoid flexure, and retained for half an hour by a compress pressed closely against the anus by the fingers, the result is, I think, better than when we depend, as Trousseau did, entirely on stomach digestion. One objection to the use of the brush, instead of spraying the fauces with the atomizer, is that it is more likely to cause vomiting, by which nutriment, that is so much required, is lost. In malignant cases of diphtheria, as in scarlet fever of a similar type, patients are sometimes allowed to slumber too long without nutriment. It is the slumber of toxaemia, and should be interrupted at stated times in order to give food and stimulants. 1 American Lancet. 24 370 COXSTITUTIOXAL DISEASES. Stimulants. — M. Sanne, in his treatise on diphtheria, says : " De tous les antiseptiques donnes a linterieur. l'alcool est de beaucoup le plus sfir. Plus l'infection est prononcee, plus il faut insister sur les composes alcooliques." He states that Bricheteau reports the history of a patient who took daily during diphtheria a bottle and a half of the wine of Bordeaux, without the least symptom of intoxication or headache. A similar case was related to me in which nearly one and a half pints of brandy were given in twenty-four hours without any ill effect, and with an apparent good result on the general course of the disease. The same rule holds true in diphtheria as in other acute infectious maladies, that while mild cases do ^ell without alcoholic stimulants, they are required in cases of a severe type, and should be admin- istered in large and frequent doses whenever pallor and loss of appetite or strength and flesh indicate danger from the diphtheritic or septic infection. It matters little how the stimulant is administered, whether milk punch or wine whey, provided that the proper quantity is employed. If given early and frequently in grave cases — as, for example, one teaspoonful every half hour of brandy or Bourbon whiskey — it does seem to have a tendency to render the disease more tractable ; but to be instrumental in saving life in malignant cases it must be given boldly from the start. If there be marked diphtheritic toxaemia when its use is commenced it will not save life, but it may prolong it. Although the liberal employment of alcohol is apparently useful, it cannot be regarded as a specific. In the quarantine wards of the New York Foundling Asylum were four children between the ages of three and five years who had been sick a few days with severe diphtheria, and it was evident at a glance that they must soon perish with the ordinary mild sustaining remedies. Quinine, iron, the most nutritious food and a moderate amount of alcoholic stimulants were being given, and we deter- mined to increase the Bourbon whiskey to a teaspoonful every twenty or thirty minutes day and night. Nevertheless, whatever the result might have been with the earlier commencement of this treatment, the blood-poi- soning was now too profound, and one after the other died. That intoxica- tion is almost never produced in this disease by large and frequent doses of the alcoholic stimulant is probably in part due to its quick elimination from the system, but more to the nature of diphtheria. Quinia. — In fulfilling the indication of sustaining treatment the vege- table tonics have long been used, especially cinchona and its alkaloid principle, quinine. The compound tincture of cinchona and the fluid extract have been used and recommended by physicians of experience, but of vegetable agents quinine has been and is still more frequently prescribed than any other. But the doses employed vary greatly in size and frequency in the practice of dif- ferent physicians. It is administered for its antipyretic effect in large doses, so that twenty or thirty grains are given daily, and in small doses, as one or two grains every fourth hour, for its tonic effect. That there is nothing antagonistic in the action of quinine to the diphtheritic virus, and that it is beneficial in the same way as in the other acute infectious diseases, and no further, is, I think, generally admitted by physicians. Large and frequent doses do not. apparently, produce any controlling action on the course of the disease or diminish the blood-poisoning. Cases might be cited in illustration. In the case of a child of four years with malignant diphtheria forty-eight grains administered daily had no appreciable effect in staying the fatal prog- ress of the disease. Quinine in doses of three to five grains has been prescribed as an anti- pyretic in diphtheria, as also in the other infectious diseases ; but as an anti- pyretic it is not very efficient, and the temperature after the first two or three days in diphtheria is not often so elevated that an antipyretic is required. DIPHTHERIA. 371 As a tonic in doses of one to two grains it is probably to a certain extent beneficial, and it has been highly recommended by good observers for its local action upon the fauces when used by insufflation. The late Prof. Rochester of Buffalo recommended and practised in the treatment of diphtheria the insufflation of sulphate of quinine, in powders of two grains, upon the faucial surface, every two hours. 1 It is not improbable that benefit may result from its local action, for used in this manner it is antiseptic. But the employment of this agent by insufflation is very unpleasant to the child, and is likely to be resisted. Given in solution in doses of two grains, as in the following formula, it produces some local action on the fauces if drinks be withheld subsequently for a few minutes, and at the same time some tonic effect prob- ably results from its use in this manner : R. Quiniae sulphat, £ss ; Syr. yerbse santse comp., Jjij. — Misce. Give one teaspoonful every two to four hours to a child of five years. I have often prescribed quinine in this manner with apparent benefit in the treatment of diphtheria. Tinctura Ferri CMoridi. — All physicians who are familiar with diphtheria have noticed the pallor and loss of appetite, flesh, and strength which com- mence before the close of the first week in severe cases, and which are always unfavorable symptoms, indicating as they do rapid and progressive deteriora- tion of the blood. The use of iron is at once suggested as the proper medic- inal agent to arrest this blood-change, from its known effect in increasing the number of red blood-corpuscles and the amount of coloring matter in these corpuscles. By its effect on the red corpuscles, which are the carriers of oxygen, it increases the functional activity of organs and improves the gen- eral nutrition. The ferruginous preparations, therefore, hold an important place in the therapeutics of diphtheria. The one which has stood the test of experience and is now commonly employed is the tincture of the chloride of iron. It should be given in large and frequent doses, and five drops hourly to a child of three years. Ferguson 2 regards the tincture of the chloride of iron as the most valu- able of all remedies for diphtheria. He examined the blood daily or every second clay in twenty cases of diphtheria, and was astonished to observe how rapidly the red blood-corpuscles were reduced in number, those remaining presenting an unhealthy appearance. He believes that the iron partially arrests the blood-change. He administers as much as can be tolerated. It can be given in the syrup of pineapple in the following formula : R. Tinct. ferri chloridi, ^iij ; Glycerini, ^ss ; Syr. ananassse sativa, ^iv. — Misce. M. Jules Simon says : 3 " For internal treatment from three to six drops of the tincture of the chloride of iron should be given in a little water every two or three hours ; but it should not be given with milk or gum-water or from a metallic spoon, on account of the decomposition which occurs, which may pro- duce digestive troubles." The tolerance of a drug depends largely on the manner in which it is used. The best vehicle for the tincture of the chloride of iron is glycerine and the syrup of pineapple (syrupus ananassse sativa), or it may be conveniently em- ployed with two or three times its quantity of glycerine and a certain number 1 New York Medical Journal. 2 Canadian Practitioner. 3 Le Progh medical. 372 CONSTITUTIONAL DISEASES. of drops administered in water. The advice of Simon should be borne in mind not to give iron in gum-water, in milk, nor from a metallic spoon. That now after half a century of the constant use of iron in diphtheria in both hemispheres, there is an almost unanimous verdict in its favor renders it probable that the few who have not observed its good effects have treated unusually bad cases, or have given the medicine in small and inadequate doses. There is another form of iron employed, from which I have obtained the best results. The following is the formula : R. Acidi carbolici, gr. x ; Liq. ferri subsulphatis, ^iij ; Glycerini, 3J. — Misce. To be applied with a large camel-hair pencil, from three to six hours ; diluted with two or three times its quantity of water. It is destructive in a high degree to microbes, and it congeals the niuco- pus, which comes away abundantly, to the great satisfaction of the friends, who suppose that the pseudo-membrane is being detached. This remedy is a powerful detergent, so that if its use precedes solvents the latter act much more effectually. The thorough use of the iron astringent leaves nothing adventitious to cover and protect the pseudo-membrane from the action of the solvent. Potassium Chlorate. — This agent produces a curative effect on buccal inflammations, and its beneficial action when employed for the various forms of stomatitis has led to its extensive use in pharyngitis. When taken inter- nally it is eliminated in part by the salivary glands, so that it continues to exert in part a local action on the surface of the mouth and fauces until it is entirely eliminated. This medicine, the potassium chlorate, has of late years become also a domestic remedy, but the laity should be cautioned in reference to its use. It is an irritant to the kidneys in large doses, producing intense inflammatory congestion of these organs and arresting their function. The melancholy fate of Dr. Fountaine of Davenport. Iowa, in 1861. whose life was sacrificed by an experimental dose of potassium chlorate, is remembered by the older physicians. Fountaine took half an ounce in a gobletful of warm water at eight a. m. Free diuresis occurred, which ceased at four p. m. Though fatigued and pallid, he ate a hearty supper. During the following night he was in collapse, with vomiting and purging and severe abdominal pain. Early in the following morning he voided two ounces of dark urine, after which no urinary secretions occurred. The choleraic symp- toms returned, with collapse, but he again rallied. He had vomiting and intense and constant abdominal pain during the subsequent six days, when death occurred. The total cessation of fecal and urinary evacuations for six days was a notable fact. At the autopsy the lesions of an intense and gen- eral gastro-intestinal inflammation were present, the mucous membrane hang- ing in shreds and patches ; the bladder was empty, and its mucous membrane presented a similar appearance to that of the stomach and intestines. The condition of the kidneys is not stated, except that there was liquid resembling urine under the capsule of one kidney and crystals of the chlorate were in the pelves of the kidneys. A few years since, in my practice, a child of three years with active diphtheritic pharyngitis was allowed to quench its thirst by drinking water from a small pitcher in which three drachms of potassium chlorate had been dissolved, and which had been ordered as a gargle. In the morning I was summoned in haste, and found the surface of the patient cold and blue and pulse feeble. The urine was totally suppressed, and instead DIPHTHERIA. 373 of it a few drops of blood passed from the urethra. Death occurred before night . Jules Simon 1 says that potassium chlorate, acting wonderfully well in dis- eases of the mouth, produces no beneficial effect in diseases of the fauces, and it weakens the little patient when given in large doses. Dr. J. P. Esch says that he has observed that the potassium chlorate used internally in diphtheria almost invariably produces symptoms of nephritis. After such an extensive use of potassium chlorate during nearly half a century its therapeutic uses should be clearly defined, and any ill effects which may result fully determined. From what is now known of its action, it would be better to abandon its use in diphtheria, since it is a remedy of doubtful efli- cacy for throat affections. Hydrargyri CMoridum Corrosivum (Hydrargyvi percMoridum, Br. Phar.). — ■ The use of this agent in the treatment of diphtheria is based on the theory of the microbic origin of this disease. Corrosive sublimate is the most active and certain of the germicide agents employed in medicine, whether used locally or internally. It quickly destroys all micro-organisms with which it comes in contact, and in safe medicinal doses it is believed to penetrate all parts of the system. The employment of corrosive sublimate in the treat- ment of diphtheria is not new, since it appears that the late Dr. Tappan of Steubenville, Ohio, prescribed it with apparent benefit in 1860-61 ; but it was seldom prescribed as a remedy in this disease until within the last four or five years. The establishment of the theory of the microbic origin of diph- theria, and a knowledge of the fact that the sublimate is the most efficient germicide, have made it the favorite remedy with many physicians. Of course its employment demands caution, and is justified only by the fact that the disease for which it is prescribed has hitherto been very fatal with other modes of treatment. Though this agent is now widely used for diphtheria, medical journals thus far contain very few reports of its supposed toxic or injurious action, while many physicians believe that it diminishes the virulence of diphtheria and increases the percentage of recoveries. In ordinary cases the following may perhaps be regarded as about the proper quantities which should be administered in divided doses in twenty- four hours : For a child of two years, gr. -i- (gr. fa every two hours) ; for a child of four years, gr. \ (gr. fa every two hours) ; for a child of six years, gr. 1 (gr. fa every two hours) ; and for a child of ten years, gr. J (gr. fa every two hours). Thus, if we employ the vehicle which Dr. Tappan used a quarter of a century ago, the following prescription might be written for a child of six years : R. Hyd. chlor. corros., gr. j ; Alcoholi, 3y ; Elix. bismuthi et pepsinii, q. s. ad ^iv. — Misce. Dose : One teaspoonful every two hours. Dr. Oatman of Nyack, New York, has lost but 1 patient in 23 by the following local treatment : Cotton is firmly wound around the end of a stick about the size of a lead-pencil, being drawn out as it is wound, and made to project beyond the end. This is dipped into a solution of the bichlo- ride of mercury, two grains to the pint (1 to 3840), and passed into the throat until it touches the posterior wall of the pharynx. It is then instantly with- drawn and burnt. This treatment is repeated hourly with a new swab each time, until the inflammation begins to subside, which is usually in forty- eight hours. 1 Le Proges medical. 374 CONSTITUTIONAL DISEASES. Two of the prominent physicians of New York have informed me that they have witnessed poisonous effects from the corrosive sublimate in diph- theria, and I can add to the list fatal poisoning from its local use in another disease. Hence its cautious local application in some such manner as that recommended by Oatman seems preferable in the majority of instances. Calomel. — Physicians of ample experience have recommended calomel in the treatment of diphtheria, some in laxative doses and only at the beginning of the attack, and others in doses of the fractional part of a grain every two to four hours during the sickness. The majority of physicians — very prop- erly, in my opinion — discourage the employment of calomel in laxative doses, believing that it tends to weaken the patient and increase the anaemia, which in all cases of severe diphtheria soon becomes very manifest, whatever the treatment ; but a single laxative dose is perhaps sometimes useful. It may do good, as in other infectious diseases, to unload the primse, vise, in the com- mencement of the attack, so that the remedies to be employed are more readily absorbed and without alteration by admixture with chemical products in the intestinal tract. What change calomel undergoes so that it can be absorbed has not been clearly ascertained. Trypsin and Papoid. — Trypsin, unlike pepsin, is an active solvent in an alka- line medium, and it maybe effectually employed in combination with alkaline mixtures. Dr. F. C. Fernald relates the case of a boy of six and a half years who had perforations of each membrana tympani and commencing pseudo- membranes upon the tonsilar portions of the fauces and the right auditory canal was covered with a diphtheritic exudate, entirely occluding it, so that liquids did not flow from the external ear to the fauces as formerly. The ear was filled every half hour with the following mixture : R. Trypsin, gr. xxx ; Sodii bicarbonat., gr. x ; Aquse destillat, ^ss. — Misce. The fibrinous exudate gradually dissolved and disappeared, the passage through the ear and Eustachian tube became open, and the patient recovered. The literature of trypsin contains other equally striking cases, showing the solvent power of this agent. Papoid, also designated papayotin and vegetable pepsin, is a digestive fer- ment obtained from the fruit of the South American melon tree. Its diges- tive power has been fully investigated by H. H. Chittenden of the Sheffield Scientific. He stated that it " has the power of digesting all forms of pro- teid or albuminous matter" in neutral acid or alkaline media. In his opinion the commercial papoid is " a mixture of vegetable globulin albumoses and peptone, with which is associated the ferment." He details his experiments on the raw blood fibrin which comes nearest chemically to the so-called pseudo- membranes, such as are found in diphtheria. The following facts ascertained by Prof. Chittenden are important in refer- ence to the use of this agent in pseudo-membranous inflammations whatever their location. Its proteolytic action is increased by the presence of an alka- line medium, in some cases greatly increased by the presence of 2 to 4 per cent, of sodium bicarbonate ; the highest digestive power is obtained in the presence of sodium bicarbonate. We cannot affirm that any alkaline reacting fluid will give the same increase in digestive action as sodium bicarbonate. We will recommend presently a successful method of using trypsin and papoid. Peroxide of Hydrogen, Hydrogen Dioxide H 2 2 .— Sir B. W. Richardson states that in 1857, when he began experiments with the peroxide of hydro- DIPHTHERIA. 375 gen. it was a rare chemical curiosity, never previously used in medicine, and he had therefore no guide from former experience. He first employed it in the strength of four and five volumes, and gradually increased the volumes to twenty and thirty. He soon learned that the action of oxygen from the higher volumes, released in the presence of pus and other substances, was so great and rapid that the effect was practically explosive, and after many trials he came to the conclusion that the ten-volume strength was the best for ordi- nary use. As frequently happens when an active and efficient remedial agent is first prescribed, its efficiency and full value were not appreciated. The peroxide was indeed seldom employed until it was brought prominently and favorably to the notice of the profession by E. R. Squibb, in 1889, who wrote : " It is perhaps the most powerful of all disinfectants and antiseptics, acting both chemically and mechanically upon all secretions and excretions so as to change their character and reactions instantly." The new medicine began to be used in surgical and in those medical cases which required local treatment, and the laudatory opinion of Squibb was in many instances justified by the result. But the pharmaceutical peroxide was soon found to be too irritating for use in the various inflammations of the fauces and nares in children, so that even a 15 volume solution diluted with two or more times its bulk of water, applied by spray or otherwise, increased the inflammatory hyperemia of the nasal, buccal, and faucial surfaces, sometimes causing in addition to the increase of inflammation, a pellicular exudation of fibrin, as when strong ammonia having a caustic action is used. Distinguished physicians, whose opinions influence practice in both hemispheres, related cases showing the pernicious effects of the peroxide applied by spray or otherwise to the nasal or faucial surface of the child in catarrhal or pseudo-membranous inflammation, so as to increase the area and severity of the inflammation and sometimes form a thin fibrinous exudate to which I have alluded. I might mention similar results in my own practice and that of others, the induced catarrhal and pellicular inflammation abating when the use of the peroxide was discontinued. The irritating action appears to be due to the sulphuric and phosphoric acids used in the manufacture of the peroxide. " It is necessary that solutions of hydrogen dioxide should be slightly acid when they are to be kept for even a few hours. If neutral or alkaline they will decompose at the rate of two or three volumes a day, and the faster the warmer the weather, and the stronger solutions would soon burst any ordinary bottles. Squibb states that the neutralization of the peroxide by such alkaline agent as the sodium bicarbonate does not diminish its efficiency, " provided this be done very near the time of using ; then by ordering the peroxide a little stronger than you want, to compensate the loss by decomposition, you could get a fairly uniform solution for say six or eight hours after sodium has been added, provided the bottle be kept in a cool dark place." The irritating action of the peroxide due to its hyperacidity may there- fore be prevented by adding to it an alkali as the sodium bicarbonate imme- diately before its use, so as to render it neutral or preferably alkaline when used. By so doing its germicide and antiseptic powers do not appear to be diminished. There can be no doubt that the peroxide of hydrogen is not surpassed as a detergent, and it should be used every hour or every half hour. If so used there is reason to believe that the nascent oxygen which it immediately sets free combines with the toxine generated by the bacillus and diminishes its poisonous properties. The prompt' chemical action of the nascent oxygen removes the muco-pus and causes it to flow from the nares or fauces in minute bubbles, and there is reason to believe that it changes to a certain 376 CONSTITUTIONAL DISEASES. extent the character of the bacillus and toxine, if it be applied every hour or perhaps half hourly as a spray, rendering them less noxious. In order to complete the process of destroying the membrane, I obtain very successful results by utilizing the digestive action of trypsin and papoid according to the following formula : R. Trypsin, Papoid, Sodii bicarbonat., ad. j|ss ; Sulphur, sublimat., ^ij. To be insufflated every two hours immediately after the detergent action of the peroxide. The digestive power of the papoid has been investigated by R. H. Chittenden of the Sheffield Scientific School. He states " that it has the power of digesting all forms of proteid or albuminous matter in neutral acid or alkaline media." He details the soluble action of papoid on raw beef fibrin which resembled most closely the composition of the diphtheritic exudate. The remedies which we have mentioned are in my opinion the most effi- cacious and safest of those which pharmacy has heretofore furnished, but a new remedy, known as " antitoxin," has been so highly extolled by many eminent physicians as a remedy for diphtheria, that this new remedy demands attention if not employment wherever this fatal malady occurs. The distin- guished bacteriologist, M. Roux of Paris, gave a clear and full, but at the same time eulogistic description of the " antitoxic treatment " of diphtheria, at the meeting of the Congress at Budapest, as follows : Roux says that where the diphtheritic pseudo-membrane appears upon parts that are not visible the disease manifests itself by blood-poisoning, indicated by pallor, albuminuria, and respiratory and cardiac disturbances. If diphtheria be not early diagnosticated and be well advanced, antitoxin cannot be expected to be efficacious. He describes the method of preparing the serum as follows : The animal furnishing it, usually the horse or goat, is rendered immune against diphtheria — that is to say, it is rendered accustomed to the toxin of diph- theria. The preparation of antitoxin forms the basis of the treatment, and it is the more necessary to describe it because it requires a large quantity of the diphtheritic toxin to immunize large animals and to maintain their serum at a sufficient degree of activity. The most rapid method for obtaining the toxin employed for inoculating the animal consists in making a culture in a current of moist air. Vessels with flat bottoms and lateral tubes are used ; into these is poured an alkaline bouillon, peptonized to 2 per cent., the liquid being spread into a thin layer. " After sterilization, recent and very virulent diphtheria bacilli are added and the temperature of the chamber is raised to 37° C. (98.6° F.). When the development has fully commenced, in a man- ner easily imagined, the current of air that passes into the neck of each of the phials is regulated after passing through a wash-bottle. After three weeks or, at most, a month, the culture is sufficiently strong to use Since 1892 we have immunized several horses, producing very efficacious serum. Some have been brought to such a degree of immunity in less than three months that they have borne, without suffering, 300 cubic centimetres (9J fluidounces) of diphtheritic toxin injected into the veins at one time. The immunization of horses is therefore very simple. The pure toxin is injected under the skin, commencing with 1 cubic centimetre (15* minims) and progressively increasing the quantity. At the end of a month, two or three times a week from 20 to 30 centimetres (5 to 8 fluidrachms) are injected at each sitting Horses also bear very well inoculations of living and very virulent diphtheritic bacilli These inoculations, after being DIPHTHERIA. 377 repeated a great number of times, always give rise to the same symptoms, until a period is readied at which the fever following the inoculations is insignificant, and the much-reduced local lesion terminates in suppuration. Then large doses of virulent culture introduced into the veins only provoke a fleeting rise of temperature/' After the serum of the animal is rendered immune by repeated injections, extending over three months to two years, it is ready for the treatment of patients. Roux states that before treating children with the serum it is tested upon animals. The serum not only prevents general poisoning, but its action on the local lesion is most marked. That form of diphtheritic disease in chil- dren which is dreaded above all others by the laity as well as physicians — to wit, pseudo-membranous laryngo-tracheitis — experiments have shown to be more amenable to treatment by the antitoxic serum than by any or all other medicines. Roux says : " Rabbits to which tracheal diphtheria has been communicated (by injection of the diphtheritic material) die in from three to five days if not treated. Those receiving serum in sufficient quantity, even twelve or twenty-four hours after the injection, recover. Diphtheria associated with streptococci is the gravest form met with ; in children it is the most frequent determining factor of broncho-pneumonia, and the same holds good among rabbits." He believes that treatment begun in the first twelve hours, by repeated large injections of the serum, may arrest these cases of mixed infection in which both pathogenic germs — the Loeffler bacil- lus and streptococcus — are present and broncho-pneumonia is likely to super- vene. But your rabbits, treated after twelve hours, have succumbed in the great majority of cases, with centres of broncho-pneumonia, in which were found microscopically the Klebs-Loeffler bacillus associated with the strep- tococcus. Roux gives the statistics of treatment with antitoxin at the Hopital des Enfants Malades, Paris. From February 1 to July 24, 1894, 448 children were thus treated, the mortality being 109, or 24.33 per cent. The average mortality from 1890 to 1894 was 51.71 per cent, in a total of 3971 children. The benefit from the antitoxin treatment, the conditions being the same, was therefore 27.38 per cent. Within the same period 500 cases of diphtheria were entered at the Hopital Trousseau, 316, or 63.20 per cent, of whom died. Of the 448 children treated by antitoxin, 128 were found, by bacte- riological examination, not to be suffering from true diphtheria ; 20 other cases were in a dying condition when brought in. Of the 300 cases remain- ing there were 78 deaths, or 26 per cent., instead of 50 per cent., as in former statistics, before the use of antitoxin. The serum used was taken from immunized horses, with a strength of between 50,000 and 100,000. Of this 20 cubic centimetres (5 drachms) were injected under the skin of the thigh. This was not renewed if the patient was found not to be suffering from true diphtheria; otherwise, a second injection was made twenty-four hours later. 0.10 to 0.20 gramme (1J to 3 minims) being used. This was usually suffi- cient to bring about recovery. If the temperature remained elevated, how- ever, a third injection of the same amount was made. The average weight of the children being 14 kilogrammes (28 pounds), the amount of serum injected, as a general rule, equaled T wo" P ar *- °f their body-weight, and in exceptional cases y-J-g- part. Under the influence of the injections the gen- eral condition remained excellent ; the false membranes ceased to form within twenty-four hours after the first treatment ; in thirty-six or at most seventy-two hours they became detached. In only 7 of the cases did they persist longer. The temperature frequently fell suddenly after the first in- jection ; if it remained elevated in the cases of severe angina, it fell only after the second or third injection in lysis. The pulse returned to normal 378 CONSTITUTIONAL DISEASES. less rapidly than the temperature. A third of the cases of diphtheria, ac- cording to statistics, show albuminuria ; and this having been present in only 54 out of the 120 cases treated with serum, it seemed evident to Roux that the remedy diminished the frequency of the symptom. The mortality in cases of croup treated with the serum was also much less than with other methods. In mixed infection, in which the streptococcus and Loeffler bacillus are associated, the antitoxic serum is less efficacious than in those cases in which the streptococcus is absent. Roux states, as the result of his observations^ that when the diphtheritic inflammation extends to the larynx and tracheotomy is necessary the injections should be more abundant and more numerous. In the majority of cases thus treated the diphtheritic exudate disappears more rapidly from the larynx and trachea, and the cannula can ordinarily be withdrawn on the third or fourth day. Tubage being an American invention, the American reader will be pleased when he reads the following sentences with which Roux terminates his highly-instructive paper : " How many children may be spared trache- otomy if the serum were administered sooner ? We can even say that, with the use of serum, tracheotomy should, in the great majority of cases, be replaced by intubation. It is now no longer a question of leaving the tube in the larynx for days. It will suffice more frequently to retain it for twenty-four or forty-eight hours, to prevent imminent asphyxia and to give time for the false membranes to become detached. Intubation is the com- plement of the serum treatment of the future. Tracheotomy will be the exception, and greatly to the benefit of the children." A. I. H. Saw, 1 of London, relates six cases of diphtheritic croup treated by tracheotomy and Aronson's antitoxin. All except an infant of eleven months, moribund on admission, recovered rapidly. At a meeting of the Brighton Medico-Chirurgical Society held October 4th Richardson and Hollis each related two cases in which the antitoxin was employed, with speedy recovery in all. One of Hollis's cases was cyanotic from croup and was tracheotomized before the antitoxin was injected. I. A. Turner 2 has collected the following statistics of the antitoxin treat- ment : Behring and Kossel, 30 cases, with a mortality of 20 per cent. ; Ehr- lich, Kossel, and Wasserman, 67 cases with tracheotomy, with a mortality of 23.6 per cent. ; Kartz, 123 cases, with a mortality of 13.2 per cent. ; Weilger, 63 cases, with a mortality of 28 per cent ; Aronson, 192 cases, with a mor- tality of 13 per cent. ; Roux, 448 cases, with a mortality of 24.3 per cent. This gives a total of 1081 cases, with a mortality of 24 per cent. At a recent meeting of the Royal Society of Physicians of Vienna, Widehofer 3 reported the results obtained in 100 severe cases of diphtheria treated during October and November with antitoxin. Of this number 74 recovered, 24 died, and 2 were yet under observation. Diphtheria bacilli were found in all the cases except 4, 2 of which were not examined bacterio- logically. In the preceding nine months the mortality had been 52.6 per cent. Prof. Augustus Caille of the New York Polyclinic stated, in a paper read May 27, 1895, before the American Pediatric Society, " being fortunate in ob- taining from abroad an early supply of the antitoxin, I have been able thus far to observe its action in 41 cases of Klebs-Loeffler diphtheria, of which 7 cases have had a fatal termination. Of the 34 cases ending in complete recovery, 32 were treated with Behring's or Aronson's serum, 2 with serum from the Gibier Institute, New York. In the majority of cases one injec- tion (600 units) was given ; in one-third of the cases, two and three injections were administered. Judicious stimulation was carried out in all cases, and 1 October 13, 1894. 2 November 24, 1894. 3 No. 52, 1894. DIPHTHERIA. 379 nasopharyngeal irrigation was practised in all cases, with salt water or mer- curic bichloride 1 : 5000. Our clinical experience has so far upheld the claim made for the antitoxin of diphtheria as to its specific and curative powers, for a reduction of the mortality from diphtheria is conceded by the vast majority of unbiased and competent observers." We cannot write so favorably of the use of antitoxic serum in the New York Foundling Asylum. Since a reliable preparation was obtained from the Health Board 31 cases were inoculated with the serum. The number of units employed varied from 500 to 2200. The antitoxin was inserted under the skin on the first day in 12 cases, on the second or third day in 17 cases, and on the fourth or fifth day in 2 cases. Nineteen received the injection once, nine received it twice, and three three times. Microscopic examinations revealed the presence of the Loeffler bacillus in all the cases, and the strep- tococcus in nearly all the cases, so that in all. or nearly all, the infection was a mixed one. The physicians who observed these cases and wit- nessed the necropsies and microscopic investigations could not resist the conviction that the broncho-pneumonia of which so many died was due to the streptococcus, which was abundant in the lobules, and upon which microbe the antitoxin has little or no eifect. Results: Recovered, 14; died, 17 (14 from broncho-pneumonia or broncho-pneumonia and croup). In four or five of the cases the benefit was very marked after the use of the antitoxin. It is seen that statistics thus far are favorable for the antitoxine treat- ment, but it must be recollected that the type of the microbe diseases fre- quently changes, so that the experience of several years is often necessary in order to determine the full value of a remedy. Albuminuria. — This being due to septic nephritis, patients have seemed to be more benefited by the tincture of the chloride of iron, in frequent and rather large doses, than by any other remedy. If while this is being used a marked diminution in the quantity of urine occurs, it may be necessary to employ diuretics and laxatives, as in scarlatinous nephritis. The potassium bitartrate or acetate, and perhaps the more laxative salines, may be needed under such circumstances. But marked diminution of urine — and especially anuria — in diphtheria ends fatally, with few exceptions, according to my observations, whatever the treatment. Paralysis. — The loss of the tendon reflexes, and palatal and multiple paralysis, require the same stimulating and sustaining remedies which are appropriate for the primary disease, diphtheria. Iron and other tonics, nutri- tious and easily-digested diet, massage, and in some instances electricity, suffice to restore the use of the affected muscles, but sometimes weeks and even months elapse before their use is fully restored. So long as the paral- ysis does not affect any vital organ, a favorable prognosis may be expressed, although recovery may be slow. On the other hand, it is evident from its nature and from the cases which have been related that cardiac paralysis is exceedingly dangerous. and must be treated promptly and by the most active remedies. As we have seen, the attack of cardiac paralysis is usually sudden, with little fore- warning, and is often fatal before the physician, promptly summoned, is able to arrive. The patient should be as quiet as possible in bed, with the head low, and alcoholic stimulants should be administered at once. In the sudden seizures, such as have been related above, hypodermic injections of brandy act most promptly in sustaining the heart-action. Ammonia, camphor, musk and the electrical current may be useful auxiliaries. The predigested beef preparations, peptonized milk and other concentrated foods, designed for those with feeble digestion, are useful. If the urgent symptoms are relieved by these measures such remedies should be employed as are useful in other forms oi 380 CONSTITUTIONAL DISEASES. diphtheritic paralysis. The patient is ordinarily feeble, anaemic, and with poor digestion. The beef extracts and concentrated foods should be con- tinued. Iron, quinine in moderate doses, and alcoholic stimulants are indi- cated. The use of the electric current is suggested by the nature of the attack. Many physicians believe that they have obtained benefit from its use in the treatment of the more common forms of diphtheritic paralysis, while others speak doubtfully of its efficacy. If there be reason from the symptoms to suspect the presence of central lesions in the nervous system, the galvanic current in short sittings has been recommended, and not the faradic. In ordinary cases either the direct or the induced current may be employed. Strychnine is, however, regarded by good observers as the most efficacious nerve-stimulant in the various forms of diphtheritic paralysis. Oertel's objection, expressed twenty years ago, to the use of strychnine in this disease, that, acting as an excitant of the spinal cord, it is likely to aggravate central lesions, was founded on a wrong understanding of the pathology of the paralysis. Prof. Henoch cured diphtheritic paralysis in three weeks by hypodermic injections of strychnine. W. Reinard ] states that a boy three and a half years of age fifteen days after the appearance of the diphtheritic patches on the tonsils had paralysis of the inferior extremities and the velum palati, a tottering gait, nasal voice, and difficult deglutition. At the end of twelve days death seemed imminent, the paresis of the lower extremities had become a complete paraplegia, and the paralysis of the upper extremities and of the muscles of the nucha, larynx, and thorax was complete. He was unable to sustain himself in the sitting posture, his head falling heavily on his chest. He had also dyspnoea, hoarse cough, tracheal rales, and aphonia, probably from cardio-pulmonary paralysis. Reinard made a hypodermic injection each day of one milligramme (about one-sixty -fifth of a grain) of sulphate of strychnine in the nucha. Improvement occurred in twenty -four hours in the tonicity of the muscles. On the third day the cardiac and pul- monary paralysis had so improved that the tracheal rales had ceased. The respiration was more normal and deglutition possible. On the fifteenth day of this treatment and after fifteen injections the patient was considered cured. Dr. Gerasimow 2 relates the case of a child six years of age who had paralysis of the velum, pharynx, larynx, and lower extremities. Six weeks after the commencement of paralytic symptoms subcutaneous injections of strychnine (or about one-thirty-first of a grain), were given daily. With this treatment the patient improved, and after seven injections of this strength, followed by twelve of one-twenty-second of a grain, the cure was complete. With such strong testimony in favor of the use of strychnine, it is per- haps remarkable that physicians of experience state that they have not observed any marked benefit from its use in the treatment of diphtheritic paralysis. At a meeting of the New York Clinical Society, held December 23, 1887, 3 Dr. Holt stated that he was yet to be convinced that strychnine possessed any specific value in this disease, though it was of much value as a general tonic. At the same meeting Dr. A. A. Smith stated his belief that tonics and time did more for diphtheritic paralysis than anything else. He had used electricity and strychnine, and had never been able to satisfy him- self that electricity did any good, and the effects of strychnine seemed to be not specific, but those of a general tonic. On the other hand, Dr. Thatcher of New York has reported a case in which galvanism was employed on the two paralyzed upper extremities alternately, on each for a week at a time. 1 Deutsche med. Wochenschr., 1885, No. 19. 2 Med. Obser., No. 20. 3 New York Medical Journal, Jan. 14, 1888. PERTUSSIS. 381 It was invariably found that the arm receiving the electricity gained more rapidly than the one untreated, the strength being tested by the dynamom- eter. This test seems to have been conclusive as showing the efficacy of galvanization. CHAPTER VIII. PERTUSSIS. Pertussis is a highly contagious disease attended and manifested by a catarrh of the air-passages. This catarrh gives rise to a cough which does not differ, during the inception and in the declining period, from that in an ordinary catarrh, but during the middle period of the malady is spasmodic. Exceptionally, the system is so mildly affected that the spasmodic element of the cough is lacking through the whole course of the malady or is con- fined to a brief period. The spasmodic cough has been attributed to the irritating and disturbing action of the specific principle on the nerves which control the muscles of respiration. It is attributed to the impres- sion produced upon the filaments of the pneumogastric, especially upon those of the internal branch of the superior laryngeal nerve, by the mucus which collects in the larynx and trachea, and which is known to contain the contagious principle in abundance. This cough consists in a series of forcible and loud expirations, followed by a noisy and difficult inspiration. Its special character is due to spasmodic contraction of the muscles of expiration, and notably of the small muscles of the larynx, so as to pro- duce narrowing or even closure of the aperture of the glottis. Each paroxysm of the cough usually ends (not always) in the expectoration of viscid mucus. With rare exceptions pertussis affects the same individual but once. Rilliet and Barthez report a case of its second occurrence, and West another case. I have attended two adult patients, both women of intelligence, who stated that they had had previous attacks in early life. Pertussis usually prevails as an epidemic, but is occasionally sporadic, at which time its type is mild. It is highly contagious through the breath of the patient or from exhalations from his surface. Pertussis is probably a disease of antiquity, but there is no clear description of it prior to the sixteenth century. Some have thought that it was alluded to in the writings of Hippocrates, and the Arabian phy- sician Avicenna who lived in the tenth century, in describing the " violent cough of children," which is attended by the spitting of blood and lividity of the face, probably alluded to it (Rilliet and Barthez). Baillon in 1578 described a cough which appeared in Paris, attacked chiefly children, and was so violent that it caused bleeding from the nose and mouth, and often vomiting. Wilson in 1682 and Schenck in 1695 also described a convulsive cough which we can apparently identify as pertussis. In the eighteenth century whooping cough was described by many observers in different parts of Europe, among whom we may mention Alberte (1728), Brendel (1747), De Basseville (1752), Forbes (1755), Cullen, Butter, and Danz. In the present century, whooping cough, being eminently contagious and of such a nature that the patients are allowed to mingle in society, is widely dissemi- nated, and epidemics of it are of frequent occurrence. Incubative Period. — It is not improbable that this varies in different cases. Some writers believe that it is usually from two to seven days. In one instance I was able to ascertain it accurately. Mrs. B , having a 382 CONSTITUTIONAL DISEASES. cough for two weeks, which was afterward ascertained to be that of pertussis, came from Boston to a family in New York. She remained with this family from 2 p. M., January 2, 1879, till the evening, when she left the city. During her stay she held and kissed an infant that was previously well and had never been removed from the floor on which it was born. Pertussis was not at that time prevailing in New York. On the 6th, or four days after exposure, the infant began to cough, and this proved to be the beginning of a severe attack. Age. — Most cases of pertussis are between the ages of one year and eight years, but it occasionally occurs in adults and even old people who have not been attacked previously. It is rare under the age of three months, but through the kindness of Dr. Ewing of New York I was enabled to see a new-born infant with pertussis whose mother had had the disease during the two months preceding her confinement. This infant was fifteen minutes old, and during the washing had the first convulsive seizure, which appeared to consist chiefly of a spasm of the laryngeal muscles, with temporary suspen- sion of the respiration, and attended by deep lividity of the features, with some frothing from the mouth. These attacks occurred nearly every hour, with intervals of complete cessation of symptoms. The mucus between the lips finally became stained with blood, and death occurred on the third day. The mother, the intelligent wife of a clergyman, believes that the infant had similar attacks before its birth, for she frequently experienced in the last weeks of gestation what seemed to be strong convulsive movements in the foetus, the duration of which corresponded with that of the attacks in the infant. A similar case is related by Billiet and Barthez, 1 and another by Keating. 2 These cases throw light on the pathology of pertussis, for they show that the specific principle may enter the blood. Causes. — Climate, race, and nationality do not seem to exert any decided influence on the spread of pertussis. Females are somewhat more liable to be attacked than males, and. as we have seen, a large majority of the cases occur between the ages of one and ten years. Letzerich about the year 1870 supposed that he had discovered the cause of pertussis in a microbe, which, received upon the surface of the air-passages in inspiration, increases rapidly and produces the spasmodic cough by its irritating action or the irri- tating properties which it imparts to the mucus. In the first stage of pertus- sis he found only the spores of the microbe, and at a more advanced stage, in addition to the spores, he discovered filaments. He placed mucus holding the cryptogram upon the fauces of the rabbit, and witnessed the production of pertussis in this animal. Recently, Burger 3 of Bonn states "that the micro-organism of pertussis is visible with a power of 340 to 600 diameters, appearing as little rods of unequal size. With a higher power it is seen that the rods have the biscuit form. The groups of bacteria are irregularly dis- seminated or disposed in line, and bear some resemblance to the leptothrix buccalis. The method of preparation is very simple. A small quantity of the expectoration is pressed between two cover-glasses, exposed to the flame of a Bunsen burner to coagulate the albumen ; the coloring matter is then added (watery solution of fuchsin or of methyl violet) ; it is then washed thoroughly in water, or the coloring matter removed by washing in alcohol, the bacteria alone remaining colored. These bacilli are not found in any other expectora- tion ; they are so abundant that it is difficult to contest their action ; their frequency is always in direct relation with the intensity of the disease." Dr. Poulet 4 also confirms the statement of a special micro-organism in per- 1 Treatise on the Diseases of Children. 2 System of Medicine by American Authors: Lea Bros., Philadelphia, 1885. 3 Berlin, klin. Wochenschrift ; London Medical Record, May 15, 1884. 4 La Scalpel ; London Medical Record, May 15, 1884. PEBTUSSIS. 383 tussis from his examinations. In the St. Petersburgher med. Woch., 1887, a 11 careful observer," Dr. Afanasieif, also states that he had discovered a bacil- lus in the sputum of pertussis which differs from all other bacilli. It occurs in the form of small rods, single, in pairs, or in chains. The length of the bacillus is 0.6 to 2.2 micromillimetres. Its cultures exhibit peculiar qualities. Inoculated in animals, it produces symptoms like those of human pertussis, and the air-passages of these animals exhibited the appearance of congestion and catarrh. In the St. Petersburgher med. Woch., in 1888, another distin- guished Russian observer, Seintschenko, writes that after many experiments he is able to make the following statements: 1. The bacillus of Prof. Afanasieff is specific ; 2. Bacilli may be found in the sputum about the fourth day of the disease, in some cases earlier ; 3. They multiply in the tissues of the body, and as they increase the severity of the disease increases ; 4. The bacilli disappear before the entire cessation of the attacks of coughing, or when the paroxysms are reduced to two or four daily ; 5. With complica- tions — such as, for example, a catarrhal pneumonia — there is a great increase in the number of whooping-cough bacilli found in the sputum ; 6. A pneu- monia developing under these circumstances differs from ordinary attacks of catarrhal pneumonia ; 7. The bacillus of whooping cough is of value, not only in etiology and diagnosis, but in the prognosis of the disease. After the lapse of six or eight years since the above announcements of the discovery of the specific principle of pertussis, the belief has gained ground that Afanasieff has probably made the genuine discovery. Lesions have been discovered in certain fatal cases which have been sup- posed to throw light on the etiology of pertussis, but which are now known to have been merely coincidences or results of the disease. Such are con- gestion of the spinal cord and its meninges, hyperemia of the pneumogas- trics. and tumefaction of the tracheo-bronchial glands, which it was claimed produced the spasmodic cough by compressing the recurrent laryngeal nerve. Pathological Anatomy. — Catarrhal inflammation of the air-passages is uniformly present. It occasionally occurs on the mucous surfaces of the nostril and pharynx, but is often absent from these parts. In the majority of patients the inflammation affects the surface of the glottis and that below the glottis. Herff examined his own larynx during paroxysms of pertussis. He observed a moderate inflammatory hypersemia of the respiratory tract during the entire course of the disease. The inflammation extended from the posterior nares to the bifurcation of the trachea, but was most marked in the following locations : over the cartilages of Santorini, Wrisber, and the arytenoid, and the posterior wall of the larynx, between the vocal cords and the epiglottis, and on the under surface of the epiglottis. The vocal cords themselves were not affected. During the paroxysm a pellet of mucus was observed upon the posterior surface of the larynx on a level with the glottis, and when this was removed the cough ceased. Irritation of this part of the larynx uniformly excited a cough. Sometimes certain alveoli are found dis- tended by a thick muco-pus, producing an appearance like minute tubercles. A common lesion found in the lungs of those who have perished with this malady is emphysema, affecting chiefly the peripheral portions of the upper lobes. It is usually vesicular emphysema, occurring from over-distension of the air-cells, but in some instances the air has escaped into the connective tissue, causing interstitial emphysema. According to my recollection of fatal cases which have occurred from time to time in the institutions of Xew York, and in which I have made post-mortem examinations, the upper lobes were exsanguine and inflated to nearly the fullest extent possible within the thorax, while other portions of the lungs presented areas of pneumonic or more or less complete atelectatic solidification. Pneumonia, atelectasis, and small extrav- 384 CONSTITUTIONAL DISEASES. asations of blood in the lungs are, indeed, common lesions. Hyperplasia of the bronchial glands is also common, and hyperplasia has also been occasion- ally observed of other lymphatic glands, as the mesenteric. An ulcer under the tongue which observers have frequently noticed is now attributed to the pressure of the tongue on the lower incisors during the cough. In fatal cases small extravasations of blood in or upon the brain are com- mon, as is also passive congestion of the sinuses, veins, and capillaries, men- ingeal and cerebral, attended with more or less transudation of serum within the ventricles of the brain and between the meninges. Large dark and soft clots, and occasionally some that are white or yellow, are common in the intra- cranial sinuses, especially if, as often happens, death have occurred in convul- sions which supervened upon the severe spasmodic cough. Symptoms. — Pertussis consists of three stages : first, that of catarrh of the air-passages ; secondly, the stage of spasmodic cough, or, for brevity, the spasmodic stage ; thirdly, the stage of decline. The first period is characterized by the symptoms of coryza and bron- chitis, which present nothing peculiar or different from ordinary catarrh of the same parts, unless occasionally the cough be more frequent and teasing. Trousseau has known it to be repeated forty or fifty times per minute. The eyes present a moderately suffused appearance, and there is sneezing, with defluxion from the nostrils, but less than in the commencement of measles. The cough, which begins as soon as the catarrh affects the larynx, is accom- panied by little or no expectoration. The pulse and respiration are moderately accelerated, and such other symptoms as commonly accompany catarrh of a mild grade are present — to wit, increased heat of surface, thirst, and impaired appetite. The duration of the first stage varies in different cases. In severe whoop- ing cough it may last only two or three days, and in mild cases be protracted to five or six weeks. It may be absent especially in very young infants. We have alluded above to the new-born infant, in whom there is no first stage, a glottic spasm occurring soon after birth. The first stage commonly ends in from eight to fifteen days. In fifty-five cases observed by Dr. West its aver- age duration was twelve days and seven-tenths of a day. It is stated above that the first stage in rare instances continues during the entire course of per- tussis ; at least no spasmodic cough occurs. In two such cases which I now recall to mind, both girls, the inflammatory symptoms abated somewhat after the first few days, and an occasional easy cough remained, like that of simple bronchitis, and it continued during a period corresponding with the ordinary duration of pertussis. The diagnosis would have been doubtful, except for the occurrence of pertussis, with its regular stages, in other children of the same families. Second Period. — This may commence quite abruptly, but ordinarily its beginning is gradual. While the cough commonly has the character present in the first stage, it is now and then observed to be more severe and spasmodic, especially at night and when the patient is in any way excited. The spasmodic element increases, so that in the course of a week all doubt as to the nature of the disease is removed. The severity of the cough in the second stage varies considerably in dif- ferent cases. It sometimes commences quite abruptly, with little warning,, but commonly there is premonition of it, and the child endeavors to repress it. He experiences a tickling sensation in the throat or median line of the chest, or a feeling of constriction. He leaves his playthings and rests his head on his mother's lap or takes hold of some firm object for support ; his face has a grave or even anxious appearance, while the pulse and respiration are somewhat accelerated. Immediately the cough begins. It consists in a PERTUSSIS. 385 series of short and hurried expirations, which expel a large part of the air contained in the lungs, followed by a hurried inspiration, which is difficult and noisy on account of the spasmodic contraction of the laryngeal muscles and narrowing of the glottic aperture. The sound which accompanies the inspiration, and which is often absent, especially in infants, is designated the whoop. The forcible expirations and difficulty experienced in expelling the air from the lungs on account of the constriction of the glottis afford expla- nation of the emphysematous distention of the air-cells in the upper lobes which we have seen is so common in severe pertussis. There may be a single series of expirations terminating in the manner stated, but often there are several such series embraced in a paroxysm. The cough commonly ends in the expulsion of frothy mucus from the bronchial tubes, and sometimes in vomiting. During the cough there is temporary arrest of blood in the lungs, leading to congestion in the right cavities of the heart and throughout the systemic circulation ; therefore the face is flushed and swollen, and occasionally hemorrhage occurs under the conjunctiva or from one of the mucous surfaces. The most frequent hemorrhage is epis- taxis. When the cough ceases, the normal respiration is restored and the ful- ness of the vessels immediately abates ; but often puffiness of the features is observed, due to serous infiltration of the subcutaneous connective tissue, and continuing for days or weeks during the period when the cough is most severe. The paroxysms last from a quarter to a half or even a whole minute, and in that time, in cases of ordinary severity, there are often as many as fif- teen or twenty series of expirations. At the close of the paroxysm, if there be no complication, the symptoms soon abate ; the temperature, pulse, and respiration become normal, and there is no evidence of disease. The cough in the second stage is much more fre- quent in one case than another. At the height of this stage it is generally more severe if it occur at long intervals than when frequent. During the week in which pertussis is most severe there is, on the average, about one paroxysm of coughing in each hour. The cough increases in severity till the third week of the second stage, or the thirtieth to the thirty-fifth day of the disease, after which it remains sta- tionary for a certain time. It is apt to be more frequent in the night than day-time. Sometimes it occurs while the child is quiet ; it may even awaken him from sleep, but it is often also produced by mental excitement or by physical exertion. Anger or fright gives rise to it, and therefore the child is likely to cough when being examined by the physician or when his wishes are not complied with. The ordinary duration of the second stage is from thirty to sixty days, It may, however, be considerably longer or shorter than this. The third stage, which commences at the time when the spasmodic cough begins to abate, is short, not continuing longer than two or three weeks. A protracted stage of decline indicates some complication. While the sputum in the second stage is mucous and frothy, that in the third stage is more opaque and puriform. In the third as in the second stage, if there be no complication, the pulse and respiration in the intervals of the paroxysms are nearly or quite natural. Febrile excitement may. however, now and then occur from trifling causes, or. indeed, without any apparent cause. The digestion and the general health in uncomplicated pertussis remain unimpaired, with the exception of more or less emaciation, which is likely to occur in all but the mildest cases in conse- quence of the frequent vomiting. After complete recovery it is not unusual for the spasmodic cough to reappear at times for one or even two years. The cough of ordinary simple laryngitis or bronchitis assumes this character. Complications. — These, like the symptoms, are chiefly of a twofold 25 386 CONSTITUTIONAL DISEASES. character — to wit, inflammatory and neuropathic. From the nature of the cough in pertussis, it would naturally be supposed that the spasmodic affection which is now designated internal convulsions, and which is charac- terized by spasm of certain muscles of respiration, would be a frequent com- plication. It does sometimes occur in young children, but it is not common. Clonic convulsions affecting the external muscles are, on the other hand, not infrequent. They occur chiefly in the second stage, when the cough is most severe, and in infancy much more frequently than in childhood. They are likely to be general and severe, or, if not of this character at first, to become such. The convulsions commence in most instances in or directly after the paroxysm of coughing, but they sometimes occur in the interval when the child is quiet. Rilliet and Barthez remark: " Almost all infants succumb to this com- plication, ordinarily in the twenty-four hours which follow the first attack ; nevertheless, life may be prolonged during two or three days " (article Coqueluche). In my own practice this complication usually ended fatally before bromide of potassium and chloral were employed, but with the proper use of these agents it can often be arrested. In the month of June, 1867, I was attending a little girl two years and four months old who had reached the fifth week of pertussis when she was seized with general clonic convul- sions. The mother, who was requested to keep a record of the number of convulsions, stated that there were twenty in all occurring within forty-eight hours. They affected both sides, the shortest lasting only three or four minutes, the longest seventy-five minutes. The treatment in this case, which eventuated favorably, will be noticed hereafter. In those who die of convulsions occurring in whooping cough the most constant lesion is congestion of the cerebral veins and sinuses, often with transudation of serum. This congestion is due in part to the cough which precedes the convulsions and in part to the convulsions themselves. At the autopsies which I have made of two infants who died in hospital practice from whooping cough, accompanied by convulsions, all the cerebral sinuses were filled with clots, which were generally soft and dark ; but in the lateral sinuses clots were found which were light-colored. The light color of a clot, either in a vein or sinus, indicates its ante-mortem formation. The gravity of the convulsive attack can be ascertained by observing whether the patient readily recovers consciousness. Its speedy return to con- sciousness indicates that there is no serious congestion. On the other hand, great drowsiness remaining or a semi-comatose state indicates persistent con- gestion, and perhaps even the formation of clots in the sinuses of the brain. Death from convulsions is usually preceded by coma. Occasionally menin- geal apoplexy supervenes upon the congestion, and death is immediate. The most frequent inflammatory complications are bronchitis and pneu- monitis. Inflammation of the bronchial tubes of a mild grade, we have seen, is a common accompaniment of pertussis, but when it extends to the minuter tubes or becomes so severe as to cause acceleration of respiration, it is prop- erly a complication. Both bronchitis and pneumonitis, occurring as compli- cations, are developed, with few exceptions, in the second stage. Bronchitis is accompanied by accelerated respiration and pulse and increased tempera- ture. The danger is proportionate to the amount of dyspnoea. Pneumonitis is a less common complication than bronchitis, but it occurs more frequently in pertussis than in any other constitutional malady of early life, excepting measles. The congestion which results and remains in the lung when the cough is frequent and severe favors the development of pneumonia. The symptoms and physical signs which accompany this inflammation and serve for its diagnosis are the same as in the primary form of the disease, PERTUSSIS. 387 and are described elsewhere. Bronchitis or pneumonia usually moderates the severity of the spasmodic cough, for when the inflammatory element in pertussis increases the spasmodic abates. On the abatement of the inflam- mation, however, the cough usually regains its former convulsive character. The fact may be stated in this connection that any complication or intercur- rent disease which is attended by decided febrile reaction ordinarily renders the cough for the time less spasmodic. The occurrence of bronchitis or pneumonia is shown by the elevated tem- perature, acceleration of pulse and respiration, short and frequent cough. These symptoms do not cease so long as the inflammation continues, whereas in uncomplicated pertussis the patient seems nearly or quite well between the coughs. In pneumonia the respiration is accompanied by the expiratory moan, and in both bronchitis and pneumonia there is more or less depression of the inframammary region during inspiration. These symptoms, in con- nection with the physical signs, render diagnosis in most instances easy. Although the general character of the cough is changed, a cough now and then occurs, even when the inflammation is pretty severe, sufficiently spas- modic to indicate the nature of the primary affection. Capillary bronchitis and pneumonia are always serious complications. Not only is more or less emphysema a common complication of severe pertussis, but bronchiectasis also occurs in certain cases, due to the same conditions. Emphysema is a common lesion in young and feeble infants, even when there is no history of any previous severe disease of the respira- tory organs. I have found it one of the most common lesions in infants of feeble constitutions who die in the hospitals and asylums of New York, but it is usually interstitial and confined to a small part of the upper lobes. It is not accompanied by that general distention of the alveoli and consequent enlargement of the lobes which occur in the emphysema of pertussis. Its chief cause in these feeble and wasted infants appears to be impaired nutri- tion and change in the molecular state of the pulmonary tissue. The same molecular change often occurs in severe and protracted pertussis, and there- fore serves as an additional and efficient cause of the emphysema. The following was a not unusual case of this disease as it occurs in the tenement-houses and asylums of New York. At the meeting of the New York Pathological Society, October 14, 1868, I exhibited emphysematous lungs removed from an infant who died at the age of nineteen months at the commencement of the fourth week of pertussis. Death occurred from thrombosis in the lateral sinuses of the cranium, resulting from the severe spasmodic cough, eclampsia, and feebleness of the circulation, as the infant was previously in a reduced state from chronic entero-colitis. At the au- topsy the superior lobes of both lungs were found exsanguine, doughy to the feel, and enlarged so as to rise above the level of the other lobes. The resiliency and elasticity of the lung-tissue in these lobes were evidently greatly impaired, and their air-cells in a state of over-distention. The other lobes were healthy, except that one of them was the seat of catarrhal pneumonia. In this case there had been no disease affecting the respira- tory apparatus previous to the pertussis, so that the incipient vesicular emphysema was referable to the severe cough and impaired nutrition of the lungs. Occasionally we meet cases of severe pertussis in which, while there is over-distention of the alveoli of the upper lobes, collapse occurs over a greater or less extent of the lower lobes. Collapse, like emphysema, may continue for weeks or months subsequently to pertussis, and then gradually disappear, but in the following case, rare in my experience, it was permanent : John O'Neil, aged five and a half years, was brought to the Bureau for the Relief 388 CONSTITUTIONAL DISEASES. of the Out-door Poor in New York in December, 1876. He lived in the underground basement of a tenement-house, and was supported by charity, except at intervals, when his father, who was dissipated, could obtain work. At the age of fifteen months he had a glandular swelling on the right side of the neck, which suppurated, and three months later one on the opposite side, which also suppurated. At the age of two and a half years he had bron- chitis, the cough of which did not abate till two months subsequently. When near the age of three years he had measles, and the cough from this disease lasted three or four months. In the summer of 1875, or about one year subsequently to the measles, he contracted pertussis, which was severe, but was allowed to run its course without treatment. It lasted four months, never, however, confining him to bed or materially impairing his appetite. One morning about the close of the second month of the malady the parents first observed depression of the right side of the thorax. This gradually increased a few weeks, and has been permanent. The parents stated that he had never been confined to the house or without appetite except during the week of measles. Since his recovery from pertussis he has had his usual appetite and gen- eral health, but crying or excitement commonly brings on a pretty severe cough. The depression of the thorax, examined in front, begins quite abruptly in the line of the left costo-chondral articulations. Circumferen- tial measurement of the left side from the mid- dle of the sternum to the spine, the tape lying a little below the nipple, gives eleven and a half inches, while corresponding measurement of the right side gives seven and a half inches ; pulse 136, sounds of the heart normal ; respiration 44. On auscultation over the right side of the chest we observed bronchial respiration and a feeble bronchophony, with perhaps slight vocal fre- mitus. The accompanying figure is from a photograph by Mr. Mason, photographer to Bellevue Hospital. My first impression on ob- serving this case was that it was one of unex- panded lung which had been compressed by a pleuritic effusion, but it is seen that the history points clearly to pertussis as the cause of the deformity. The depression occurred somewhat suddenly when the cough was most severe and when there was no fever, loss of appetite, or other symptoms of pleuritis. The patient had not presented any marked evidence of rachitis, but was decidedly strumous. Pertussis is sometimes complicated by the eruptive fevers. There does indeed seem to be some affinity between it and measles, so that many epidemics of the two have been observed at about the same time. During my term of service in the New York Foundling Asylum, in May, 1878, measles and pertussis prevailed in the wards at the same time. Eighteen of the chil- dren who were having pertussis contracted measles, and the Sisters, who were very intelligent and faithful observers, and were requested by me to notice the effect of the complication, stated that with few exceptions the severity of the whooping cough was increased during the continuance of PERTUSSIS. 389 the exanthem. This is contrary to the general belief of the eifects of inter- current febrile diseases. Diagnosis. — During the period of invasion it is impossible to diagnosticate pertussis. Its nature can only be conjectured from a known exposure or from the epidemic occurrence of the disease. In the second stage, which is cha- racterized by the spasmodic cough, diagnosis is ordinarily easy, and often the parents are able to announce the nature of the disease when the physician is called. Still, a mistake is sometimes made : a spasmodic cough very similar to that of pertussis occasionally occurs in other maladies. Young infants with bronchitis frequently experience great difficulty in the expectoration of mucus, which collects in the air-passages and provokes a suffocative cough. The following facts will aid in making the diagnosis : Bronchitis, accompanied by a suffocative cough, is an acute disease, and the cough occurs at an early period, usually in the first week. It lacks the inspiratory sound or the whoop, and is associated with constantly accelerated respiration and well-marked febrile symptoms, dependent on the inflammation. Moreover, the cough is occasion- ally suffocative, according to the amount of mucus in the tubes. The spas- modic cough of pertussis, on the other hand, is preceded by the stage of inva- sion, and it occurs only in the second stage, when the febrile symptoms have abated. Again, the suffocative cough of bronchitis rarely ends in vomiting, which is common in the cough of pertussis. The only other disease with which there is much likelihood of confound- ing pertussis is bronchial phthisis. The points of differential diagnosis are the following : the one epidemic and spreading by contagion, the other non- contagious and isolated ; the one embraced in three distinct stages and much shorter, the other chronic and presenting no stages, but commencing with mild, non-febrile symptoms and progressively becoming more severe ; in the one an absence of symptoms in the intervals of the cough, provided that there be no complication ; in the other constant symptoms, such as are com- mon in tubercular disease. The previous health and the presence or absence of a tubercular cachexia should be considered in determining the nature of the disease. Usually in bronchial phthisis the lungs are also affected, so that auscultation and percussion may furnish positive proofs of the nature of the cough. The attacks of suffocative cough which are produced by the lodgement of a foreign body in the larynx or lower down in the air-passages bear a close resemblance to those of pertussis. The diagnosis can be made by the history, for in the one case there is a preliminary catarrhal stage, and in the other the cough begins abruptly, and usually after the known swallowing of the offending substance, which produces dyspnoea and a spasmodic cough as soon as it enters the larynx. The presence of the body can also be deter- mined in a large proportion of cases by the laryngoscope and auscultation. Prognosis. — A larger proportion doubtless recover under the better ther- apeutics of the present time than in former years. According to Hirsch (ii. p. 105), 72,000 persons perished from this disease in England and Wales between 1848 and 1855, or 1 in every 40 who died ; and Wilde's reports show that it stands fifth as regards mortality among the epidemic diseases of Ireland. In New York City, during the half century ending with 1853. 4840 died of pertussis, or 1 died from this disease in every 76 of deaths from all causes. As a rule, the older the child the better the prognosis. Young infants may die of suffocation due to the glottic spasm. Eclampsia with extreme passive congestion of the encephalon is a not infrequent complication in chil- dren under the age of five years, and it is apt to terminate fatally. It may. however, be averted in most cases by proper treatment when threatening. 390 CONSTITUTIONAL DISEASES. In rare instances death may occur in or immediately after a paroxysm of coughing, in consequence of rupture of a cerebral or meningeal vessel and the effusion of blood, or from stasis and coagulation of blood in the venous system, especially if convulsions have supervened upon frequent and pro- tracted paroxysms of coughing. Other complications which are likely to arise under conditions which favor their development, and which greatly increase the danger aud render the prognosis unfavorable, are capillary bronchitis, pneumonia, diphtheria, and in the summer season intestinal catarrh. Feebleness of system and antecedent and accompanying chronic disease increase in danger. Pertussis sometimes produces so much emaciation and loss of strength, in consequence of the severity and frequency of the cough and the repeated vomiting, that intercurrent diseases, which in favorable states of the system would probably end in recovery, are very apt to prove fatal. I usually inform the family that the patient is doing well if he seem entirely well between the paroxysms ; but if he appear ill, whether with som- nolence, fretfulness, fever, loss of appetite, accelerated breathing, or diarrhoea, he is not doing well, and probably has some complication which requires attention. Treatment. — In the catarrhal stage the treatment should be the same as in mild idiopathic bronchitis. Demulcent and soothing cough mixtures are required. Care should be taken to employ nothing which reduces the strength or impairs the general health. If there be much bronchitis with accelerated breathing and frequent cough, mild counter-irritation to the chest and the use of the oil-silk jacket are proper. Therapeutic measures are chiefly indicated in the second stage or that of convulsive cough. Proper treatment may control the severity of the cough, and abridge the duration of the second stage, and prevent or control complications. Pertussis has received a great variety of treatment. The enumeration of the medicines and modes of treatment which have had their season of repute and been employed by intelligent physicians would occupy too much time. The treatment should vary in some respects according to the case, but a small number of medicines suffices even in the most severe and obstinate forms of the malady. Knowledge and appreciation of the patho- logical state in pertussis assist us to the choice of the proper remedies. The specific principle of pertussis produces but little depression of the vital pow- ers. It does not impair the appetite by its direct action on the nutritive function, nor does it produce those profound blood-changes which we observe in scarlet fever and diphtheria. It affects the system injuriously by the sever- ity of the cough, the vomitings and consequent loss of nutriment, and the complications which frequently occur, some of which involve fatal conse- quences. Remedies are required which diminish the sensitiveness of the laryngo- tracheal surface, which destroy the specific principle in those parts where the local manifestations of the disease occur, or control its action ; that is. in the larynx and trachea, The use of inhalations is at once suggested as most likely to fulfil the indications, since by inhalation the medicine employed is brought into immediate contact with the parts which are chiefly concerned in the disease. Carbolic Acid. — During an epidemic of pertussis a few years since in the New York Foundling Asylum, after trial of the older remedies without any marked result, carbolic acid, half a drachm to eight ounces of glycerin and water, was employed by inhalation from three to six minutes, and at intervals of two to six hours according to the severity of the cough. The result was apparently better than with the other remedies, since the cough became less . PERTUSSIS. 391 frequent and severe. Carbolic acid seems to have an anaesthetic effect on the laryngotracheal surface. It is also an efficient antiseptic and germicide agent, so that if inhaled frequently it probably destroys the specific principle in the mucus and epithelial cells of the air-passages. It has been in my practice conveniently employed in the croup-kettle. Three teaspoonfuls of the saturated solution of carbolic acid are added to water sufficient to cover the bottom of the croup-kettle to the depth of two inches, and when it is brought nearly to the boiling-point, the vapor is inhaled a few minutes every hour or second hour through the tube. If an equal quantity of the oil of eucalyptus be added, the inhalations are more agreeable and the germicide effect is probably increased. Dr. Keating 1 recommends the following formula for inhalation : R. Acidi carbolici cryst., gr. iij ; Sodii biborat., Sodii bicarb., da. gr. x ; Glycerini, Aquse, da. %j. x\n alkali, as in the above mixture, is believed to render the mucus more fluid, and water, even when not medicated, increases its fluidity and renders expectoration more easy. Pick also highly recommends carbolic acid in the treatment of pertussis (Archiv f. Kinderheilk., 1886), and believes that when not effectual it is too much diluted. He adds fifteen to twenty drops to a roll of cotton, which is introduced into a mask. The patient inhales the vapor of the gas several times each day, and the cotton wadding is renewed three times. The duration and severity of the disease were diminished by the inhalation, and no ill results occurred in any case. Miller has also used car- bolic acid internally in doses of one minim in children over the age of five, with, he states, good results ; but its use by inhalation appears to be equally or more effectual, and is devoid of the risks which attend its internal use {Medical Register, 1888). Cocaine. — This has been quite largely used as an application to the throat on account of its anaesthetic effect, but its action is evanescent, so that in order to obtain the full benefit from its use it is necessary to apply it often. Labrie states that the repeated application to the throat of a 5 per cent, solution immediately diminishes the number of paroxysms (Lond. Med. Bev., 1888). Holt, in discussing the safety of its use (iV. Y Med. Journ., 1888), states, " 1st. It must be used with great caution in young children under all circumstances ; 2d. The spray is never to be recommended, since an uncertain quantity is given ; 3d. Solutions stronger than 4 per cent, should not be used in children under two years ; 4th. In cases where it was tried he failed to see any notable benefit." Probably cocaine will not come into general use, because frequent applications would be necessary in order that its effect be continuous, and this would apparently be dangerous ; still, it might be occasionally used in order to obtain temporary respite from the cough when it involves danger in consequence of its frequency and severity. Antipyrine. — This agent is now largely used, and many physicians have written in its favor. Sonnenberger regards it as a specific (Tlierapeut. Monat- schrifte, 1888). He prescribes it in doses of as many centigrammes (one-sixth grain) as the child is months old, and as many decigrammes (one and a half grains) as it is years old, three times daily. He says that the earlier it is employed the better is the result. Genser administers only one and a half grains daily for each year of the age, and he found that it diminished the frequency and severity of the cough (AUgemeine med. Cent. Zeit., 1888). 1 Medical News, Feb. 28, 1885. 392 CONSTITUTIONAL DISEASES. Laborderie reports the complete cure of pertussis by the use of antipyrine in twelve to sixteen days. He says : " (1) Children take antipyrine without difficulty, and as a rule easily bear its effects ; (2) The spasmodic condition is rapidly calmed, and in a few days the disease declines ; (3) Its action is so prompt and free from accidents that it becomes a valuable remedy in a malady which may be of prolonged duration and give rise to many complications " (Bull. gen. de Therap., 1888). In my practice antipyrine has also in some cases been a very important remedy, reducing the severity of the paroxysms. I have administered it in small or moderate doses every third or fourth hour in com- bination with an alcoholic stimulant. Antipyrine is especially useful in cases attended by fever. But the use of antipyrine is attended by some danger. and it should be discontinued if depression or lividity occur. An editorial in the Montreal Med. Journ., Oct., 1889. states that antipyrine, besides being dan- gerous, exerts no controlling effect over pertussis. Quinine. — The use of quinine in whooping cough was strongly recom- mended by Binz, who attributed the good effects which he had observed to its germicide action. It has been employed with apparently good results, both locally and internally. Kolover prescribes the following solution as a spray : R. Quiniae sulph., gr. 50; Acidi sulphur., gtt. 30 ; Aquae destillat., ^5f . The fauces are sprayed with this every two hours for the first three days, and three hours for the rest of the week, when treatment is no longer necessary (X' Union Med., 1887). Bachen employs insufflation into the nostrils of fifteen grains of a finely triturated powder of twenty parts of quinine and one of benzoin (Lond. Med. Rec, 1887). Swett also prescribed the insufflation of quinine morning and evening, and observed improvement after the first day. Forchheimer and the late Prof. Rochester have likewise recommended the local use of quinine. The internal use of quinine has been supposed to be useful by diminishing reflex irritability (Schlakow and Eulenberg). It is undoubtedly a useful remedy in those common cases in which febrile symp- toms arise from bronchitis or broncho-pneumonia. Paulet 1 recommends the evaporation, over a suitable fire, of R. Spirits of thymol, grammes 10 Alcohol, " 250 Water, " 750 Keating also recommends the same agent in the following formula : R. Thymol., gr. xv ; Alcoholis, .^iij ; Glycerini, ^ss ; Aquae, '^xxxiv. — Misce. Internal remedies, formerly much used, now occupy the second place in the therapeutics of pertussis. Belladonna has been largely employed, since it appears to diminish the spasmodic element in the cough of pertussis. Brown-Sequard, in remarks made before the United States Medical Associa- tion in May, 1860, maintained that the duration of pertussis, so far as its nervous element is concerned, might be abridged to a few days by doses of atropia sufficiently large to cause toxical effect ; but in one case which I saw 1 London Medical Record, May 15, 1884. PEBTUSSIS. 393 in consultation, in -which one teaspoonful of tincture of belladonna was given by mistake to a child of about three years, the subsequent cough, though mild, did not lose its spasmodic element. Children require a larger proportionate dose of belladonna than adults, and it can be safely administered in gradually in- creasing doses until physiological effects are produced, when some mitigation in the cough may be expected. Probably the action of the drug is on the respiratory centres in the medulla, and not directly on the muscles of respira- tion. The effect of belladonna in controlling the spasmodic cough is most marked when physiological symptoms are produced, and some children require larger doses than others. Thus I gradually increased the doses of belladonna to twelve drops for a child of three and a half years who had severe pertussis, without producing the characteristic efflorescence, while smaller doses from the same bottle produced this effect in older children. Rarely I have discon- tinued the belladonna on account of diminished flow of urine, which this agent may or may not have produced, and very rarely on account of suddenly developed muscular weakness, which 1 had reason to think the belladonna caused. This occurred in the case alluded to above in which twelve drops of the tincture were given, so that the muscles seemed flabby and the trunk and head were supported with difficulty. The tincture of belladonna is con- venient for use, and most of that in the shops is active and reliable. The doses which I ordinarily found to be sufficient when prescribing belladonna for pertussis, and which also produced efflorescence, were as follows : to a child of two years three drops, and to one of six or eight years eight or ten drops, morning and evening. I always, however, commenced with a smaller number, and continued to administer the dose which produced the local effects alluded to, unless the cough were moderated by smaller doses. In the majority of cases I have noticed no decided effect till the rash was produced, when the symptoms improved, the cough becoming less frequent or less severe. By the belladonna treatment the spasmodic stage may not only be rendered mild, but be abridged to two or three weeks. In some cases the severe cough begins to yield almost immediately under full doses of this agent, but in other cases its continuance for some days is necessary, with other remedies as adjuvants, before there is any appreciable benefit from its use. But since the germicide treatment of pertussis has come into use, it is probable that belladonna will in a measure be superseded by those agents which are believed to exert a destructive effect on the sup- posed cause. Sulphur. — Much benefit is said to result from fumigating the room occu- pied by the patients with burning sulphur. The children having the disease are attired in clean clothes and removed, and the room which they have occu- pied, containing the furniture, clothes, and toys, is fumigated five hours with burning sulphur, after which the doors and windows are thrown open. The children sleep in the same room during the following night. Immediate improvement is said to follow. This treatment of pertussis is recommended by Manby, Gelhert, Mohn, and others. The distinguished Brazilian physician Moncorvo advises, and uniformly employs, local treatment with a solution of resorcin. In an interesting paper read before the Pediatric Section of the Ninth International Medical Con gress in 1887 he states that he employs resorcin as a local antiseptic on account of its slight irritating properties, its great solubilit\ r , and its absence of odor. Beginning with a 1 per cent, solution, he had increased it to 8 per cent. He first applies to the periglottic region a 10 per cent, solution of hydrochlorate of cocaine, which diminishes the reflex excitability of the laryngeal mucous membrane and renders the paroxysms less frequent, and then applies the resorcin. I have largely employed a 10 per cent, solution 394 CONSTITUTIONAL DISEASES. of resorcin as a spray from a barrel atomizer every hour to two hours. It is not unpleasant, and is apparently useful. I continue to use it as one of the most efficient remedies. Another apparently good remedy for pertussis is bromoform. This is a clear fluid not disagreeable, with a specific gravity of 2.9, chemical formula CHBr 3 . Steppe employed it in 70 cases of whooping cough in children. In a few days the paroxysms diminished, and in three weeks the patients were well. Cresoline, a product of coal-tar, having the formula C 6 H 5 CH 3 0, vaporized in the nursery by a flame underneath, also has its advocates. Most of the remedies mentioned above have apparently been sufficiently employed to justify the belief that when judiciously prescribed they diminish the severity and duration of the paroxysmal stage of pertussis. Additional observations are required in order to determine the comparative efficiency of each. Since the paroxysms are likely to be more severe at night, and the patient consequently is deprived of the required sleep, a medicine is needed which will procure some hours of rest and thereby diminish the number of parox- ysms. For this purpose the hydrate of chloral is especially useful, given in doses of two to five grains according to the age. and perhaps repeated. It does not seem to me that chloral exerts any marked influence upon the cough ; it appears to be useful chiefly in the manner stated — to wit, by pro- curing prolonged sleep. One of the chief dangers from pertussis we have seen to be the occur- rence of passive congestion of organs, especially of the brain, with the liability to hemorrhages, serous effusion, and eclampsia. This is in great part prevented by the action of the medicines mentioned above, which diminish the severity of the cough or its frequency. But when there are great and frequent congestions of the nervous centres, producing eclampsia or premonitions of eclampsia, the use of one of the bromides is indicated for its prompt and decided action in averting the danger. Even if the symp- toms be not urgent, its tranquillizing effect, and especially its prompt action in diminishing reflex irritability, render it one of the most useful agents in pertussis. If there be sudden twitching of the muscles, marked stupor, headache or fretfulness, or adduction of the thumbs across the palms of the hands during the cough, I never fail to give the bromide of potassium in sufficiently large and frequent doses ; and now eclampsia occurs much more rarely in a case which I treat from the commencement than in former years. The complications of pertussis require prompt treatment. Whenever the child feels ill between the paroxysms, he should be carefully examined, and some complication will probably be found which requires treatment. If the bronchitis have increased so as to become a complication or pneumonia have arisen, the whole chest should be covered with a light flaxseed poultice containing one-sixteenth part of mustard, while quinine and ammonia with alcoholic stimulants are given at regular intervals. Ammonia carbonate dis- solved in teaspoonful doses of water and given in milk will be found useful. Cerebral accidents are best arrested by the warm foot-bath, cold to the head, and by the bromide or chloral. Diphtheria not infrequently supervenes as a complication in a locality where it is endemic or epidemic, and if mild it is often overlooked. Recently I have seen a case in which diphtheria complicating pertussis had continued four days, without being recognized by the attending physician, the symp- toms being attributed to other causes. The diphtheritic patch in these cases appears upon the well-known sore under the tongue, in addition to its occur- MUMPS. 395 rence upon other parts. The secondary form of diphtheria requires the same treatment as the primary form. Hauke in 1862 published experiments which showed that both carbonic acid and ammoniacal vapors when inhaled increase the cough, while the inha- lation of oxygen produced no cough and was agreeable to the patient. Hence children in close and crowded apartments suffer most severely from pertussis, and those who are taken to parks or the country, where vegetation absorbs the carbonic acid, not only obtain benefit from the general invigorating influence, but also as regards the cough. The fact that fresh and pure air benefits the cough has indeed long been known, and has influenced practice, for patients are almost universally allowed to be much of the time in the open air and are taken to the parks and upon excursions. Nevertheless, caution in this regard is required, for exposure in wet weather or to sudden changes of temperature is very likely to develop bronchitis or pneumonia. Prophylaxis. — Pertussis is very contagious, and it appears to be, in nearly all instances, if not in all, contracted by inhaling the breath of the patient. I have never observed a case in which it seemed to be communicated through a third person, and it is not, I think, usually contracted by children living in the same house if there be no personal contact. There is not, therefore, that urgent need of personal disinfection and of caution on the part of the phy- sician and nurse in their subsequent intercourse with healthy children, as in the case of the eruptive fevers. CHAPTER IX. MUMPS. Synonyms. — Parotitis. Parotiditis. — Mumps is a constitutional or blood disease with local manifestations. It occurs chiefly in childhood, youth, and early manhood, cases being rare in infancy and old age. Its chief character- istic, by which it is readily recognized, is inflammation of the salivary glands, causing swelling and tenderness. Etiology. — This disease is highly contagious, and it commonly occurs as an epidemic. It is usually communicated through the air, which is tainted by the breath or by exhalations of a patient, but cases are recorded in which it seems to have been communicated by a third person or by infected articles. Thus Roth relates a case in which it appears to have been communicated by a physician, and another case in which it was attributed to the use of bedding in which a patient with mumps had slept (Bost. M. and S. Journ., 1887). Mumps is probably a microbic disease. The investigations of Ollivier are confirmatory of those of Capelan and Charin on the occurrence of peculiarly shaped micrococci in the blood and urine of patients with mumps (Halde- mann, in the Journ. Am. Med. Assoc, 1887). Pasteur found in the blood in mumps rod-shaped bacteria one millimetre broad and two millimetres long, but attempts to inoculate animals were fruitless (Annual of Med. Sci., vol. i., 1889). Incubation. — Dr. Dukes states that the incubative period appeared to be from sixteen to twenty days in 32, and perhaps 31, of 42 cases. Henoch believes that the incubative period is usually about fourteen days. Goodhart relates a case which occurred fourteen days after exposure, and in two others the incubation appeared to be twenty-one days. Ringer says that the incubative 396 CONSTITUTIONAL DISEASES. period varies from eight to twenty-two days. Flint says that the incubation varies from ten to eighteen days. Bristowe states that the average is about fourteen days ; and his opinion, I think, is correct. Symptoms. — Mumps begins with languor and fever, the temperature in some cases rising to 103°, and if the fever be considerable headache and vomiting are common. In a few hours, usually as early as the first visit of the physician, the patient complains of pain and tenderness in the depression below one ear and posterior to the ramus of the jaw. Notwithstanding the fever, the features are often pallid. Along with the pain and tenderness, swelling begins in the site of the parotid gland on one side, and more fre- quently, it is said, on the left than right. In most instances the swelling soon begins upon the opposite side, so that the disease is bilateral. Exceptionally, it begins on the two sides simultaneously. Rarely only one side is affected. The swelling gradually increases ; it fills the depression under the ear, ex- tends forward and upward upon the cheek, and downward to a greater or less extent upon the neck. It reaches its maximum from the third to the sixth day. The most prominent point at this time is immediately underneath the lobule of the ear, which is pressed outward by the swelling of the gland. The tumor yields on pressure, but is elastic and tense, and the fulness immediately returns when the pressure is removed. The skin covering it preserves its normal appearance or it presents a faint blush. The fever, more or less intense, does not usually continue more than two to four days, but occasionally it re- mains longer. The pressure which movements of the jaw and of the pharyn- geal muscles produce on the gland renders mastication, swallowing, and even speech, painful and difficult. The submaxillary glands, and also the sublin- gual, are occasionally involved, so that the features are greatly disfigured by the swelling. The swelling is at its maximum between the third and sixth days, after which it begins to decline, and between the tenth and twelfth days it has entirely disappeared. Occasionally, during an epidemic of mumps, we observe cases in which the parotids are but slightly or not at all affected, and the chief manifes- tations of the disease are in the submaxillary glands, which undergo the characteristic inflammatory changes. Rarely the tonsils are also tumefied. Free perspiration occurs in certain patients at the commencement of conva- lescence. Anatomical Characters. — The opinion expressed by Tirchow has been generally accepted, that inflammation of the gland-ducts occurs, with conse- quent oedema of the connective tissue. The oedema extends also to the con- nective tissue adjacent to the gland. Complications ; Sequelae. — The swelling of the salivary glands some- times suddenly abates, and in the male the testicles and epididymis, and in the female the mammary glands or ovaries, are involved, with sometimes more or less oedema of the labia majora. Occasionally these inflammations, which are less frequent in young children than in those nearer the age of puberty, when the sexual organs are becoming more developed, occur without subsid- ence of the parotid swelling. They cause considerable increase in the fever and constitutional disturbance, but with proper treatment decline in six or eight days, pursuing the same course as the parotid inflammation. Some- times repellant applications to the neck appear to produce the metastasis, as in the following case: On March 19, 1877, I was requested to see a young gentleman of eighteen years. He had been well till March 14th, when he complained of pain below his ears, and his mother applied a towel wrung out of cold water around his neck. On the following day slight swelling was observed under the angle of the lower jaw on the right side (submaxillary gland), and the cold application was continued. On the 17th the swelling MUMPS. 397 had disappeared, but the fever and headache had greatly increased, so that he was compelled to lie in bed. On the 19th, at my first visit, he had such violent headache and was so intolerant of light and noise that I greatly feared that he had acute encephalitis. All swelling under the ears was gone ; the left testicle was tender and beginning to swell ; axillary temperature 102°. The cold cloths were removed from the neck and applied to the head, and potass, bromid.. gr. xxv. administered every third hour. 20th. Axillary temperature 104° ; symptoms unabated and alarming. Ordered six leeches to be applied upon the temples and left groin, and a purgative, and two drops of the tincture of aconite to be given with each dose of the bromide. 21st. Temperature 103°. States that numbness and a pricking sensation which he had felt in both legs during the last forty-eight hours had ceased (possibly from the aconite). 23d. Is convalescent ; has no return of the swelling under the ears and the orchitis has abated. Several writers mention the fact that in rare instances orchitis precedes the parotiditis. Thus, Eustace Smith mentions a case in which the orchitis preceded by sixteen hours the symptoms referable to the salivary glands. The complications alluded to which involve the sexual organs occur more frequently at puberty or in youth than in childhood. It is said that deafness sometimes occurs during mumps, due to extension of inflammation along the Eustachian tube to the middle ear, and if the treat- ment proper for otitis media be employed this form of deafness abates. Dalby mentions another form of deafness which comes on suddenly, and is supposed to be due to injury of the auditory nerve, since no appreciable lesion of the auditory apparatus is observed. The impairment of hearing in this form of deafness is likely to be permanent. Diagnosis. — If the physician have seen but few cases of mumps, there is danger that he may mistake the swelling for an inflamed cervical gland, or vice versa ; but an inflamed cervical gland presents to the finger a hardness almost like that of cartilage, and it is circumscribed or round, and does not invest the ear. These characteristics contrast with the elasticity, seat, and shape of the parotid swelling, which extends forward upon the cheek and surrounds and elevates the lobule of the ear. Tumefaction resulting from diphtheritic or any other form of faucial inflammation, or from periostitis affecting the root of the posterior molar, may be detected by examining the fauces and interior of the mouth. Inflammation of the parotid sometimes occurs in debilitated states of the system, as in or after severe typhoid fever, scarlet fever, measles, etc. Occurring under such circumstances, the gland usually suppurates. The differential diagnosis between this form of parotid- itis and mumps can be made by the history of the case, because mumps rarely occurs as a complication of another disease and does not cause sup- puration. Prognosis. — The result as regards life is favorable. The orchitis, if bilateral, sometimes destroys the virility of the individual. Permanent im- pairment of hearing may also occur, as stated above. Treatment. — This is simple. In ordinary cases it suffices to cover the swelling with oakum or carded wool. If the tenderness or pain be consider- able, the gland should be covered with spongiopilin soaked in water, and gently rubbed with tincture of belladonna and glycerine in equal parts. If the patient have severe headache, with high temperature, more active meas- ures are required, especially if delirium be also present. Saline laxatives should be given, a warm general bath or mustard foot-bath employed, and antipyrine with one of the bromides prescribed. The following prescription will be useful for a child of ten years : 398 CONSTITUTIONAL DISEASES. R. 01. cinnamom., gtt. v ; Phenacetin, Bij; Sodii bromidi, 31SS; Cafieini (alkaloid), gr. x ; Sacchr. lactis, 3j. — Misce. Divid. in chart JSo. x. Give one powder every three hours in headache or fever. The rise of temperature is a premonitory warning of a complication, espe- cially of orchitis in the male, and the early application of a poultice diminishes its severity. If a complication occur, fomentations should be constantly applied over the inflamed part, and phenacetin or antipyrine given at regu- lar intervals to reduce the fever. SECTION III. OTHER GENERAL DISEASES. CHAPTER I. INTERMITTENT FEVER. This is a constitutional malady produced by an organism which exists in marshy soil. I have notes of 36 cases of this disease occurring under the age of three and a half years. Several of these patients were treated in private practice, and the rest in institutions with which I have been con- nected. In children above the age of three and a half years intermittent fever differs but little from that of the adult, while in those under this age it presents certain peculiarities. Of the 36 cases which I have observed, 19 had the quotidian form, 10 the tertian, 2 the tertian becoming afterward quotidian, 1 the quotidian becoming afterward tertian, while in the remain- ing 4 cases the form of the disease is not stated. In quotidian ague the malaria has been supposed to act more powerfully on the system or the sys- tem is more susceptible to its influence than in the tertian form, and hence the fact that the quotidian is the prevailing type of ague in tropical regions, where vegetation is luxuriant, marshes extensive, and the heat intense. According to this theory, the feeble resisting power in the system of the infant explains the fact that it has quotidian more frequently than tertian intermittent, although the latter is much more common in the adult in this climate. Facts demonstrate that infants sometimes receive intermittent fever from their mothers. If mothers during gestation have malarious cachexia, their infants, whether born at full time or, a» often happens, prematurely, are apt to be small, thin, and feeble, and occasionally they have soon after birth dis- tinct paroxysms of the ague. Dr. Stokes related the case of a pregnant woman with ague who believed that she noticed periodical tremors of her foetus, but I suspect that she was mistaken as regards the cause, for the paroxysm of intermittent in young children is not ordinarily accompanied by tremors. The youngest infant in my practice who apparently derived the ague from its mother, and probably through the foetal circulation, had the following his- tory : Its mother had occasional attacks of tertian intermittent during the two years preceding her confinement, and her baby when one week old was observed to have the same disease, occurring also each second day, the cold- ness and blueness in the first stage of the paroxysm lasting from half an hour to one hour. It is not fully ascertained whether a nursing infant may contract inter- 399 400 COXSTITUTIOXAL DISEASES. mittent fever by lactation, but if it be admitted that it is sometimes com- municated to the foetus through the maternal circulation, it does not seem improbable that the specific principle occasionally enters the milk as well as other secretions. I have frequently remarked the presence of the disease in nursing infants whose mothers were affected, and in one instance an infant at the breast, whose mother had the ague, having contracted it in a suburban village, but now living in a non-malarious part of the city, presented evident symptoms of the disease. Similar observations by Frank, Burdel, and others do not indeed fully prove the communicability of intermittent fever by lacta- tion, but render it highly probable. The period of incubation in the infant varies greatly, as in the adult. When the malaria is concentrated and unusually active or the condition of system is favorable for its reception, the disease may commence soon after exposure. Thus, in tropical regions travellers exposed for a single night have been known to sicken within twenty-four hoars, but in our cooler latitude a longer incubative period is the rule. In the infant, however, in our climate, intermittent fever often begins in a very short time after exposure, though there may be an incubative period of some weeks. The following have been my observations relating to this point : A. M , female, eight months old, remained two days on Long Island in October, 1870, and three days after her return to the city a quotidian commenced. P. S . male, eleven months old, remained three days on Long Island, and a quotidian commenced four clays after his return. K , nine months old, remained on Staten Island one week, and eleven days after his return a tertian commenced. Gr. Im- aged three years, remained a day and a night on Staten Island in 1870 ; three weeks afterward intermittent fever commenced, preceded by a week of lan- guor. A. U , female, aged two years and two months, had the first paroxysm of a tertian two and a half weeks after returning from a visit of one week in Hoboken. As there was no malaria in the portions of the city where these infants resided, the incubative periods are nearly ascertained. Etiology. — The cause of the fevers, intermittent and remittent, due to marsh miasma, is an organism, designated the plasmodium malarias. Hun- dreds of microscopists had previously searched for the malarial microbe in vain, when it was discovered in 1880 by M. Laveran, a French army surgeon in Algeria. He was successful in the discovery because the technique em- ployed by him differed from that of his predecessors. The plasmodium is the most interesting and remarkable pathogenic body yet discovered in the blood. The following figures, representing stages of its development, are copied from the paper by Dr. Manson, published in the London Lancet. Jan- uary 6, 1894. Fig. 51 represents a red blood-corpuscle, having in its inte- Fig. 51. Fig. 52. Fig. 53. rior a pale body with ill-defined edges. Within this body are very black particles which, closely examined under the microscope, are seen to be moving, so as to change their relation to each other. The shape of the shadowy body within the corpuscle also changes. Fig. 52 represents a INTERMITTENT FEVER. 401 similar body which, instead of being intercellular, floats free in the blood- plasma. Fig. 53 represents circular disk-shaped bodies, transparent except at their centres, where very black granules are aggregated, some of which o-ranules are agitated and moving. Some of these transparent bodies are inrracorpuscular and surrounded by a rim of haemoglobin, but most of them float free in the plasma, and are designated by Manson " centrally pigmented disks." Fig. 54 exhibits a body similar to the last, but with a properly Fig. 54. Fig. 55. Fig. 56. adjusted microscope the pale peripheral substance external to the black granules is seen to be arranged in leaflets, so as to resemble the petals of the daisy. These ki rosettes 1 ' occur both within cells and free in the blood- plasma, but are not common. Fig. 55 represents another view of the Plas- modium — to wit, crescenta, with the horns rounded, and in some cases an indistinct shadowy body lying in the cup or upon the concave surface with its edge presenting the appearance of a line with its convexity outward. Fig. 56 represents a form of the Plas- modium which has most remarkable cha- racteristics, and is apparently very harmful to the blood. I can do no better than quote Manson's graphic description of this remarkable form of the malarial parasite. Says he : u Some- times in searching through a slide of mala- rial blood, at a particular point of the field you will see one or more of the blood- corpuscles moving about a little and agi- tated without any evident cause. If one of the corpuscles happens to be standing on edge, you may see it bend over upon itself as if pressed down by some force, and then spring up again as if this force had been removed. Sometimes in such a slide you will see one or more of the corpuscles crushed up, as it were, or dashed aside and tumbled about. If now you turn on the high power and inquire as to the cause of this disturbance among the corpuscles, you will be brought face to face with one of the most striking of the many strange sights the microscope reveals to us. Imagine a microscopic cuttle-fish, or octopus, with a clear globular body in which a number of rather large black piquant particles are tumbling and chasing each other about in a state of incessant motion. Imagine, also. proceeding from and attached to this body one, two, three, or four long, slen- der arms, each of them three or four times the length of the diameter of a blood-corpuscle, and all these long cuttle-fish-like arms whirling about like so many whiplashes or flails in a state of frantic activity. This is what is known as the ' flagellated organism of malarial blood.' The long arms thrust the corpuscles about, double them up, coil around them, squeeze 26 402 CONSTITUTIONAL DISEASES. theru out of shape, and treat them like so many india-rubber balls. Occa- sionally one of the arms breaks away from the spherical body it was attached to. It swims about, wriggling its way among the corpuscles, and quickly passes out of the field. Some one of the arms coils itself up or starts into an extended position, shivering like a wand when it is struck." The relation of these forms of the plasmodium to each other is still a matter of conjecture. Manson believes that the "rosette" form is the ma- tured organism, and that the petals of the rosette are the germs, some of which, as they separate, enter the red blood-corpuscles, and others remain in< the plasma, where they develop. It is believed by him that the bronzing of the tissues which occurs in severe cases, attended by recurrences, is caused by the pigmentary matter which, developed in the organisms which we have described above, are conveyed to the different tissues. The periodicity of the fevers due to marsh miasm requires explanation. That a fever produced by an animal parasite should be quotidian, tertian, or quartan cannot, in our present knowledge, be satisfactorily explained. Another subject requiring explanation is the fact that one affected by the malarial miasm remains so long under its influence, so that attacks of malarial fever recur even under circumstances favorable for its elimination. Thus a child of ten years had every year for seven years attacks of intermittent fever. The disease was contracted at the age of three years in Harlem, and the subsequent residence of the family had been in a part of the city where no malaria exists. Symptoms. — In infancy, and especially prior to the age of eighteen months, the symptoms differ in certain respects from those which characterize the malady in the adult, and are universally known. In childhood the symp- toms are similar to those in the adult, and need not therefore be described in this connection. In the infant the type, as we have seen, is quotidian, with now and then a tertian. Advancing beyond the age of eighteen months, we meet more and more cases of the tertian type, and in childhood the tertian is the common form. I have known the quotidian in the infant, when cured, to reappear a few weeks later as a tertian : but ordinarily it remains quotidian, unless the patient has reached the age at which the tertian type predominates. The paroxysm in the young infant presents three stages, as in the adult, but while the second, or febrile, is well marked, the first and third are much less pronounced. The patient does not shake (exceptionally one does even within the first year) in the first stage, but a slight tremor may or may not be observed. The countenance presents a sunken appearance, the lips and fingers are livid, while portions of the surface not livid are pallid, with the goose- flesh appearance, which is, however, less marked than in children of a more advanced age. The blood leaves the surface, which consequently shrinks, while it accumulates in the veins and internal organs ; the pulse is feeble and readily compressed ; the surface grows cool from the diminished supply of blood, but the breath is warm, and the internal temperature, so far from being reduced, is elevated two or three degrees. The parents may be alarmed at the sudden sinking of the vital powers and seek medical advice, but in other instances the first stage is so slight that it passes unperceived till they have been taught to watch for it. In the second or febrile stage, which immediately succeeds, the pulse becomes full and rapid, 120 to 130 or 140 beats per minute, and the external as well as internal temperature is elevated as in few other diseases (104°- 108°). The face is flushed, surface dry, and head painful, as evinced by the features. This stage lasts about two or three to six or eight hours. The third stage, or that of perspiration, succeeds, which terminates the suffering of the patient till the following paroxysm. In infancy the perspiration is not INTERMITTENT FEVER. 403 abundant, and in the first half of this period is nearly absent. In the interval of the paroxysms the patient appears well, except a degree of languor. In 24 of the cases of infantile intermittent which I have treated my notes describe the character of the paroxysms. In 16 of these there was no chill or trembling in the first stage, but blueness and coolness of the extremities and features and sudden prostration. This stage lasted from ten minutes to one hour. In the 8 remaining cases the infants were observed to tremble or shake as in adult cases. The perspiration of the third stage was in nearly all cases, when observed, slight and of short duration, but in some it was not observed. During the cold stage passive congestion of the internal organs occurs to a greater or less extent, but the circulation is equalized during the reaction of" the second stage. The spleen, whose capsule is distensible, soon enlarges in many patients in consequence of the frequent and great congestions, con- stituting the - : ague cake." This enlargement is more common in children than adults. Since my attention has been particularly directed to this sub- ject I have been able to feel the enlarged spleen, by examination through the abdominal walls, in probably one-third of the cases under the age of ten years. This organ returns to the normal size after the ague is cured. From the intimate relation of the spleen to the composition of the blood, it is evi- dent that the character of this fluid must be affected if intermittent fever be protracted. The blood becomes more and more impoverished and a state of decided hydraemia supervenes. A few weeks' continuance of the ague suf- fices to produce decided pallor of the features and surface generally, and as all watery blood is prone to transudation, such patients not infrequently present more or less oedema of the face, ankles, and other parts. Sometimes also, especially under unfavorable hygienic circumstances, purpuric spots (purpura hemorrhagica) appear under the skin, affording additional proof of the change which the blood has undergone. In long-continued cases of malarial disease in the adult waxy degenera- tion of organs is apt to occur, as well as melansemia. Pigment-cells, flakes, and particles appear in the blood, the coats of the minute arteries, and in various organs, as spleen, liver, etc. In the child these results are more rare. Intermittent fever in children, if proper remedial measures are employed at an early period, is ordinarily not dangerous, and is quite amenable to treatment ; but that comparatively infrequent and fatal form of it desig- nated the " pernicious " occurs more frequently in children than in adults. In New York City, where the type of malarial diseases is mild, I have never met a case of pernicious intermittent in the adult, but I can recall to mind such cases in children, two of them fatal. This form of the fever occurs in a smaller proportionate number of cases in infancy than in childhood, proba- bly because the cold stage is less pronounced. In the pernicious ague the system is overpowered — it does not react in a degree commensurate with the intensity of the disease. The patient enters the cold stage, becomes stupid, and, if not relieved by prompt and efficient measures, passes into fatal coma. A type of the disease, therefore, which would not be pernicious in a robust individual may be such in one of a broken-down constitution and feeble reactive power. In most cases occurring in children the coma is preceded by eclampsia, which is apt to be general and contracted. Eclampsia increases the passive congestion of the cerebro-spinal axis already present in this stage, and if not speedily relieved may end in trans- udation of serum over the surface of the brain, and perhaps meningeal apoplexy, causing fatal coma. This has occurred twice in my practice. Sometimes in young children the diagnosis of intermittent fever is doubt- 404 CONSTITUTIONAL DISEASES. ful, either because the disease has not continued sufficiently long or there has not been the characteristic paroxysm. The patient may be feverish and fret- ful, with anorexia and evidences of headache, but without the usual distinc- tive symptoms. I have sometimes in such cases been able to establish the diagnosis by detecting enlargement of the spleen. In examining for the " ague cake " the child must lie quietly on its back, and the fingers, placed midway between the epigastrium and umbilicus, be carried gently but with firm pressure outward in the direction of the spleen, when the anterior edge of this organ will be felt if it be enlarged. It is impossible to make the examination when the child cries, on account of the contraction of the abdominal muscles. Treatment. — It is evident that no time should be lost in applying appro- priate remedies in a case of infantile ague, for, although the first paroxysm may be mild, the next may be more severe and attended with danger. More- over, the sooner the disease is cured the less liable it seems to be to return. Therefore we prescribe at once the sulphate of quinia or cinchona, one and a half grains of the latter producing the effect of about one grain of the former. Our experience in the children's class in the Outdoor Department has been chiefly with the sulphate of cinchona on account of its cheapness, and there has yet been no case of ague which it has failed to control. A recent writer has published statistics showing his success in curing intermittent fever by this agent, but nothing in therapeutics is more easy than to cure this disease in our climate by either of the sulphates mentioned. The chief difficulty consists in preventing a return. To an infant of two years I prescribe one grain of sulphate of quinia or the equivalent of sulphate of cinchona three times daily, till all symptoms of the ague have disappeared ; then twice a day during the subsequent week, and afterward once a day for some days, and finally twice or thrice a week. It is only by the protracted use of the drug in occasional doses that the return of the intermittent fever can be prevented. It is important in administering these sulphates to infants to employ a vehicle which will, so far as possible, disguise the bitterness. The vehicle which I prefer for their administration is the elixir adjuvans, elixir tarax. comp., or, better still, the syrupus yerbse santaa comp. The following formula is for a child of three years : R. Quinise sulphat,, gr. xvj ; Syr. pruni virginiani, Syr. yerbse santse comp., da. §j. — Misce. The following is also a good formula : R. Quinise sulphat., gr. xvj ; Syr. yerbse santse comp., §ij. — Misce. One teaspoonful three to five times daily. The first dose should be given immediately after the fever abates. In this climate two or three days suffice to cure the disease, after which, by daily but gradually diminished use of medicine in the manner stated above, the return of the malady is prevented. Protracted cases attended by anaemia require the use of iron in addition to the remedy which is designed to con- trol the disease. For children with irritable stomachs, who cannot retain the salts of quinine which are ordinarily prescribed, the tannate may be employed in powder or lozenges with chocolate ; but in order to produce the same effect the dose must be two and a half times greater than that of the sulphate or muriate. REMITTENT FEVER. 405 The protracted cachexia which follows an attack of malarial fever is best treated in children, as it is in adults, by arsenic, especially the liquor potassae arse nit., and iron. Quinine is much less efficient in curing this cachexia than these agents CHAPTER II. REMITTENT FEVER. If a physician were to consult the standard treatises on diseases of children in order to ascertain the nature of remittent fever, he would rise from the perusal with no clear idea of it. One tells us that the remittent fever of children is identical with typhoid fever of adults ; another, that it is a gastro- intestinal inflammation ; and, finally, Hillier believes that there is properly no such disease, and that the term should be dropped from the nosology of diseases of children. There is, however, a remittent fever of children as well as of adults, and much of the confusion which exists in reference to it arises from the fact that writers have not kept in view what constitutes a fever. Febrile action which has a local cause is not an essential fever, and should not be described as such. It happens that in children a symptomatic remit- tent fever arises from a variety of local causes, as dentition, intestinal worms, subacute gastro-intestinal inflammation, etc. But all such cases should be excluded from our consideration of remittent fever as clearly as we distin- guish the continued fever of pneumonia or bronchitis from that of typhus or typhoid. There is an essential remittent fever of children due to malaria. The same conditions which produce intermittent fever do, in a certain proportion of cases, produce a fever which does not intermit, but continues with more or less pronounced exacerbations a certain number of days, when it ceases or becomes intermittent. Those who practise in malarious localities notice a larger proportion of cases of remittent fever among children than adults, because their constitutions are less able to resist the malarial poison, so that an exposure which in an adult would produce milder disease — to wit, a tertian ague — frequently causes a quotidian or remittent in the child. In hot countries, where the malarial poison is more active and the diseases due to malaria more severe than in the temperate regions, cases of remittent fever due to the marsh miasm are more common than in the temperate regions. The "jungle fever 1 ' of India is a malarial remittent fever of a severe type. In my opinion, the term " remittent fever," if retained in nosology, should be restricted to those fevers of a remitting type which are due to marsh miasm, so that it differs from intermittent fever in the fact of a greater intensity and not in its essential nature. The one disease is characterized by intervals of apyrexia, and the other by periods of a diminution, but not cessation, of the febrile symptoms. In New York City, and probably in other localities in the temperate zone, a continued fever of a mild type not infrequently occurs in children, espe- cially in the spring and autumn, running a course of one to two, three, or even four, weeks, with in many cases a slight increase in the latter part of the day. Children with this fever are languid, moderately thirsty, and with- out appetite. They complain in the first days of headache. Their tongue is 406 COXSTITUTIOXAL DISEASES. moderately furred. They have a slight cough, no diarrhoea, a temperature of 101° or 102°, and many of them do not feel ill enough to go to bed, except at the usual hours of sleep, during the whole progress of the disease, which continues a variable time, from one to three weeks. This disease physicians of New York sometimes designate remittent, sometimes malarial, and occa- sionally, the severe cases, typho-malarial. I have noticed that this light form of fever occasionally occurs in a household or asylum in connection with typical cases of typhoid fever, and therefore am led to regard it as a mild form of this disease. Thus in a family in West Fifty-fourth street two children had this fever so mildly that they were every day dressed and sitting quietly in the room, but their aunt, a lady of about thirty years, who took care of them, sickened with a severe typical and protracted typhoid fever while she was attending them. In the Roman Catholic Orphan Asylum of this city typhoid fever occurred some years ago, and some of the cases were of the mild form described above, but two or three were fatal, and the characteristic lesions of typhoid fever were discovered at the autopsies. Therefore this mild continued fever, having perhaps a slight but scarcely appreciable morning remission, should not, in my opinion, be designated remittent, malarial, or typho-malarial— terms which have been applied to it — but be regarded as a mild typhoid fever. It seems to me that typhoid fever, like diphtheria, does sometimes present so mild a type in childhood that the patients are not confined to bed, and their sickness terminates in one or two weeks, instead of three or four, as stated in the books. Symptoms. — This disease begins with chilliness and headache, and exacer- bations and remissions occur each day. In severe cases the temperature during certain hours reaches 104° or 105°, and the exacerbation may be accompanied by delirium or stupor. The severe headache, restlessness, and jactitation show that the nervous system is profoundly involved in certain cases. There may be distinct remissions in the beginning, and afterward, for a few days, the fever be pretty uniform, when it again remits or ceases. The tongue is covered with a light fur. Thirst, loss of appetite, a tendency to constipation, and scanty, high-colored urine containing urates, are common symptoms. Diagnosis ; Prognosis. — Typhoid fever usually comes on more grad- ually than remittent fever, and is not attended by so great a daily variation in temperature. It is of more importance to make the differential diagnosis between remittent fever and the acute local diseases, especially meningitis and pneumonitis ; but a careful examination of the signs and symptoms, which will be considered hereafter in our remarks on the local diseases, will enable us to make the diagnosis. The prognosis is favorable with prompt and appropriate treatment. Treatment. — Prompt treatment by one of the salts of quinine is required. Formerly it was thought advisable to employ first laxative and diaphoretic remedies, in the belief that quinine, if administered immediately, might cause cerebral congestion. But since the bromides and antipyrine came into use, no treatment preparatory to the use of quinine is required, unless a single laxative dose in the beginning, as by calomel or the magnesium citrate. Alternate doses of quinine and bromide of potassium, at intervals of two hours, will in a few days control the fever. The bromide will prevent any ill effects of the quinine in producing cerebral congestion, which was formerly feared. In cases attended by marked pyrexia, jactitation, and delirium anti- pyrine should be added to the bromide. TYPHOID FEVER. 407 CHAPTER III. TYPHOID FEVEE. Typhus and typhoid fevers occur in children, but the former is mild and infrequent, rarely occurring except when adults of the same household are affected. It requires little treatment besides good nursing. Typhoid fever, on the other hand, is not infrequent in children, and, as it presents certain peculiarities prior to the age of puberty, it is proper to describe it in this con- nection. This disease is much less common in infancy than in childhood, and in the first half of infancy is believed to be rare. Still, there can be no doubt that many cases in the first years of life are not diagnosticated, being mistaken for subacute and protracted entero-colitis. It is probably more common under the age of six years than is usually supposed, although the younger the child below this age the less frequent does it appear to be, while above the age of six years it is more and more frequent until puberty. In the statistics of Cadet de Gassicourt, embracing 276 children, 3 were at the age of two years, 7 at the age of three years, 8 at four years, 13 at five years, and the number gradually increased in successive years until there were 32, 41, and 42 cases at the ages of twelve, thirteen, and fourteen years. Farnham has reported a case occurring in a girl of three years whose father was at the time convalescing from the fever. She complained of feeling tired, and was listless, but fretful. Her surface was hot and face flushed in the latter part of the day. Her temperature on the seventh day reached 104.8°, when she was put to bed. The fever ceased on the sixteenth day, after which the temperature was subnormal for ten days. Causation. — Klebs in 1881 announced that he had discovered a bacillus in cases of typhoid fever, which he believed to be the cause of the disease, and which he designated the bacillus typhosus. Each bacillus contained a spore in its interior, and often one at its extremity from which new bacilli developed. 1 About the same time Eberth also discovered the bacillus in the intestinal mucous membrane, the mesenteric glands, and spleen in typhoid fever, and ascertained that it differed from other bacteria in the staining. In 17 cases these bacilli were found in 6, and not found in ll. 2 Gaffky announced the results of his observations and experiments with the bacillus typhosus. He succeeded in cultivating it in various substances. Upon the surface of potato, sterilized by steam, it grows abundantly, forming rods 0.2,u thick and 0.6,u to 0.8/7. in length. The rods have active movement and are aerobic. The bacillus typhosus is constantly found at an early stage of typhoid fever in the spleen, mesenteric glands, Peyer's patches, and the solitary follicles. Occasionally it has been discovered in the lungs, liver, and kidneys, and rarely in the blood. When the symptoms pertaining to the fever begin to abate, the bacillus also begins to disappear, so that in the fourth week it sometimes cannot be discovered, and is usually less abundant than in the first and second weeks ; but it may be present after the fourth week. The bacilli occur in colonies or irregular masses. The figure represents the bacilli as observed in the spleen. The bacillus typhosus has not been discovered in any other disease than typhoid fever, although search has been made for it. Frankel and Simmonds inoculated rabbits with it. The animals were sick in consequence, and in those that died the spleen, the solitary follicles, Peyerian patches, and certain 1 Phila. Med. Times, Dec. 3, 1881. 2 Brit. Med. Jour., Nov. 26, 1881. 408 CONSTITUTIONAL DISEASES. lymphatic glands were found tumefied. For the reasons stated, pathologists for the most part agree that this bacillus is the cause of typhoid fever, but from the fact that no bacilli, or but few, are found in the blood, it is not Fig. 57. Fig. 58. improbable that the fever and other prominent symptoms of the disease may be largely due to ptomaines which the bacilli produce. The bacillus typhosus is very tenacious of life. Prudden found that it could be cultivated after it had been frozen in ice one hundred and three days ; also after it had been subjected to a heat of 132.8°, and again when it had been alternately frozen and thawed. 1 Yidal and Chantemesse, by capil- lary punctures of the spleen during the life of the patient, obtained the bacillus, with which they inoculated mice and guinea-pigs, and subsequently discovered this organism in their lungs and abdominal organs. They also found it in the placenta of a typhoid patient who aborted at the fourth month. 2 Yaughan and Novy obtained cultures of the typhoid bacillus from the water used by a considerable number of typhoid-fever patients, and the syrupy extract containing the bacillus and the ptomaines produced by it, injected under the skin of cats, caused 2° to 4.5° of rise in temperature. They have formulated the following definition of the disease : i- An infectious disease arises when a specific pathogenic micro-organism, having gained admittance to the body, and having found the con- ditions favorable, grows and multiplies, and in so doing elaborates a chemical poison which induces its characteristic effects." 3 The discover}* of the bacillus typhosus and of its causal relation to typhoid fever affords import- ant aid to our knowledge of the manner in which typhoid fever is produced. The theory advocated by Murehison, that this disease may originate de novo by exposure to filthy accumulations of any kind, is now known to be false. Only such sub- stances can communicate the disease as contain the specific bacillus, and it is obviously necessary 2 Lond. Lane, 1887. 3 Ptomaines and Leucomaines, 1888. Diagrammatic representation of Peyer's patches in typhoid fever : a, early stage* with swelling of the patch ; b, later stage with sloughing; c. ulcer with infiltrated walls (Thier- felder). 1 iV r. Med, Rec, 1887. TYPHOID FEVER. 409 that this bacillus should in some manner enter the system, so as to infect the individual. Exhalations from the most filthy accumulations, and even inocu- lation with the most fetid material, will not cause typhoid fever unless the bacillus typhosus be present. But the remarkable vitality of this organism, and its power of propagation in certain substances in common use, as water and milk, give rise to epidemics in localities where it happens to be introduced. Typhoid fever is seldom, and perhaps not at all, contracted by inhaling the breath of a patient or exhalations from his surface, but his urinary and fecal excreta contain the bacillus in abundance and are the most common source of infection. Many instances are on record of epidemics caused by the use of water for culinary or drinking purposes which had been in some manner polluted by the excreta of typhoid patients. One of the earliest recorded instances of this kind was observed by the late Prof. Austin Flint in 18-43. In a village in Western New York a traveller with typhoid fever was cared for at the inn, and his excreta were deposited near the well which supplied the whole village except one family. The stranger died, and within a month typhoid fever occurred in all the families of the village except the one that obtained water from a different well. At Pierrefonds 23 persons occupied adjacent houses. The water which they used was obtained from shallow wells into which it had percolated through a porous soil from a neighboring stream. This stream received the drainage of two cesspools, one being thirty and the other sixty-five feet from the well, and the well was on lower ground than the cesspools. In August and September, 20 of the 23 persons were attacked with typhoid fever, and in one of the houses 4 died. The water supplying this house was examined by Chantemesse in October, and was found to contain the bacillus of typhoid fever in abundance. A month subsequently none could be found. Vienna, Angouleme, Cincinnati, and Bordeaux may be mentioned among the places where the occurrence of typhoid fever has been traced to pollution of the drinking-water. In 1888 a severe epidemic of typhoid fever occurred at Iron Mountain, Michigan, and in the drinking water employed in families that had suffered from the disease Vaughan and Novy found the typhoid bacillus. Therefore, sufficient obser- vations have been made to show that many epidemics of typhoid fever have been caused, and are still caused, by the use of polluted drinking water which contained the specific bacillus, and that when epidemics arise from this cause it apparently gains admittance into the system through the digestive appa- ratus. In 1871, Ballard, health officer of Islington, called attention to the fact that the use of infected milk sometimes causes typhoid fever. He had investigated an outbreak of the disease which was apparently produced by rinsing milk-cans with water which was polluted by direct communication of the tank with drains. Since then a considerable number of epidemics have been traced to the use of infected milk. The milk in most of the investigated cases was contaminated by polluted water employed in rinsing the cans or added to the milk for the purpose of diluting it. Milk may also receive the typhoid bacillus from ice which contains this organism and is employed for the purpose of reducing the temperature or for dilution. Seitz, Wolf- hiigel, and Reidel have shown that the typhoid bacillus grows freely in milk. Yaughan mixed water containing the typhoid bacillus with milk, and sub- sequently was able to obtain from the milk a poisonous extract due to the growth and activity of the bacillus (Med. News, Jan. 28, 1888). Therefore the milk-supply should also be investigated on the occurrence of an epidemic. But typhoid fever is probably communicated by the inhalation of air which contains the typhoid bacillus, although, as we have seen, the disease is not likely to be contracted by the attendants of typhoid patients if there be prompt and efficient disinfection of the excreta. In New York Cit} T many 410 CONSTITUTIONAL DISEASES. observations show that the filthy flowing streams in the sewers are infected with the typhoid bacillus, and cases occur in which the fever seems to be due to the escape of the sewer gas into the houses. Thus, in my practice, in a house whose plumbing was supposed to be faultless three children who, so far as known, had not been exposed outside, sickened with typhoid fever. A thorough examination finally revealed the escape of sewer gas into the cel- lar in a strong current. The inference is that in such instances the tainted air conveys the bacillus to the lungs, and this organism enters the system through this organ. But it is true that the bacillus in such instances may be deposited from the air in the food or drink, or in the mouth or fauces, and be swallowed, so that the systemic infection may occur through the digestive system. But it suffices, so far as the employment of preventive measures is concerned, to know that an atmosphere infected by exhalations from filthy sources may communicate typhoid fever without the actual presence of a typhoid patient. Between 1873 and 1885 one hundred and forty -six cases of typhoid fever occurred in one of two barracks occupied by the German artil- lery, while cases did not occur in the other barrack, although the water and food used in the two were the same. Finally, suspicion fell upon the bed- linen and clothing, and the discovery was made that recent patients had worn the clothes of men previously attacked, and even stains of dried fecal matter were found in their pants. Saturation of the infected articles and the barrack with chlorine gas followed by dry heat was now employed, and no more cases occurred (Med. Press and Oirc, March 28, 1888). Therefore the typhoid bacillus gains admittance into the system not only by the use of infected drinking water, milk, and solid food, but also by the inhalation of an infected atmosphere. Anatomical Characters. — Since typhoid fever is a constitutional dis- ease, we would expect to find early and important changes in the blood. No alteration, however, has been discovered in this fluid peculiar to typhoid fever. The amount of fibrin is diminished, as in most of the essential fevers r and its coagulation is feeble, forming, when the blood stands, soft, small, and dark clots. When the fever has continued for some time a state of anaemia more or less decided supervenes in which the amount of albumen and blood- corpuscles is diminished. Although there are often decided symptoms refer- able to the nervous system, no constant changes have been discovered in the brain or spinal cord. The changes observed in them when death has occurred in the course of typhoid fever have been for the most part due to other causes. It is different with the respiratory system. After the first week of typhoid fever mild bronchitis is almost as constant as inflammation of the fauces in scarlet fever, and accordingly we find in fatal cases redness and thickening of the bronchial mucous membrane, which is covered with a viscid and ordinarily scanty secretion. Hypostatic congestion of the lungs, with more or less oedema, and in severe and enfeebled cases hypostatic pneumo- nia, are not uncommon. In the bronchitis and state of feebleness we have the causes of pulmonary collapse, and this lesion is not infrequent over limited portions of the lungs, especially if the bronchitis affect the smaller tubes. The lesions occurring in the digestive system are important. The pharynx is normal or slightly affected. The mucous membrane of the oesophagus and stomach is sometimes normal or nearly so, and in other cases hyperaemic. It is said that ulcers have been occasionally observed in the cardiac end of the oesophagus. The mucous membrane of the small intestine is more or less injected, and at an early period, even by the second or third day, the patches of Peyer, solitary glands, and at the same time the mesenteric, begin to enlarge. I have made microscopic examination of these glands in TYPHOID FEVER. 411 typhoid fever of the adult, and have found a considerable increase of the small round granular cells of which they are composed. It appears, there- fore, that the enlargement is due mainly to hyperplasia of the cellular ele- ments of the glands, though there is probably infiltration to a certain extent of inflammatory products between the cells. The mucous membrane over the glands undergoes inflammatory thickening and softening. In the adult sloughing of this membrane is frequent, with the disintegration of the glands and their elimination into the intestines, producing ulcers, small and circular, corresponding with the site of the solitary glands, or large and oval or irreg- ular, corresponding with the site of Peyer's patches. Disintegration of these glands and the formation of ulcers are less frequent in children than in adults. In the adult who recovers the mesenteric glands and the solitary and agminate which are not destroyed return to their normal state by fatty degen- eration, liquefaction, and absorption of the redundant cells. In the child this is the common result, instead of sloughing and disintegration, as regards both the solitary and agminate glands, and the uniform result as regards the mesen- teric, and I may add bronchial glands, which are also in a state of hyperplasia. The absence of ulceration or its slight extent aiFords explanation of the fact that intestinal perforation is very rare in children. The inflammatory changes described above pertain chiefly to the ileum. The duodenum and jejunum present their normal appearance or are moderately hyperaemic in places and their follicles swollen. The spleen gradually enlarges, often to twice the normal size, has a dark- red color, and is softened. Enlargement of the spleen possesses great diag- nostic value in those cases in which the diagnosis is obscure. For while very similar intestinal lesions may occur in chronic entero-colitis, the coexistence of these lesions with the splenic enlargement and softening shows the con- stitutional nature of the malady. The liver usually presents its normal appearance, or it may be pale in consequence of the anaemia, or, on the other hand, it may be hyperaemic. Microscopic examination sometimes reveals a granular state of the hepatic cells with indistinct nuclei. In cases which are severe and which present a decidedly adynamic type the muscles become soft and flabby, the action of the heart is feeble, and more or less passive congestion of the viscera results. In such cases con- gestion of the kidneys and albuminuria are not infrequent. Parenchymatous degeneration of the kidneys occasionally occurs, the epithelium becoming granular, the cells indistinct, and their nuclei invisible. Liebermeister states that he has frequently noted the absence of albuminuria during the fever when the autopsy showed marked degenerative changes in the kidneys. Inflammation of the endocardium and pericardium is rare, but the myo- cardium exhibits structural changes in severe cases. Atrophy and fatty degeneration of its muscular fibres sometimes occur, which may lead to the formation of clots in the cavities of the heart, and consequent emboli in other organs. Hoffmann demonstrated the occurrence of fatty degeneration of the minute arteries in various organs in prolonged cases of typhoid fever, and degenerative changes have also been observed in the voluntary muscles. Pathology. — Recent investigations relating to the acute infectious dis- eases of childhood render it probable that as regards most, if not all, of them systemic infection occurs through ptomaines or poisonous chemical agents which are produced by the action of the microbes which are the specific principles. This is believed to be true as regards typhoid fever. In 1885, Brieger obtained a ptomaine from cultures of the typhoid bacillus which, inoculated in guinea-pigs, caused salivation, hurried breathing, dilated pupils. diarrhoea, paralysis, and death within one to two days. 1 From such observa- 1 L. Brieger, Ueber Ptomaine, Berlin, 1885-86. 412 CONSTITUTIONAL DISEASES. tions and experiments the theory has arisen that the symptoms which characterize typhoid fever are mainly due, not directly to the action of the bacillus, but to a ptomaine or ptomaines created by the bacillus and ab- sorbed into the system. This theory also receives support from the observations and experiments of Hoffa. Sirotirvin, Beaumer and Peiper, and others. Incubative Period. — As in scarlet fever and diphtheria, the incubative period in typhoid fever varies. In three cases detailed by Griesinger the fever began twenty-four hours after exposure. In a school at Clapham, 20 out of 22 boys sickened, according to Murchison, within four days after exposure. Authenticated cases of a longer incubative period are on record, so that Murchison believed that it is commonly about two weeks, and William Budd that it is in most instances from ten to fourteen days, but cases have occurred in which it seemed to be as long as twenty-eight days. 1 Symptoms. — Typhoid fever has a prodromic stage of a few days, some- times of a week or more, in which the child appears languid, indisposed to play, and has little appetite, but complains of no pain unless occasional slight headache, and has no symptoms which would lead the friends, or even physicians, to suspect the nature of the disease which impends. By and by a slight fever occurs. In exceptional cases typhoid fever begins with a chill, followed by pronounced fever. It occurred in 3 of the 14 cases observed by Dr. Jacobi in Bellevue Hospital. This was a larger proportion of cases with such com- mencement than I observed in the epidemic of 1882 or have since observed, but the cases in Bellevue seem to have been unusually severe, since 5 of the 14 died. The fever, which gradually becomes more pronounced, remits, but does not cease in the morning, and it has evening exacerbations. After the first week of fever the remissions are less marked, but the fever is not uniform at any period in its course. Hence some of the writers on diseases of children continue to designate typhoid fever of children remittent fever, fully aware of its identity with typhoid fever of the adult. As the case advances the appetite fails, all solid food being refused, and liquid food being taken more from thirst than hunger. The tongue in the first week, and in some patients throughout the course of the disease, is covered with a light moist fur, while in others having a graver type of the fever the tongue after the first week is dry and brown. During the prodromic period and in the first week the bowels act regularly or are slightly relaxed, and they are readily affected by purgative medicines. After the first week there is in some children a tend- ency to diarrhoea, which requires now and then the use of astringents, the stools being watery and brown or dark yellow. Diarrhoea is less frequent in children than in adults, and in some children it does not occur during the entire sickness. The abdominal walls are seldom retracted, but prominent, especially after the first week, in consequenee of meteorism, which is present in children as well as adults. Sometimes there is apparent tenderness when pressure is made over the right iliac region, but this must not be confounded with hypersesthesia, which is common in the commencement of febrile diseases in children, and which is observed especially upon the abdomen, chest, and inner part of the thighs. The respiration in the first week is slightly accelerated, as it is in all febrile diseases. In the second week, and subsequently when bronchitis is developed, the respiration is ordinarily more accelerated, though not in a 1 8ee article ''Typhoid Fever," American System of Practical Medicine, Philada., 18S5, Lea Bros. TYPHOID FEVER. 413 marked degree, unless in those exceptional instances in which there is an abundant collection of mucus in the smaller bronchial tubes. A cough is often present, dependent on the bronchitis, and varying in character accord- ing to the degree and stage of the inflammation. In the first days of the fever it is infrequent or lacking ; at a later stage it is more frequent and not so dry, though in cases of ordinary severity the amount of expectoration is inconsiderable. Hypostatic congestion, oedema, hypostatic pneumonia, spleni- zation or thickening of the alveolar walls, and collapse, which not infre- quently occur in the advanced disease, increase more or less the frequency of the respiration and the cough and modify the physical signs. The pulse in the first week, in ordinary cases, is from 100 to 110 or 115. It gradually becomes more accelerated, numbering in the second week 123 or more ; in grave cases even 160. The more frequent the pulse, the greater the danger and more unfavorable the prognosis. During the exacerbations the number of pulsations per minute is fifteen or twenty more than in the remissions. The change in temperature corresponds with that of the pulse, being from 1° to 2° higher in the exacerbation than remission. The ex- tremes of temperature in cases of ordinary severity are about 101° to 104°. A temperature above 105° shows a grave, perhaps a fatal, type of the disease or else a serious complication. There is great variation as regards the symptoms referable to the nervous system. Headache is common in the prodromic and initial stages, after which it ceases. A few are delirious even from an early period, screaming loudly or muttering incoherently, but the majority are quiet, having, indeed, a degree of mental dulness, but being able to appreciate questions when aroused and answering correctly. Subsultus tendinum and carphologia, which some exhibit, show that there is profound disturbance of the nervous system. Epistaxis occurs occasionally in the first week, as in the adult, but is usually slight. The rose-colored eruption appears in children as well as adults between the sixth and twelfth days, but is more frequently absent in the former than the latter ; sometimes the number of spots is less than half a dozen. Su- damina are common in the second and third weeks, and perspirations may occur at any time in the course of the fever, but without amelioration of symptoms. More or less deafness is common, being in most instances a purely nervous symptom, without, therefore, any structural change in the ear, but it is possible, as has been suggested by certain writers, that it some- times results from inflammatory thickening of the Eustachian tube or exter- nal meatus, or from a weakened and flabby state of the muscles of the ear. Duration. — As in diphtheria, so in typhoid fever, the duration varies greatly in different cases. Mild forms of the disease terminate within one week, but cases of a severe type may continue several weeks. Henoch states that the duration of 80 cases which he observed were as follows : from seven to ten days, 11 ; from ten to fifteen days, 26 ; from fifteen to twenty days, 16 ; from twenty to thirty days, 21 ; and from thirty to forty-nine days, 6 cases. The limits in the duration were therefore seven days in the shortest and mildest cases, and forty-nine days in those that were the most protracted. In the cases of short duration the diagnosis was ren- dered clear by the roseola, enlargement of the spleen, and diarrhoea. When the disease begins to abate, there is frequently in the morning a complete apyrexia, and a return of the fever in the latter part of the day. This period of an intermittent fever usually varies from two to five days. Forchheimer, who observed a severe epidemic of typhoid fever in Cincinnati, says that this disease in children sometimes terminates in six days (Columhus Med. 414 CONSTITUTIONAL DISEASES. Jour.. 1888). In a discussion relating to typhoid fever at a recent session of the New York Medical Association. Dr. E. G. Janeway also stated that this disease sometimes terminates within ten clays. In cases continuing three or four weeks the patient becomes progressively more emaciated and feeble, and in a severe form of the disease his condition seems very unprom- ising to one not familiar with the clinical history of the fever. Pale, emaciated, and feeble, probably passing his evacuations in bed, and taking little notice of objects around him, he presents at the close of the third week or in the fourth an appearance of helplessness, notwithstanding the best nursing and the constant employment of sustaining measures, which is truly discouraging. Relapses — Second Attacks. — Rilliet and Barthez called attention to the fact that relapses sometimes occur, although they observed only 3 such cases in 111 patients. Henoch witnessed 21 relapses in 137 cases, the relapses occur- ring after severe and after mild cases. The majority of the cases in which relapse occurred were, however, mild. As a rule, the relapse occurred between the third and fifth weeks, and after a complete apyrexia of three to ten days. In one case even eighteen days of apyrexia had occurred when the fever was renewed. In some cases the relapse took place during the decline of the fever, when there was a morning intermission and an evening fever, the fever again becoming continuous. Eichhorst. in examining the records of 6Q6 cases occur- ring in Zurich, ascertained that second attacks occurred in 28 persons, or in 4.2 per cent, of the cases. He has observed cases of a third and even of a fourth attack, so that, as in diphtheria, a first or even a second attack does not destroy the susceptibility to the disease. Complications. — The chief complications of typhoid fever are broncho- pneumonia, already sufficiently described, enteritis, intestinal hemorrhage, peritonitis, otitis, parotiditis, and muguet. In one instance I lost a patient about ten years old. in whom the fever had nearly terminated, by the sudden accession of croup. There is, as we have seen, in ordinary cases more or less inflammation of the mucous membrane of the air-passages and of the intes- tines, especially in the vicinity of the patches of Peyer. It is easy to under- stand how, under circumstances which may arise in the fever favorable to the development of mucous inflammations, the bronchitis and enteritis may so increase as to constitute complications. They are the most frequent of the serious complications. Feeble action of the heart, common in severe cases of typhoid fever, and which after the second week is partly attributable to granulo-fatty degenera- tion of the muscular fibres of the heart, which is frequent in grave forms of the infectious diseases, obviously favors the occurrence of bronchial and pul- monary congestion. Hence the proneness in these cases of the inflammation to extend downward from the larger to the smaller bronchial tubes and to the lungs, so that broncho-pneumonia becomes an occasional very grave complication. In the child as well as adult with this disease the mucous membrane of the lower part of the ileum in the vicinity of Peyer's patches is fre- quently thickened and hyperaemic — a true intestinal catarrh. We can readily understand how under certain circumstances this may become aggravated so as to constitute an intestinal inflammation of considerable extent and gravity — a severe entero-colitis, so that the local symptoms predominate over the constitutional and aggravate the latter. In the adult, as is well known, the Peyerian and solitary glands, becom- ing more and more prominent by proliferation of the cellular elements (the lymphoid cells), begin to ulcerate in the second week, and slough in the third, forming the typhoid ulcer, which is slow in healing and aids in keeping up TYPHOID FEVER, 415 the diarrliceal state. Such destructive or necrotic inflammation is rare in young children, but it may occur in those of a more advanced age. Intestinal hemorrhage is therefore an occasional accident. Hillier met 4 cases in 30 of the fever. It indicates the presence of ulcers upon the surface of the intestines. The younger the child the less the liability to it. Some in whom it has occurred recover, but others die. A girl of nine years com- plained of severe abdominal pain on the seventeenth day of the fever, which was followed by syncope and death. At the autopsy one of Peyer's patches was found deeply ulcerated, and at the bottom of the ulcer was a perforation through which blood had escaped into the peritoneal cavity. Intestinal perforation is more rare in children than in adults, as might be inferred from the statement already made that intestinal ulceration is less frequent and extensive in them. Statistics show that perforation in children occurs only once in 232 cases. Therefore, as perforation is the common cause of peritonitis in this disease, this inflammation is a rare complication. Peri- tonitis may. however, occur in typhoid fever without perforation. In one such case (an adult) in the fever wards attached to Charity Hospital local peritonitis with fibrinous exudation occurred opposite two ulcerated patches of Peyer. the ulcers extending nearly to the peritoneum, but not perforating. The lesions observed in this case throw light on those cases of peritonitis complicating typhoid fever which recover, the cause of which has received a different explanation. In advanced and greatly debilitated cases thrush sometimes appears in the interior of the mouth and upon the fauces. It is always an unfavorable prognostic symptom in children suffering from chronic or protracted disease. Parotiditis is also a rare complication. Otitis, commencing with pain and pro- ducing a discharge which may continue for weeks, is not rare, though less frequent than in scarlet fever. The otitis is commonly external, but it may in scrofulous subjects extend to the middle ear. Diagnosis. — This is more difficult in children than in adults, and the younger the child the greater the difficulty. In infants protracted entero- colitis, with fever and a dry furred tongue, cannot in certain cases be posi- tively diagnosticated from typhoid fever by the symptoms and clinical history. Typhoid fever is believed, however, to be rare at this age, for an infant nourished at the breast is very seldom exposed to the cause of the disease. When, however, as now and then happens, a young child presents the symp- toms characteristic of protracted subacute entero-colitis or typhoid fever, and older members of the household have the fever, it is highly probable that the case is one of the latter disease, and it should be treated accordingly. Even in older children typhoid fever is frequently mistaken for simple subacute enteritis or entero-colitis, or vice versa. The following facts aid in the differential diagnosis : In typhoid fever there is a total loss of appetite, while in the subacute intestinal inflammation food is not entirely refused. Diarrhoea commences early in the inflammation, while in the fever it does not occur ordinarily till after the lapse of a few days. Abdominal tenderness in the fever is not appreciable or is located in the right iliac region ; in the other disease it is general over the abdomen or located in the umbilical region. In typhoid fever there is bronchitis with a cough, which is absent in the inflammation. In typhoid fever there are certain other symptoms, more or fewer of which are present in most cases, and which do not occur in the intestinal diseases, except as a coincidence ; for example, headache, epistaxis, stupor, delirium, and perhaps the rose-colored spots. The evening rise of temperature and enlargement of the spleen are also important diagnostic symptoms. When it is very important to make a positive diagnosis, cultures may be made from blood drawn from the spleen, from the sediment of albu- 416 CONSTITUTIONAL DISEASES. minous urine, or from the feces, and if the disease be typhoid fever the specific bacillus will be found. Typhoid fever may be mistaken for meningitis during the first week, but in meningitis there is more constipation, irritability of stomach, and less ele- vation of temperature. Moreover, in meningitis at a comparatively early stage we are able to detect patches of congestion of the features coming and disappearing suddenly, and slight inequality of the pupils or their oscilla- tion when the light is uniform — signs which are lacking in typhoid fever. In a doubtful case the ophthalmoscope might be employed, which in menin- gitis discloses congestion of the vessels of the retina, oedenia, etc.— anatomi- cal changes which do not pertain to typhoid fever. The differential diagnosis of typhoid fever and acute tuberculosis may be made by attention to the following points : In tuberculosis there is cough, with some acceleration of respiration from the first, without epistaxis, stupor, or other nervous symptoms, and without the abdominal symptoms which are so prominent in the fever. The occurrence of typical cases in the same house or in those patients who have been similarly exposed has in certain instances enabled me to make a clear diagnosis. In localities where diseases due to marsh miasm occur, the remittent fever arising from this cause and typhoid fever bear considerable resemblance to each other. The two, indeed, may coexist — a fact observed during the late Civil War, so that cases in which this coexistence occurred were designated typho-malarial. In malarial remittent fever the commencement is more abrupt, the vomiting and headache more severe, and the remissions more marked than in typhoid fever. Moreover, quinine exerts a decided control- ling effect in the fever due to marsh miasm, while its effect in typhoid fever is much less pronounced. Prognosis. — A much larger percentage of children recover than of adults. Although there be great emaciation with loss of strength, recovery may be confidently predicted, provided that no serious complication occur. Grave symptoms, as high fever, delirium, severe diarrhoea, an unusually rapid and feeble pulse, have a bad import. If from any cause the system is in a marked degree debilitated when the fever begins, the prognosis is much less favorable than in those who are robust. Thus the presence of hereditary syphilis, of tuberculosis, of severe scrofula, or of bronchial or intestinal catarrh when typhoid fever begins, greatly increases the danger. But in fatal cases which I have met the unfavorable result occurred, as a rule, from the complications rather than directly from the malady. Of the compli- cations, the most serious are intestinal ulceration, giving rise to hemor- rhage or even perforation, and consequent peritonitis, diphtheria, pneu- monia, nephritis, pleuritis with serous or purulent effusion, meningitis, and granulo-fatty degeneration of the myocardium. Complications like these largely increase the mortality of typhoid fever. The condition in which severe typhoid fever leaves a patient is favorable for the development of tubercles, and now and then they occur, disappointing our expectations and prediction of recovery. The possibility of a relapse should be borne in mind, so that the patient should remain in bed, free from excitement and with plain but nutritious and easily digested diet, until convalescence is well advanced. Treatment. — Typhoid fever, like typhus, cannot be abridged by treat- ment, and the indication is to sustain the vital powers, diminish the intensity of the fever, and arrest if possible any untoward symptom or complication. Quinia, so useful in malarial diseases, may be administered in small doses for its tonic effect and as an aid in promoting digestion. It is commonly and properly prescribed in some convenient vehicle for this purpose, but it does TYPHOID FEVER. 417 not antagonize the typhoid as it does the malarial poison. Perturbating medicines, and especially cathartics, should be given with caution. The tendency to intestinal ulceration and hemorrhage and the anaemic nature of the fever require abstinence from or cautious use of such agents. A temperature remaining under 103° usually involves little danger. If it remain above 103° morning and evening, antipyretic measures should be employed. I therefore order the nurse to bathe frequently the forehead, face, hands, arms, neck, and sometimes the chest, with cold water, to which it is proper to add alcohol or some spirituous lotion. A cloth wrung out of ice-water, or an ice-bag. should be applied over the head, and the hands may be allowed to lie a considerable time in a washbowl containing the lotion, which is always grateful to the patient. The water treatment thus applied will usually reduce the temperature one. two, or three degrees within a few hours. Cold general baths are not so well tolerated by children as by adults. Collapse has sometimes followed their use, and, on the other hand, benefit has apparently in some cases accrued from their employment when the tem- perature was above 104°. The bath, if used, should be at a temperature of about 88°, and the patient should not be immersed in it longer than five to eight minutes (Henoch). It seems preferable, however, in most cases of high temperature, to endeavor to reduce it by cold sponging or cold compresses. A compress frequently wrung out of ice-water or containing broken ice mixed with bran, or a rubber ice-bag applied over the head and another over the abdomen, or Leiter's coils applied over the same parts as the compress, grad- ually abstract the heat, and with more safety to the patient than the use of the cold bath. Ice applications should be discontinued if the temperature fall to 103° or if the patient complain of chilliness. Even an afternoon tem- perature of 104° does not require ice applications or any active antipyretic, provided there is a decided morning remission. Moderate doses of quinine and general sustaining remedies suffice for such cases. Of the internal antipyretics, sodium salicylate, antipyrine, phenacetin, acetanilide, and quinine have been chiefly employed. The sodium salicylate is likely to retard digestion, and it sometimes causes albuminuria. Its use, therefore, cannot be recommended. Antipyrine effectually reduces the tem- perature, but is depressing. It may be given, especially in the early stages of typhoid fever, in doses of two to five grains according to the age, along with an alcoholic stimulant, with a good result. Some physicians recommend the use of phenacetin instead of antipyrine, as being equally effectual and less depressing. It may be given in about half the dose of antipyrine. Ace- tanilide in one-fourth the dose of antipyrine also reduces the fever, but it is also depressing, and it does not, so far as I am aware, possess any advantages over antipyrine. In- the majority of cases the reduction of temperature is best effected by cold-water bathing or cold compresses and the internal use of quinine. Quinine in moderate doses as a tonic appears to be useful during the entire course of the fever, but in cases of a temperature dangerously high antipyrine, acetanilide, or phenacetin is now preferred by good observers to the use of large doses of quinine, which were formerly employed (Von Ziemssen). The fact that in a large proportion of cases the typhoid bacillus enters the system in the ingesta, and effects a lodgement upon the gastro-intestinal surface, suggests the query whether the early use of antiseptics administered by the mouth might not be destructive to the bacillus, and thus in a measure destroy the cause of the disease. The remedy which has thus far been used for this purpose, and which is supposed by some to exert a specific action upon the disease, apart from its purgative or eliminative effect, is calomel. Its mode of action is not fully understood. It is supposed by some to be in 27 418 CONSTITUTIONAL DISEASES. part changed into the bichloride in the stomach and intestines. Von Ziems- sen in treating adults administers early in the attack three 7 i -grain doses of calomel at intervals of two hours, and obtains by so doing a considerable reduction of temperature during the following twelve hours. Liebermeister claims that the use of calomel diminishes the intensity of the disease, and Wunderlich even believed at one time that it might abort the fever. On the other hand, Weil, Griesinger, and Baumler assert, from their observations and statistics, that the mortality is not diminished nor is the number of aborted cases increased by the use of calomel, and that it is only useful as a mild, non-irritating evacuant. Wilson says : " Attempts to fix the hypothetical specific action by long-continued calomel treatment, and to force a true abor- tive calomel treatment, have at different times failed, as has also the subli- mate treatment of typhoid fever." The use of calomel should probably be restricted to one or a few doses at the commencement of the attack. Since it is impossible to arrest typhoid fever or abridge its duration by any therapeutic measures of which we are cognizant, the indication is to sustain the vital powers and alleviate, so far as possible, the symptoms. Quinine is not only employed in large doses to reduce the fever, but it is often prescribed in small doses during the subsequent progress of the disease, in the belief that it may exert some tonic effect. It does not appear, how- ever, to exert any marked controlling effect upon the symptoms. Iodine, iodide of potassium, and carbolic acid have also been employed internally, but their efficacy is doubtful ; but Liebermeister states that the iodide of potassium employed in two hundred cases, although it did not appreciably ameliorate the symptoms, apparently diminished the mortality. The mineral acids have also their advocates, and statistics appear to show benefit from their use. The late Prof. Austin Flint treated 78 patients with the acids with a death-rate of 10.25 per cent, and 70 patients without the acids with a death-rate of 20 per cent., the treatment otherwise of the two classes being alike. The mineral acid which, in my opinion, is most useful is the muriatic, since it aids digestion, which is greatly impaired by the fever, and since the digestive ferments in this disease are apparently secreted in insufficient quantity. I usually prescribe this acid with pepsin, as in the following formula : R. Pepsini puri, in lamellis, gj ; Acidi muriat. dilut., ^ij ; Syr. simplic, ^j ; Aquae, ^iij. — Misce. Give one teaspoonful in water every two hours to a child of ten years. The wine of pepsin of the National Formulary may also be employed, but each teaspoonful contains only about one minim of the dilute muriatic acid, so that the quantity of the acid might be increased. In all but the mildest cases alcoholic stimulants are required, especially after the first week. In the first week they may be withheld in ordinary cases, but in attacks of a severe type and attended by early prostration they may be required at or soon after the commencement of the fever. The indi- cations for their use are feeble pulse with faint systolic sound and marked nervous symptoms, as subsultus tendinum, stupor, and delirium. In the prostration consequent on high fever and protracted and obstinate diarrhoea the use of alcohol is important as a cardiac stimulant. Still, such large and frequent doses of the alcoholic compounds are not needed as are useful in diphtheria. The object in employing them is to sustain the flagging pulse and promote digestion and assimilation. The preferable mode of employing alcoholic stimulants rs in the form of milk punch or wine whey. TYPHOID FEVER. 419 Wakefulness, which is sometimes an unpleasant symptom, and which may occur with, and is perhaps largely due to, the headache, may be relieved by a powder of phenacetin and bromide of potassium or sodium, two to five grains of the former and double or treble its amount of the bromide. The new remedy, sulphonal, triturated and given in sweetened water or milk, will also relieve the insomnia, and in some instances it appears to be prefer- able to the other agents which have been employed for the purpose of procur- ing sleep. An opiate, as Dover's powder, is also useful in relieving wakeful- ness, and should be prescribed if the patient at the same time have diarrhoea. Three grains may be given to a child of eight years. For headache, whether accompanied by wakefulness or not, I know no better remedy than phenacetin in combination with the bromide of potassium or sodium, as given above. At the same time, cool lotions should be applied to the head. The same remedies which are appropriate for the insomnia are also useful for the delirium which occasionally occurs in cases of a grave type. The constant application of cold to the head and an increase in the stimulation may also be required. AVe have stated elsewhere that diarrhoea is less common in the typhoid fever of children than in that of adults, but it sometimes occurs, and should be promptly checked. The subnitrate of bismuth in rather large and fre- quent doses, along with an opiate and vegetable astringent, will usually con- trol the diarrhoea, and the same remedies should be employed in intestinal hemorrhage. Recently in my practice in the case of a boy of about fifteen years near the close of the second week of typhoid fever, so large a flow of blood occurred from the intestines that the condition of the patient was very critical. But the loss of blood was quickly checked by large doses of subnitrate of bismuth and teaspoonful doses of equal parts of the cam- phorated tincture of opium and tincture of catechu, and the patient recovered. The constipation which is sometimes present in typhoid fever, and more fre- quently in children than in adults, may be relieved by an enema of water, half a pint containing one or two teaspoonfuls of glycerin. The distention of the stomach and intestines with flatus is sometimes so great that it requires treatment. It may cause a sensation of fulness and prevent the descent of the diaphragm in respiration, and it increases the danger of perforation if a deep intestinal ulcer exist. External pressure and manipulation should not be employed under such circumstances, since they might cause rupture, nor should the hypodermic needle be used. Jacobi has witnessed a fatal peritonitis produced by the escape of fecal matter through the punctures caused by the needle (Arch, of Pediatrics, Dec, 1888). The proper remedy for the flatus is either turpentine or the aniseed cordial of the National Formulary. Sustaining measures are of the highest importance. Typhoid fever ceases after some days or weeks with or without medicinal treatment, and the patient recovers if the strength be adequately supported. Hence the food should be sufficient in quantity, of the most nutritious kind, and easily digested and assimilated. It must be liquid, since the repugnance to food and the mental state of the patient render it impossible to feed him with solids unless in the mildest cases. Milk sterilized by heat or peptonized, the meat broths, and gruels with milk must be the food chiefly employed. Since the digestive fer- ments are apparently secreted in small quantity during the fever and diges- tion is feebly performed, it is well to employ predigested food when the dis- ease is unusually severe and the temperature very high. Peptonized milk and the beef peptones of the shops are useful under such circumstances. Milk with some farinaceous food long boiled, as barley flour, should in most instances be employed as the principal article of diet. The mistake is some- times made by anxious friends of giving the nutriment too frequently, even 420 CONSTITUTIONAL DISEASES. every half hour. As in health, so in this disease, the digestive function requires intervals of rest, so that, as a rule, the food should not be given oftener than every two hours, and then in sufficient quantity. A dose of pepsin before each feeding, employed in the formula recommended above, has been useful in critical cases in my practice. So important is the diet in typhoid fever that the physician neglects an important duty if he do not give as full and explicit directions in regard to the feeding as he does in refer- ence to the use of medicines. The room occupied by the patient should be large and well ventilated. Statistics show that the result is far better if there be a plentiful supply of pure fresh air than in closed and ill-ventilated apart- ments ; so that in some of the hospitals patients are treated in canvas tents upon the hospital grounds when the weather is suitable. Nearly forty years ago an emigrant-ship arrived at Perth Amboy, N. J., with more than 300 passengers, 82 of whom were sick with fever, and several had died at sea. There being no hospital in the town, the fever patients, 12 of whom were insensible, were placed in hastily-constructed wooden shanties with sail roofs. To add to their discomfort, a violent thunder-storm occurred which drenched the interior of the shanties, and yet with simple medicinal treatment and the use of buttermilk and animal broths only 1 of the 82 patients died. Four sailors who sickened with the fever after the arrival of the vessel were taken to a dwelling-house, and two of them died. These facts, which were related to the New York Academy of Medicine at the June meeting in 1853 by the late Dr. John H. Griscom, and were published in the Transactions of the Academy for that year, strongly impressed the profession of New York with the importance of fresh air in the treatment of typhus and typhoid fevers, and the knowledge thus obtained has no doubt been instrumental in saving many lives. But in the treatment of children the sudden reduction of tem- perature and currents of cold air should be avoided, for by taking cold the bronchial catarrh which is ordinarily present in a mild form might be aggra- vated, or a croup or pneumonia might be developed. Von Ziemssen states that in severe cases attended by feeble heart-action the patient should not be allowed to move without assistance or get out of bed, for sudden heart-failure and death " frequently result from a neglect of this rule " {Annual of Med. Sci., vol. i., 1888). The occurrence of bed-sores should be guarded against by change of position and the use of a soft mat- tress or water-bag. In severe cases attended by much prostration the patient should not be allowed to leave the bed until some days after the fever has ceased and the strength is in a measure restored. Prophylaxis. — The duty of the physician does not cease with the care of the patient. He should employ efficient measures to prevent the propaga- tion of the disease. Especial attention should be given to the disinfection of the excreta. This may be accomplished by adding six ounces of chloride of lime to one gallon of water, and mixing one quart of this solution with each fecal evacuation and a less quantity with each urinary discharge. Crude carbolic acid (one part to ten or fifteen of water), sulphate of copper (one part to twenty of water), or, best of all, corrosive sublimate (one part to two hundred to four hundred of water) may be employed for the same purpose. The disinfected discharge should be allowed to stand a few moments before it is emptied into the water-closet, and the closet should be thoroughly flushed out. In country practice great care must be taken that the dis- charges be not emptied in such a place that they can by any possibility percolate into the well which supplies the drinking-water to the families or neighbors. ^ A pound or more of corrosive sublimate in solution should be sprinkled in the vault, and chloride of lime should be dusted over the con- tents. The milk used in the family should be sterilized by steaming two CEREBROSPINAL FEVER. 421 hours at a temperature of 180° to 190°, or by boiling, and the drinking- water should be boiled or distilled. Care should be taken to disinfect promptly the clothing worn by the patient and the bedding. This may be accomplished b} T placing them immediately when removed in boiling water or bv immersing them in a solution of corrosive sublimate (one part to one thousand), or carbolic acid (one part to fifty), or sulphate of copper or chloride of lime (one part to one hundred). CHAPTER IV. CEREBROSPINAL FEVER. Definition. — Probably a microbic disease. It is manifested chiefly by the occurrence of cerebro-spinal meningitis. Its prominent symptoms are such as meningitis gives rise to — to wit, fever, headache, tonic contraction of the muscles of the nucha, hyperaesthesia, and neuralgic pains in the trunk and extremities. It is non-contagious, or contagious in a very low degree, and, as with most of the microbic diseases, its victims are chiefly the young. It is ordinarily a primary disease, but it sometimes occurs as a complication of other acute as well as chronic maladies. It begins abruptly or without a premonitory stage, and it is often speedily fatal from the intense hyperemia of the nervous centres or the severity of the cerebro-spinal meningitis. In other cases, after weeks or months of suffering and progressive loss of flesh and strength, death occurs in a state of extreme prostration. In those who recover convalescence is protracted and slow. This disease has been designated by different terms in different countries, as spotted fever, cerebro-spinal fever, malignant purpuric fever, typhus petechialis, typhus syncopalis, and febris nigra, expressive of its constitu- tional nature. Those who employ such terms regard it as a general or systemic disease, with the meningitis as its local manifestation, just as pharyngitis is a local manifestation of scarlet fever or bronchitis of measles or pertussis. This opinion of its nature receives strong support from the clinical fact that in severe forms of the disease extravasations of blood occur early under the skin, indicating a profoundly altered state of the blood and systemic infection. The disease has also been designated by terms expressive of its local nature, as epidemic meningitis, epidemic cerebro-spinal menin- gitis, typhoid meningitis, malignant meningitis. We will treat hereafter of the nature of this malady, and endeavor to justify the opinion which has led to the use of terms that indicate its constitutional character. History. — Whether cerebro-spinal fever occurred previously to the pres- ent century is uncertain. If it did it was confounded with other diseases. Vieussens in 1805 was apparently the first who wrote a clear and unmistak- able description of it, designating it " a malignant non-contagious fever." He described an epidemic of it which appeared in Geneva, Switzerland, in a family of 3 children, of whom 2 died in twenty-four hours. Two weeks later -1 children in another family died of it, after an illness of less than a day, and a young man in another house died with similar symptoms after an equally brief illness, his surface having a deeply congested or violet appear- ance. In these and subsequent cases the attack began in the latter part of the day or at night, and was attended by vomiting, violent headache, con- vulsions, dysphagia, petechia, and tonic contraction of the posterior muscles 422 CONSTITUTIONAL DISEASES. of the neck and trunk, producing retraction of the head and opisthotonos. Thirty-three lost their lives during this epidemic, after a sickness varying from twelve hours to five days. Within the next two years epidemics of cerebro-spinal fever occurred in Bavaria, Holland, Germany, and at about the same time or soon after in parts of England. The first American cases of the disease, so far as is now known, were at Medfield, Massachusetts, in 1806. From 1806 to 1816 occasional outbreaks of it occurred in England, France, and America in several localities. It appeared in both Canada and the United States. From 1816 to 1828, so far as is now known, only two epidemics of it occurred, and they were limited to small areas and were of brief duration. The one was at Middletown, Con- necticut, and the other at Vesoul, France. In 1828 it occurred in Trumbull county, Ohio, in 1830 at Sunderland, England, and in 1833 at Naples. After the Naples epidemic a respite from the disease appears to have occurred, in both the Eastern and Western Hemispheres, until 1837. In that year it appeared in the south of France, in and around Bayonne, and gradually extended to isolated localities over almost the whole of France. It occurred at this time among troops in their barracks as well as civilians, and in some localities, of the troops affected from 50 to 75 per cent. died. Even Versailles and Paris did not escape. During the twelve years from 1837 to 1849, France suffered far more than any other country from this disease. It was especially common and fatal among the soldiers in many localities, and at some of the military stations in France several successive epidemics occurred. In the decade from 1839 to 1849 cerebro-spinal fever extended to Naples, the Komagna, Sicily, Gibraltar, Algeria, and various places in Denmark, England, and Ireland. In 1842 the United States was again visited by cerebro-spinal fever in localities at a distance from the seaboard, and therefore, apparently, not by communication from Europe. In 1842-43 it occurred in Kentucky, Tennes- see, Alabama, Illinois, Mississippi, and Arkansas. From 1840 to 1850 it visited Montgomery in Alabama, Beaver county in Pennsylvania, Cayuga county in New York, and New Orleans in Louisiana. Between 1850 and 1854 there is no record of its occurrence in either hemisphere, but from 1854 to 1860 it ravaged the Scandinavian peninsula and caused more than four thousand deaths. Since 1860 certain localities in nearly every civilized country have been severely visited by this disease. In all these countries it is justly regarded as one of the most fatal and important of the epidemic maladies. An interesting fact in regard to these many epidemics on both continents, which have been reported by competent observers, is that they have occurred in isolated localities far apart and without the least evidence of transporta- tion. Cerebro-spinal fever has not, so far as I am aware, in any instance extended from one locality to an adjacent one in the manner of contagious diseases. The cause of the malady has evidently arisen or been created in the places where the cases have occurred, and is not susceptible of transpor- tation so as to produce the disease elsewhere. Cerebro-spinal fever resembles in this respect the diseases due to marsh miasm. But since 1860 this disease has appeared in this country in another phase. It has become or is being established — or. to use the phrase commonly em- ployed in medical literature, naturalized — in the cities of the United States. For some years not a week has passed without the report of deaths from this cause in New York, Philadelphia, Jersey City, and Chicago. It is probably already permanently established in Cincinnati, St, Louis, Minneapolis, Newark, and San Francisco, since deaths from it have been reported in these cities during many consecutive weeks. CEREBROSPINAL FEVER. 423 In Xew York City prior to 1866 only 4 deaths occurred from what was perhaps cerebro-spinal fever, since in 1838, 2 deaths were reported from so- called spotted fever. 1 in 1850 and 1 in 1861. What was the nature of this spotted fever is now a matter of conjecture. In 1866, 18 patients died of cerebro-spinal fever within the city limits, and not a year has passed since, and in the last few years not a week, without deaths from it. From 1866 to 1872 the annual deaths from this disease in New York varied from 18 to 48. Commencing in December, 1871. and continuing during the first half of 1872, a severe epidemic occurred, producing a large mortality. Many who recovered permanently lost their hearing and some their sight from the attack. In this epidemic the physicians of New York were fully aroused to the importance of the disease which was causing so much suffering, and which attacked the lower animals, especially the jaded horses of the city car- and stage-lines, not a few of them dropping down in harness, so suddenly did the attacks occur. In 1872, 782 deaths, chiefly of children, resulted from cerebro-spinal fever within the city limits. This epidemic appeared to produce a greater dissemi- nation of the disease and more firmly established it in the city, for since then the annual deaths from it have varied between 97 in 1878 and 461 in 1881. In Philadelphia cerebro-spinal fever began in 1863, causing 49 deaths in that year, and it has never been absent from that city since. Prof. Stille states that between 1863 and 1882 it has caused 2049 deaths within the city limits. In Philadelphia, as in New York, it has for some years produced a nearly uniform weekly mortality. The prevalence of cerebro-spinal fever in the United States and its probable importance in the future may be inferred from the fact that it has recently occurred also in Cincinnati, Minneapolis, Denver, Norfolk, Boston, Worcester, New Haven, Albany, Syracuse, Auburn, Mil- waukee, Wilmington, Detroit, Baltimore, Charleston, Toledo, Mobile, Salt Lake, Grand Rapids, Providence, Chattanooga, Hartford, New Orleans, Fall Biver, Bichniond, Knoxville, and Nashville. Etiology. — That this disease is produced by a micro-organism is generally believed. Dr. A. Frankel and other European microscopists have carefully examined the bacteria found in the blood and tissues of those affected by it. At a meeting of the Berlin Medical Society, held February 12, 1883, Herr Leyden showed under the microscope specimens of micrococci found in a case of cerebro-spinal fever. They had an oval shape, were mostly in pairs, and were faintly tremulous. They resembled those found in pneumonia and erysipelas, but Leyden did not think them identical. At the same meeting Herr Baginsky related cases which seemed to show that in some instances the cause of cerebro-spinal fever and that of pneumonia might be identical. 1 Dr. Y. 0. Pushkareff, connected with one of the barrack- infirmaries of St. Petersburg, states that in five cases of croupous pneumonia in which cerebro-spinal meningitis occurred as a complication he discovered in the pus taken from the cerebral meninges swarms of micrococci whose appearance under the microscope seemed identical with that of Friedlander's pneumococ- cus. They were either isolated or in groups of two, seldom in four, having distinct capsules, and they were absent from the fluid taken from the men- inges in simple pneumonia. Pushkareff" was able to cultivate the micrococ- cus taken from the meningeal pus, and the cultivated microbes, like their parents, presented an appearance identical with that of the pneumococcus. 2 Moreover, Eberth, in a case of meningitis following pneumonia, believes that he found the same micrococcus in the lungs and in the liquid exuded from the inflamed pia mater. Frankel also states that he obtained from the puru- 1 Deutsch. med. Wochenschr., April 4, 1883. 2 Ejen.klin. Gazeta, April 21, 1885. 424 CONSTITUTIONAL DISEASES. lent exudation in the pia mater, in a case of meningitis occurring with pneu- monia, a microbe resembling that in the pneumonic exudation. 1 From the investigations of so many competent microscopists, therefore, it appears that the microbe found in the exudate of the meninges in cerebro- spinal fever, and which is supposed to sustain a causal relation to this dis- ease, bears a close resemblance in form to the pneumococcus, if it be not identical with it. But we would infer, from the fact that croupous pneu- monia is so universal a disease occurring in localities where there is no cerebro-spinal fever, that the cause of the two must be different, or, if there be a form of croupous pneumonia which is produced by the same microbe as that of cerebro-spinal fever, the pneumonia which is universal must have a different origin. The microbic causation of cerebro-spinal fever needs further investigation, which it will doubtless receive, before positive state- ments can be made. Among the conditions which are favorable for the occurrence of cerebro- spinal fever, and may therefore be regarded as predisposing to it, we may mention the winter season. Statistics collected in Europe and the United States show that while 166 epidemics occurred in the six months commencing with December, only 50 were in the remaining six months of the year. Ac- cording to the statistics of Prof. Hirsch, which were collected mainly from Central Europe, 57 epidemics were in winter or in winter and spring, 11 in spring, 5 between spring and autumn, 4 commenced in autumn and extended into winter or into winter and the ensuing spring, and 6 lasted the entire year. I suspect that the opinion expressed by Prof. Hirsch is correct, that the excess of epidemics in the winter months is due mainly to the greater crowding and less ventilation in the domiciles during the cold than during the warm months, especially among European peasantry. In New York City, where the state of the domiciles is about the same the year round, the season appears to exert little influence on the prevalence of the disease. The fact has repeatedly been observed that antihygienic conditions in- crease the liability to cerebro-spinal fever. Soldiers in barracks and the poor in tenement-houses suffer most severely when the epidemic is prevailing. In New York City the fact is often remarked that multiple cases occur for the most part where obvious insanitary conditions exist, as in apartments which are unusually crowded and filthy or in tenement-houses around which refuse matter has collected or which have defective drainage. The interesting chart prepared under the direction of Dr. Moreau Morris for the Health Board shows that comparatively few cases occurred in the epidemic of 1872 in those portions of the city where the sanitary conditions were good. Antihygienic conditions probably predispose to cerebro-spinal fever in the same way that they do to other grave epidemic disease, as, for example, to Asiatic cholera, whose ravages are chiefly where hygienic requirements are most neglected. We will presently relate striking examples which show how foul air increases the number and malignancy of cases. Insanitary conditions not only ener- vate the system and render it more liable to contract any prevailing dis- ease, but probably promote the development and activity of the specific principle. Is Cerebro-Spinal Fever Contagious ? It is the almost unanimous opinion of those who are most competent to judge from their observations that it is either not contagious or is contagious in a very slight degree. It is certain that the vast majority of cases occur 1 Deutsch. med. Wochenschr., Nov. 13, 1886. CEREBROSPINAL FEVER. 425 without the possibility of personal communication. Thus, in the commence- ment of an epidemic the first patients are affected here and there at a dis- tance from each other, often miles apart, and throughout an epidemic usually only one is seized in a family. Children may be around the bedside of the patient, passing in and out of the room without restriction, and yet we can confidently predict that none of them will contract the malady if there be proper ventilation and cleanliness and none of the conditions of insalubrity exist within or around the domicile. Moreover, when multiple cases occur in a family the disease begins at such irregular intervals in the different patients that there can be little doubt in most instances that it is not com- municated from one to the other, but, like the fevers from marsh miasm, is produced by exposure to the same morbific cause, existing outside the indi- viduals, but within or around the premises. Thus, in the Brown family treated by the late Dr. John Gr. Sewell x of New York, the first child sick- ened January 30th, and subsequently the remaining five children at intervals respectively of five, seven, eleven, twenty-five, and forty-five days. That so many were affected in one family was attributed by the doctor to the filthy state of the house and the bad plumbing, which allowed the free escape of sewer-gas. In my own practice, in the family which suffered the most severely of all, four patients were seized in succession, and yet I could see no evidence of contagiousness. The family occupied a small plot of ground, not more than thirty feet by one hundred, and their occupation was to pre- pare for the meat-market what is known as head-cheese. They lived on the second floor of the two-story wooden house in which the work was carried on. At the time of the sickness the shop contained four hundred heads of animals from which the meat for the cheese was obtained, and it was evident that decaying animal matter was present. The occupation and surroundings of this family afforded sufficient explanation of the fact that so many were attacked. Two workmen contracted the disease within about one week of each other, and were removed from the house. On January 26th, four weeks after the commencement of the malady in the workman who was first attacked, one child sickened with it, and died on February 1st. Fifteen days subsequently (February 16th) a second child was attacked, and, after a tedious sickness, finally recovered. The long and irregular intervals between these cases indicate that the disease was not contracted by one from the other. The important factor in causing so severe an outbreak of cerebro-spinal fever in this family was probably the miasm produced by such an occupation in the house where the family resided, with neglect of ventila- tion and cleanliness. But the strongest evidence that cerebro-spinal fever is either noncon- tagious or very feebly contagious is afforded by the fact that a large majority of the cases occur singly in families, although there is no isolation of the patients. The following are the statistics relating to this point in the cases which I have observed since cerebro-spinal fever commenced in New York, in 1871 : Single cases occurred in seventy families ; dual cases occurred in nine families ; three cases occurred in one family, and four cases in one family. Intercourse with the sick-room was unrestricted in all these fami- lies, so that children frequently went out and in, and sometimes assisted in the nursing. The most striking example of apparent contagiousness which has come to my knowledge was related by Hirsch, and is quoted by Yon Ziemssen. A young man sickened with cerebro-spinal fever on February 8th. The woman who nursed him returned to her home in a neighboring village, and there died of the same disease on February 26th. To her funeral mourners 1 Medical Record, July, 1872. 426 CONSTITUTIONAL DISEASES. came from a neighboring township, and after their return home three of them died with the same disease — one within twenty-four hours, another on March 4th, and a third on the 7th. In one instance only in my practice did the facts point to contagiousness. A boy of twelve years died of cerebro-spinal fever, and was buried on Satur- day or Sunday. On Monday the mother washed the linen and bedclothes of the boy, which had accumulated and were in a very filthy state. Two days subsequently she was attacked, and her infant soon afterward, both perishing. The state of the bedding and apartments in this house, as seen by myself, was such as would be likely to concentrate and intensify the poison, render- ing it peculiarly active, for they were very dirty, and the mother, exhausted by her long and incessant watching and lack of sleep, and depressed by grief, rendered her system more liable to the disease by her self-imposed duties on the day after the funeral. One in her state of mind and body, standing for a considerable part of a day over the bedclothes and bedding of her child soiled by the excreta, would certainly be in a condition to contract the disease if it were contagious in any, even in the lowest, degree. In the present state of our knowledge, therefore, upon this important subject the evidence leads us to believe that with proper ventilation and cleanliness and the suppression of antihygienic conditions in an infected domicile those who are in a good state of body and mind will not contract the disease, but in the opposite con- ditions it is not improbable that the poison may be so intensified, and the sys- tem rendered so liable to receive the prevailing malady through impairment of the general health and diminished resisting power, that cerebro-spinal fever may, though rarely, be communicated either by the breath of the patient or by exhalations from his surface or from soiled clothing. The occurrence of cerebro-spinal fever in certain of the lower animals is a very interesting fact, especially as the question is sometimes asked whether it may not be communicated from them to man. In the epidemic of 1811 in Vermont, according to Dr. Gallop, even the foxes seemed to be affected, so that they were killed in numbers near the dwellings of the inhabitants. Cerebro-spinal fever, previously unknown in New York City, began, as stated above, in 1871, among the horses in the large stables of the city car- and stage-lines, disabling many and proving very fatal, while among the people the epidemic did not properly commence till January, 1872, although a few isolated cases occurred in December of 1871. No evidence exists, so far as I am aware, that the disease was in any instance communicated by these animals to man. Those who had charge of the infected horses, as the veter- inary surgeons, and stable-men, did not contract the malady, certainly not more frequently than others who were not so exposed. Although we may admit slight contagiousness, there has probably been no well-established example of the transmission of cerebro-spinal fever from animals to man. If transmission ever does occur, it is so rare that practically no account need be made of it. In some instances we are able to discover an exciting cause. An indi- vidual whose system is affected by the epidemic influence may perhaps escape by a quiet and regular mode of life, but if there be any unusual excitement or if the normal functional activity of the system be seriously disturbed, an outbreak of the malady may occur. Among the exciting causes we may mention overwork and lack of sleep, fatigue, mental excitement, depressing emotions, prolonged abstinence from food followed by over-eating, and the use of indigestible and improper food. Thus, in one instance among my cases a delicate young woman, at the head of one of the departments in a well-known Broadway store, was anxious and excited and her energies over- taxed at the annual reopening. Within a day or two subsequently the disease CEREBROSPINAL FEVER. 427 began. Another patient, a boy. was seized after a day of unusual excitement and exposure, having in the mean time bathed in the Hudson when the weather was quite cool. Those children have seemed to me especially liable to be attacked who were subjected to the severe discipline of the public schools, returning home fatigued and hungry, and eating heartily at a late hour. In one instance which I observed a school-girl ten years of age returned from school excited and crying because she had failed in her exam- ination and had not been promoted. In the evening, after she had closely studied her lessons, the fever began with violent headache. Dr. Frothingham x writes as follows of the brigade in which cerebro-spinal fever occurred in the Army of the Potomac : " Under General Butterfield, a stern disciplinarian, .... the men were drilled to the full extent of their powers, often to exhaustion. I did not at the time recognize this as the cause of the disease in question, but I learnt that in the present epidemic in Pennsylvania the attack generally follows unusual exertion and exposure to cold.'' Many observers have noticed that bodily fatigue and mental depression and excitement are important factors in causing an attack of cerebro-spinal fever when this disease is epidemic. Dr. Gallop, in his history of cerebro- spinal fever as it occurred during the war of 1812, directs attention to the severity of the cases among the troops under General Dearborn, who were fatigued by marches and greatly dispirited on account of a repulse which they had sustained from the British. In one case which occurred in my practice a boy, six years and eleven months of age, was punished at school and came home with cheeks flushed from excitement, the excitement con- tinuing during the ensuing night. On the following day cerebro-spinal fever began with vomiting and chilliness, the attack ending fatally on the seven- teenth day. In another case, which was related to me by the mother and the physician, the patient, a bright girl twelve years of age, of nervous tem- perament and forward in her studies, had been much excited in competing for a prize in athletic exercises. In the evening of the same day a violent thunder-storm occurred, and after a severe clap she started from bed pallid and excited, and expressed the belief that she had been struck by lightning. The disease began immediately after this, and terminated fatally on the fifth day. Secondary Cerebro- Spinal Fever. Fagge 2 says : " Several observers have found that during or just after an epidemic of cerebro-spinal fever, meningitis has presented itself with unusual frequency as a complication of other acute diseases." He mentions croupous pneumonia, pleurisy, acute tonsillitis, and scarlatinal nephritis as the diseases upon which it is very liable thus to supervene. In this respect cerebro-spinal fever resembles diphtheria and erysipelas, which we know are very liable to occur in those who are suffering from other diseases. A striking example of cerebro-spinal fever occurring as a complication was recently seen by me in consultation. A child of about ten years with typical typhoid fever had reached about the twelfth day of a mild form of the disease. The initial headache had ceased, there was no delirium, the temperature was but moderately elevated, and no doubt had arisen in the mind of the experienced physician in attendance that the disease, which presented the characteristic signs, would terminate favorably after the usual time. Suddenly violent headache occurred, the temperature rose to 103° or 104° F.,and in a few days fatal coma terminated the case. Another disease 1 American Medical Times, April 30, 1864. 2 Practice of Medicine, vol. i. p. 614. 428 CONSTITUTIONAL DISEASES. in which I have seen cerebro-spinal fever occur as a complication is gastro- intestinal catarrh. Sex. — It is stated by certain writers that more males are affected than females. The statistics of hospitals and camps show this, for men subject to lives of hardship are especially liable to be attacked ; but in family prac- tice, in which a large proportion of the patients 1 are children, the number of males and females is about equal. Thus, in 105 cases occurring chiefly in my practice, but a few of them in the practice of two other physicians of this city. I find that 59 were males and 46 females : 91 of these were children. In New York City, during the epidemic of 1872, 905 cases of cerebro-spinal fever were reported to the Board of Health between January 1 and Novem- ber 1, and of these 484 were males and 421 females. Dr. Sanderson's statistics of the epidemic in the provinces around the Vistula, the cases being chiefly children, give also but a slight excess of males. Probably, therefore, in the same conditions and occupations of life the sexes are equally liable to contract this malady, and the excess of males in the above statistics is due to the fact that they lead a more irregular life and are more subject to privations and exposures. That soldiers on duty in barracks have been attacked while families in the vicinity escape, thus increasing the proportion of male cases, probably occurs in consequence of irregularities, hardships, and perhaps the lack of sanitary regulations in their mode of life. Age. — My observations lead me to think that the younger the patient the more frequently is cerebro-spinal fever overlooked and some other disease diagnosticated. Nevertheless, all published statistics, so far as I am able to ascertain, show that a large proportion of cases occur under the age of five years, and that a larger proportion of fatal cases are in the first year of life than in any other year. Thus, in New York City the ages of those who died from this disease in 1883 were as follows: Under 1 year 57 From 1 to 2 vears 31 From 2 to 3 " " 22 From 3 to 4 " 12 From 4 to 5 " 9 From 5 to 10 " 37 From 10 to 15 " 18 From 15 to 20 " 15 From 20 to 25 vears 7 From 25 to 30 " 3 From 30 to 35 " 4 From 35 to 40 " 3 From 40 to 45 " 1 From 45 to 50 " 2 From 50 to 60 " 1 Over 60 vears 1 The following are the statistics of the New York Health Board relating to the ages of the cases during the epidemic of 1872 : Under 1 year . 125 From 1 to 5 vears 336 From 5 to 10 " " 204 From 10 to 15 " 106 From 15 to 20 vears 54 From 20 to 30 " " 79 Over 30 years 71 Total 975 In the cases which occurred in my own practice, and in a few cases in the practice of other physicians added to mine, I find that the ages were as follows : Under 1 year 16 From 1 to 3 vears 27 From 3to 5 " 25 From 5 to 10 " 20 From 10 to 15 years 10 Over 15 years 15 Total 113 In my practice, therefore, three-fourths of the cases have been under the age of ten years ; and the statistics of epidemics in other localities correspond CEREBROSPINAL FEVER. 429 with mine in giving a large excess of cases in childhood. Thus, Dr. Sander- son, in examining the records of deaths in one epidemic, ascertained that 218 had perished under the age of fourteen years, and only 17 above that age ; and although this does not show the exact ratio of children to adults in the entire number of cases, it is evident that the children were greatly in excess. The more advanced the age after the tenth year, the less the liability to this malady, so that very few who have passed the thirty-fifth year are attacked, and old age possesses nearly an immunity. In New York City, in which, as we have seen, cerebro-spinal fever has been occurring since 1871, only two cases have come to my knowledge which had passed the fortieth year. The age of one was forty-seven, and of the other sixty-three years. But nearly every year the statistics of the Health Board show that one or two old persons have died of this disease. Not a few cases occur in this city in infants of the age of three or four months. An infant of four months died of cerebro-spinal fever in the New York Infant Asylum, the nature of the disease not being known until it was revealed by the autopsy. Symptoms. — During the prevalence of cerebro-spinal fever cases now and then occur in which the symptoms are mild and transient and the health is soon fully restored. It seems proper to regard some, at least, of these as gen- uine but aborted forms of the disease. The following cases which occurred in my practice may be cited as examples : A boy eight years of age, previously well, was *taken with headache and vomiting, attended by moderate fever, on April 2, 1872. The evacuations were regular, and no local cause of the attack could be discovered. On the following day the symptoms continued, except the vomiting, but he seemed somewhat better. On April 4th the fever was more pronounced, and in the afternoon he was drowsy and had a slight convulsion. The forward move- ment of the head was apparently somewhat restrained. On the 6th the symptoms had begun to abate, and in about one week from the commence- ment of the attack his health was fully restored. A boy aged six was well till the second week in May, 1872, when he became feverish and complained of headache. At my first visit, on May 14th, he still had headache, with a pulse of 112. The pupils were sensitive to light, but the right pupil was larger than the left. The bromide and iodide of potassium were prescribed, with moderate counter-irritation behind the ears. The headache and fever in a few days abated, the equality of the pupils was restored, and within a little more than one week from the com- mencement of the disease he fully recovered. These cases occurred when the epidemic of 1872 was at its height ; but if the symptoms are so mild and the duration of the disease short as in these two cases, the diagnosis must sometimes be doubtful. Observers in different epidemics report similar cases, and as the symptoms, so far as they appeared in my patients, seemed characteristic, I have not hesitated to regard them as genuine, but aborted cases. On such patients the epidemic influence acts so feebly, or their ability to resist it is so great, that they escape with a short and trivial ailment. Occasionally also during the progress of an epidemic we meet patients who present more or fewer of the characteristic symptoms, but in so mild a form that they are never seriously sick and never entirely lose their appetite. but the disease, instead of aborting, continues about the usual time. Thus, on January 4, 1873, I was called to a girl aged thirteen who had been seized with headache, followed by vomiting, in the last week in Decem- ber. During a period of six to eight weeks, or till nearly March 1st. she had 430 CONSTITUTIONAL DISEASES. the following symptoms : Daily paroxysmal headache, often most severe in the forenoon ; neuralgic pain in the left hypochondrium, and sometimes in the epigastric region ; pulse and temperature sometimes nearly normal, and at other times accelerated and elevated, both with daily variations ; inequality of the pupils, the right being larger than the left during a portion of the sickness. The patient was never so ill as to keep the bed, usually sitting quietly during the day in a chair or reclining on a lounge, and she never fully lost her appetite. Quinine had no appreciable effect on the fever or paroxysms of pain. There can, in my opinion, be little doubt that this girl was affected by the epidemic, but so mildly that there was, for a considerable time, much uncertainty in the diagnosis. Cases like these, in which the disease is so feebly developed that the patient is never seriously sick, though unimportant pathologically, must be recognized in a treatise on cerebro-spinal fever. Mode of Commencement. — Cerebro-spinal fever rarely begins in the fore- noon after a night of quiet and sound sleep. In the cases which I observed in the severe and fatal epidemic of 1872, and in the 36 cases of which I have records observed since 1872, the commencement was almost without exception between midday and midnight. The fact that this disease does not commence after the repose of night till several hours of the day have passed shows the propriety and need of enjoining a quiet and regular mode of life, free from excitement and with sufficient hours of sleep, during the time in which the epidemic is prevailing. The commencement is usually without premonitory stage and sudden — unlike, therefore, the beginning of other forms of meningitis, which come on gradually, and are preceded by symptoms which, if rightly interpreted, direct attention to the cerebro-spinal system. Exceptionally certain premonitions occur for a few hours or days before the advent of the disease, such as lan- guor, chilliness, etc. Mild cases usually begin more gradually than cases of a severe type. The ordinary mode of commencement is as follows : The patient is seized with vomiting, headache, and perhaps a chill or chilli- ness, so that there is a sudden change from perfect health to a state of serious sickness. Rigor or chilliness is a common initial symptom, especially in adult patients. One patient, an adult female, had three or four chills of considerable severity in the commencement of the attack. Chil- dren often have clonic convulsions- in place of the chill, or immediately after it, partial or general, slight or severe. Stupor more or less profound, or, less frequently, delirium, succeeds. In the gravest cases semi-coma occurs within the first few hours, in which patients are with difficulty aroused, or profound coma, which, in spite of prompt and appropriate treatment, is speedily fatal. Those thus stricken down by the violent onset of the disease, if aroused to consciousness, complain of severe headache, with or without or alternating with equally severe neuralgic pains in some part of the trunk or in one of the extremities. The pain frequently shifts from one part to another. Among the early symptoms of cerebro-spinal fever are those which pertain to the eye. The pupils are dilated or less frequently contracted, and they respond feebly or not at all to light if the attack be severe or dangerous ; often they oscillate, and occasionally one is larger than the other. Vomiting with little apparent nausea, and often projectile, is common in the commencement of cerebro-spinal fever. It occurred as an early symptom in 51 of 56 cases observed by Dr. Sanderson. In 98 cases occurring in New York, most of them observed by myself, but a few of them related to me by the late Dr. John G. Sewall, vomiting occurred as an early symptom in 68 cases. Its absence on the first day was recorded in only 3 cases, while in the remaining 27 patients the CEBEBEO-SPINAL FEVER. 431 records of the first day make no mention of its presence or absence. It was probably present in most of these 27 cases as one of the first symptoms. Since the epidemic of 1872. in examining patients, now numbering thirty- six, as has been already stated, I have made careful inquiry in regard to the mode of commencement, and with only two or three exceptions either the previous health had been good, or, if symptoms of ill-health antedated the cerebro-spinal fever, they were due to some ailment entirely distinct from this disease. In a boy four and a half years of age, living in Broadway, it was stated to me that the cerebro-spinal fever came on gradually with pains in the head and elsewhere : this case was mild throughout and the patient was never in imminent danger. In nearly all the cases, if the patients were at home and under observation, the exact moment of the beginning of the disease could be stated. Thus, a man aged twenty-eight returned from his work at midday, April 23, 1883, in good health and cheerful, ate a hearty meal at twelve M., and at one P. M. had a chill, with intense headache and severe vomiting. Minute red points appeared on his face after vomiting, from capillary extravasations. In this case the interesting fact was observed of a cessation of the symptoms, so that on the 24th and 25th, being free from pain, he went to Brooklyn. On the 26th, however, the symptoms returned. He had pains in the head, back, and extremities, and was seriously sick. Occasional remissions, so that very grave symptoms become mild for a time and then return in full severity, as well as distinct intermissions, as in this case, have been frequently noticed by observers in different epidemics. A little girl, previously entirely well, was slightly punished on June 11, 1882; immediately she vomited and seemed quite sick ; by kind nursing on the part of the mother she became better, so that on the 12th she had some appetite and went out. On the 13th cerebro-spinal fever began, with a temperature of 103° F., and its course was tedious. A robust girl, aged thirteen, vivacious and cheerful, went as usual in the morning to one of the public schools entirely well. Before the school was dismissed she returned home crying on account of dizziness and violent pain in the top of her head, in her knees, and in the calves of the legs. The case was attended by Prof. Alonzo Clark, Prof. Knapp, and myself, and was fatal after four and a half weeks. A boy aged ten returned from another public school in a similar manner, having gone to it in the morn- ing in apparently perfect health. We may therefore summarize as follows the symptoms which commonly attend the commencement of cerebro-spinal fever : Violent pain in some part of the head, and sometimes also in the trunk or limbs, vomiting, a chill or chilliness, clonic convulsions, dizziness, dilated, sluggish, or altered pupils, fever of greater or less intensity according to the severity of the attack, heat of head, and in most patients heat of the surface generally. If the disease be of a severe and dangerous type, these symptoms are frequently followed within a few hours by delirium, semi-coma, or coma. Nervous System. — Since in cerebro-spinal fever extensive and severe inflammation of the cerebral and spinal meninges occurs, with more or less congestion of the brain and spinal cord— lesions which we will consider here- after — we should expect that this disease would be attended by severe and dangerous symptoms, inasmuch as the cerebro-spinal axis exerts such a con- trolling influence upon the functions of the body. Also we should expect that the symptoms would vary according to the portion of the meninges which happens to be most severely inflamed. There is, indeed, variation in symptoms according to the extent and intensity of the meningitis and the degree in which the cerebro-spinal axis is congested or implicated, but cer- tain symptoms occur in all or nearly all cases, and as they are characteristic they render diagnosis easy. 432 CONSTITUTIONAL DISEASES. Pain, already described as an initial symptom, continues during the acute period of the malady. It is ordinarily severe, eliciting moans from the sufferer, but its intensity varies in different patients. Its most frequent seat is the head, and the location of the cephalalgia varies in different patients and in the same patient at different times. One refers it to the top of the head, another to the occiput, and another to the frontal region, and the same patient at different times may complain of all these parts. The pain is described as sharp, lancinating, or boring. It is also common in the neck, especially in the nucha, the epigastrium, the umbilical and lumbar regions, along the spine (rachialgia), and in the extremities, where it shifts from one part to another. It is more common and persistent in the head and along the spine than elsewhere. The patient, if old enough to speak and not delirious or too stupid, often exclaims, " Oh my head ! " from the intensity of his suffering, but after some moments complains equally of pain in some other part, while perhaps the headache has ceased or is milder. In a few instances the headache is absent or is slight and transient, while the pain is severe elsewhere. After some days the pain begins to abate, and by the close of the second week is much less pronounced than previously. Vertigo occurs with the headache, so that the patient reels in attempting to stand or walk. I have stated above that vertigo may be a prominent initial symptom, as in the girl of thirteen years who suddenly became sick in the public school which she was attending, and reached her home with difficulty on account of the headache and dizziness. Contributing to the unsteadiness of the mus- cular movements is a notable loss of flesh and strength, which occurs early and increases. The state of the patient's mind is interesting. It is well expressed in ordi- nary cases by the term apathy or indifference, and between this mental state and coma on the one hand and acute delirium on the other there is every grade of mental disturbance. Some patients seem totally unconscious of the words or presence of those around them, when it subsequently appears that they understood what was said or done. Delirium is not infrequent, especially in the older children and in adults. Its form is various, most frequently quiet or passive, but occasionally maniacal, so that forcible restraint is required. It sometimes resembles intoxication or hysteria, or it may appear as a simple delusion in regard to certain subjects. Thus, one of my patients, a boy of five years, appeared for the most part rational, protruding his tongue when requested, and ordinarily answering questions correctly ; but he constantly mistook his mother — who was always at his bedside — for another person. Severe active delirium is commonly preceded by intense headache. In favor- able cases the delirium is usually short, but in the unfavorable it often con- tinues with little abatement till coma supervenes. On account of the pain and the disordered state of the mind patients seldom remain quiet in bed, unless they are comatose or the disease be mild or so far advanced that muscular movements are difficult from weakness. In severe cases they are ordinarily quiet for a few moments, as if slumbering, and then, aroused by the pain, they roll or toss from one part of the bed to another. One of my patients, a boy of five years, repeatedly made the entire circuit of the bed during the spells of restlessness. In mild cases or cases attended by less headache or mental disturbance patients are quiet, usually with their eyes closed unless when disturbed. Hyperesthesia of the surface is another common symptom. Few patients, not comatose, are free from it during the first weeks, and it materially increases the suffering. Friction upon the surface, and even slight pressure with the fingers upon certain parts, extort cries. Gently separating the eyelids for the purpose of inspecting the eyes, and moving the limbs or changing the position CEREBRO-SPIXAL FEVER, 433 of the head, evidently increase the suffering and are resisted. I have some- times heard such expressions of suffering from slowly introducing the ther- mometer into the rectum that I was led to believe that the anal and perhaps rectal surfaces were hypersensitive. The hyperesthesia has diagnostic value, for there is no disease with which cerebro-spinal fever is likely to be con- founded in which it is so great. It is due to the spinal meningitis, and is appreciable even in a state of semi-coma. The headache and hyperesthesia fluctuate greatly in the course of the disease, and the former sometimes recurs at times, especially from mental excitement or from an afflux of blood to the brain from physical exertion, for months after the health is otherwise fully restored. Some contraction of certain muscles or groups of muscles is present in all typical cases. In a small proportion of patients it is absent or is not a prominent symptom — to wit, in those in whom the encephalon is mainly involved, the spinal cord and meninges being but slightly affected or not at all. This contraction is most marked in the muscles of the nucha, causing retraction of the head, but it is also common in the posterior muscles of the trunk, causing opisthotonos, and in less degree in those of the abdomen and lower extremities, and hence the flexed position of the thighs and legs, in which patients obtain most relief. The muscular contraction in not an initial symptom. I have ordinarily first observed it about the close of the second day, but sometimes as early as the close of the first day, and in other instances not till the close of the third day. Attempts to overcome the rigidity, as by bringing forward the head, are very painful and cause the patient to resist. In young children having a mild form of the fever, with little retraction of the head, the rigidity is sometimes not easily detected. I have been able in such cases to satisfy myself and the friends of its presence by placing the child in an upright position, as on the lap of the mother, and observing the difficulty with which the head is brought forward on presenting to the patient a tumblerful of cold water, which is craved on account of the thirst. The usual position of the patient in bed in a typical or marked case is with the head thrown back, the thighs and legs flexed, with or without forward arch- ing of the spine. The muscular contraction and rigidity continue from three to five weeks, more or less, and abate gradually ; occasionally they continue much longer. Through the kindness of Dr. Henry Griswold I was allowed to see an infant of seven months in the tenth week of the disease. It was still very fretful, and exhibited decided prominence of the anterior fontanel, probably from intracranial serous effusion, and marked rigidity of the muscles of the nucha, with retraction of the head. Paralysis is another occasional symptom, but complete paralysis of any muscle or group of muscles is less frequent than one would suppose from the nature of the malady. It may occur early, but is sometimes a late symptom. It may be limited to one or two of the limbs, as the legs or an arm and a leg, or it may be more general. In a case occurring in Roosevelt Hospital and published in the New York Medical Record for October 10. 1878, the patient, a boy of ten years, was unable to move his legs one hour after the commencement of the disease. This sudden development of para- plegia in the commencement of cerebro-spinal fever resembled that of infan- tile paralysis, and was probably due to the same cause — to wit. active inflam- matory congestion of the anterior cornu of the spinal column. The sudden and complete loss of speech which occurs in certain cases, when consciousness is retained and the vocal organs are in their normal state, seems to be due to the fact that the portion of the brain which controls the function of speech is acutely congested or is the seat of effusion. Thus, in June, 1S82. a girl of three years whom I attended lost her speech on the second day of cerebro- .23 434 CONSTITUTIONAL DISEASES. spinal fever, and she was unable to articulate even the simplest word for two and a half months. Finally, she began to utter slowly and with difficulty the easiest monosyllables ; and after the lapse of more than a year her speech was slow and lisping, her hands were tremulous and unsteady, she was easily fatigued, and cried often from oversensitiveness. During the long period of speechlessness she daily made efforts to talk, but without uttering a sound. Strabismus, to which we will allude hereafter in treating of the eye, is a com- mon symptom, either transient or protracted, due to paralysis of certain of the motor muscles of the eye. Paralysis of more or fewer muscles has been noticed and recorded by many observers in this country and in Europe. Dr. Law observed a patient in the epidemic of 1865 in Dublin who could move neither arms nor legs, and Wunderlich saw one who had paralysis of both lower extremities and of a considerable part of the trunk. As this symptom is due to the inflam- matory process of the cerebro-spinal axis, it usually disappears in a few weeks as the inflammation abates and absorption of the inflammatory products occurs ; but it may be more protracted. In Wunderlich's case there was only partial recovery from the paralysis after the lapse of five months. Clonic convulsions have already been alluded to among the early symp- toms of the attack. They indicate a grave form of the disease, and are Fig. 59. not infrequent in young children, in whom they appear to occur in place of the chill which is common in those of a more advanced age. The eclamptic attack may be short and not repeated, or it may be protracted, or return again and again when the medicines which control it are suspended. Under such circumstances it is likely to end in profound coma, and is, of course, a symptom of great gravity. Thus, an infant of seven months had unilateral eclamptic attacks daily during the first week of the fever. The mother informed me that the convulsions seldom lasted longer than three minutes, and that the intervals between them were short. The child recov- ered with loss of sight from the cerebro-spinal fever, but still after the lapse of a year, when I examined him. he had symptoms which were apparently due to hydrocephalus. Another infant of eleven months had clonic convulsions nearly constantly during the first twenty-four hours, but with occasional brief intermissions. On the following day he was in profound coma and apparently dying, with a temperature of 105° F. To my astonishment, he gradually emerged from the state of unconsciousness, and after a week was able to sit in his cradle long enough to take drinks. CEREBROSPINAL FEVER. 435 Occasionally eclampsia does not occur in the first days, but in the second or third week, when it is usually accompanied by an increase of other symp- toms, due to a recrudescence of the disease. A female infant aged eleven months, treated by me in 1882, had been sick one week when, during an increase in the febrile movement, she had one eclamptic seizure. Her recov- ery, though slow, was complete. A boy aged eleven and a half years, whose attack began with a chill, violent headache, and fever, and whom I visited frequently, died on the fourth day. Clonic convulsions did not occur in his case until within twenty-four hours of his death, when he had six seizures, which ended in coma. Though adult patients are much less liable to eclampsia than children, they are not entirely exempt. A male patient aged twenty-eight years,' whom I saw in consultation, had a single clonic convulsion lasting ten to fifteen minutes on the third day of his illness. In five weeks he had fully recovered, except that his headache returned upon any excitement. Even drinking a cup of beer caused it. Clonic convulsions are, however, much less common than the tonic muscular contraction and rigidity already alluded to. The latter occur to a greater or less extent in nearly all cases, and are symptoms of diagnostic value, the rigidity often extending to the muscles of the extremities. Thus, in a child aged three years who had no eclampsia the tonic contraction of the muscles of the extremities did not relax till after the twelfth day. Choreic or choreiform movements are occasionally observed. I do not refer to the tremulousness which sometimes occurs from weakness or as a premonition of eclampsia, but to a movement which has the character of true chorea. An infant aged ten months began to have choreic movements during the acute stage of the disease, most marked in the upper extremities and ceasing in sleep. They continued during the remainder of the life of the child, death occurring ten months subsequently from diphtheria. Rarely a choreiform movement of the eyes is also observed — a lateral movement from right to left and from left to right, designated nystagmus. I recollect two such cases. Drowsiness, already spoken of, is a common symptom, and it exists in all grades from slight stupor to profound coma. In some patients it is present from the first hour, while in others it occurs after a period of restlessness or delirium or it alternates with it. Stupor more or less profound is common after the attack of eclampsia or the chill. That it is a frequent symptom in severe cases receives ready explanation from the state of the brain and its meninges, for the exudation which occurs upon the surface of the brain and the serous effusion within the ventricles are sufficient to cause it by compress- ing the cerebral substance. It is surprising in some cases how profound the stupor may be — a state, indeed, of coma, and yet the patient gradually emerges from it and recovers. In the epidemic of 1872, in New York City, when the malady was new with us, many physicians predicted certain death, and employed remedies without expectation of any benefit on account of the apparently hopeless state of the patients, who seemed to be in pro- found coma, and yet not a few of them gradually and fully recovered. Digestive System,. — Vomiting, which is the most prominent symptom referable to the digestive system, has already been mentioned. Occurring early in the disease, it may cease in a few hours or not till after several days, and often it returns during the periods of recrudescence which are common in the progress of the fever. It occurs with little effort and without pre- vious nausea or with little nausea, as is usual when it has a cerebral origin. It does not differ as a symptom from the vomiting which is so common in other forms of meningitis. The substance vomited consists of the ingesta 436 CONSTITUTIONAL DISEASES. and the secretions, as mucus and bile. Having a similar origin is a sensa- tion of faintness or depression, referred to the epigastrium. The appetite is usually impaired or lost during the active period of the attack, and it is not fully restored till convalescence is well advanced. Occasionally considerable nutriment is taken, and with apparent relish, as by one of my patients, twenty-eight years of age, who always had some appetite. Ordinarily, on account of repeated vomitings, constant febrile movements, impaired appetite and digestion, patients progressively lose flesh and strength, so that in protracted cases emaciation is always a promi- nent symptom, and is often extreme. Much emaciation and loss of strength, which attend many cases after the lapse of several weeks, greatly diminish the chances of a favorable termination. Thirst, already referred to, and constipation are common in this as in other forms of meningitis, but retrac- tion of the abdomen is not a notable symptom, except in protracted and greatly-wasted cases. The diarrhoea which is occasionally present in cerebro- spinal fever in the summer months must be regarded as a distinct disease and a complication. The tongue and the buccal and faucial surfaces present nothing unusual in their appearance. It is seldom, even in the most pro- tracted and emaciated cases, that the sordes and dry and brownish fur occur which are so common in typhus and typhoid fevers. The tongue is usually moist and but slightly furred. I have seen in consultation two patients that perished early with inability to swallow as the prominent symptom, attended in both by an abundant secretion upon the faucial surface, without any redness, swelling, or other evidence of inflammation. The early death of these young children, whose ages were ten months and two years, rendered the diagnosis less certain than in most other patients, but the attending physician as well as myself diag- nosticated cerebro-spinal fever with suddenly developed paralysis of the muscles of deglutition, so that no nutriment could be taken. If our under- standing of these interesting cases is correct, the paralysis was caused by lesion of that portion of the medulla oblongata which controls the function of deglutition, or else by injury of the intracranial portions of the nerves which supply the muscles concerned in this act. The following were the cases in question : , male, two years of age, became feverish and dull, but without vomiting, on October 22, 1882 ; axillary temperature, 102° F. On the fol- lowing day inability to swallow occurred, and the muscles of deglutition appeared wholly paralyzed. Death occurred on the third day, suddenly and apparently without suffering, as if from arrested function of important nerves, especially the pneumogastric. The abundant secretion of thin mucus or transudation of serum covering the faucial surface, and reaccumulating as soon as removed without any notable change in the appearance of the fauces, was remarkable. The physician in attendance, who for more than thirty years had had a large city practice, had seen no similar case, nor had I at the time. Soon afterward the second case occurred. An infant of ten months, with- out cough or embarrassment of respiration or faucial redness or swelling, lost the power of deglutition soon after the commencement of the supposed cere- bro-spinal fever, so that in the attempts to swallow the drinks entered the larynx, and the secretion or exudation was abundant, as in the other case. Death occurred in forty-eight hours. The rectal temperature was only 101° F. In another case, which was ultimately fatal and in which the diagnosis of cerebro-spinal fever was certain, a robust girl, aged twelve, suddenly lost the power of deglutition at one time during her sickness, although she was CEEEBBO-SPIXAL FEVER. 437 entirely conscious and repeatedly endeavored to swallow. The ability to swallow returned in a few days. Puke. — This is usually accelerated, and the more severe and dangerous the attack the more rapid is the heart's action, except occasionally in the comatose state, when, probably in consequence of compression of the brain from an abundant exudation, the pulse may be subnormal. Thus, in one of my patients, an adult, the pulse fell to 40 per minute, and in two others to between 60 and 70 per minute. With the exception of these three, the pulse in all cases which I have observed, so far as I recollect, has varied from the normal number of beats per minute to such frequency that it was difficult to count it. As death draws near the pulse ordinarily becomes more frequent and feeble. Intermissions in the pulse do not seem to be as common as in other forms of meningitis, but marked variations in its frequency during different hours of the day and on consecutive days constitute a conspicuous symptom. Thus, in a case which was fatal in the fifth week consecutive enumerations of the pulse in the acute stage were as follows : 128, 120, 88, 130, 84, 112. Temperature. — Some of the older writers before the days of clinical ther- mometry stated that the temperature is not increased. North remarked as follows : •• Cases occur, it is true, in which the temperature is increased above the natural standard, but these are rare ;' 1 and Foot and Gallop make similar statements. Some recent writers have held the same opinion. Thus, Lidell wrote as follows in a treatise bearing the date of 1873 : " Febrile symptoms do not necessarily belong to epidemic cerebro-spinal meningitis as a substan- tive disease, for it may, and not unfrequently does, occur without exhibiting any such symptoms." We should naturally expect that meningitis, accom- panied as it is by active congestion of the brain and spinal cord, would pro- duce more or less fever, and in eighty-six cases which I examined by the thermometer I found elevation of temperature in every case during the acute stage, except in the beginning of the attack in two instances. In a young man aged twenty-eight years who had severe headache and seemed seriously sick the thermometer under the tongue showed no rise of temperature on the first and second days, but on the third day it was at 100° F.,and it remained elevated till his death on the thirteenth day. The second case was that of a young woman whom I saw in consultation, and who at the time of my visit had fever, but had none previously, according to the statement of the attending physician. In the 87 cases which I examined the heat of the surface occasionally did not seem above normal to the touch, and now and then the thermometer, applied in the axilla or groin, did not indicate fever, but the rectal temper- ature was always elevated above that of health after the disease was fully established. The temperature fluctuated from day to day and in different hours of the same day, but there was no exception to the rule that it was above the normal during the active stage of the malady after the first few days. Sometimes the elevation of temperature was slight, as in a female patient forty-seven years of age, in whom the thermometer showed no eleva- tion of temperature when it was placed in the mouth and axilla, but on introducing it into the rectum it rose to 99J° F. In the case of a young lady attended by me in 1890, having a very asthenic and fatal form of cerebro-spinal fever, accompanied by great prostration, a brown and dry tongue, and delirium, the temperature under the tongue was subnormal during the first two or three days, but was afterward above normal. The highest temperature which I have thus far observed was 107f° F., in a child aged two years. This was in the commencement of the attack. Subsequently it fell a little, but rose again on the third day to 107°. when 438 CONSTITUTIONAL DISEASES. she died. In two other cases the temperature was 106° F. on the first day, and it did not afterward reach so high an elevation. One of these died on the ninth day, and the other in the ninth week. The next highest temper- ature was 105f F., also on the first day. in an infant aged eight months, who died on the ninth day. The first and last of these cases occurred in an old wooden tenement-house in the suburbs of the city and upon an elevated outcropping of rock. The highest temperature in any case in New York City which has come to my notice was observed in a male patient aged twenty-eight years who had active delirium, and died on the fifth day in Roosevelt Hospital. The temperature on the last day, taken four times, was as follows : 102 |°, 106f °, and, when the pulse had become imperceptible, 109° and 107f° F. Wunderlich has recorded a temperature of 110° F. in one or two cases, but so great an elevation must be very rare, and is of course prognostic of an unfavorable ending. The external temperature undergoes still greater fluctuations than the internal, rising above and falling below the normal standard several times in the course of the same day. Similar fluctuations occur in other forms of meningitis, but they are, according to my experience, less pronounced than in cerebro-spinal fever, especially as I observed them in the epidemic of 1872. Perhaps since that epidemic they have been less marked in the cases occurring in this city. The more grave the attack in those not comatose the greater these variations. The following is a common example of these sudden thermometric changes, occurring in a child of two years. The inter- nal temperature varied from 101° to 104-| o F. as the extremes, while that of the fingers and hands at the first examination was 90^°, at the second 90°, at the third 103°, and at the fourth 83°. Hence at the third examination the temperature of the extremities had risen 13°, so as nearly to equal that of the blood, and at the fourth examination it had fallen 20°. The patient recovered. These great and sudden variations in the pulse and the internal and external temperature have considerable diagnostic value in obscure and doubtful cases. Respiratory System. — This system is not notably involved in ordinary cases. Intermittent, sighing, or irregular respiration appears to be less frequent than in tubercular meningitis, but it does occur. In most patients the respiration is quiet, but somewhat accelerated, and without any marked disturbance in its rhythm. In thirty-one observations in children who had no complication, I found the average respirations 42 per minute, while the average pulse was 137. Therefore the respiration, as compared with the pulse, was proportionately more frequent than in health, due perhaps to the fact that certain muscles concerned in respiration, as the abdominal, are em- barrassed in their movements by tonic contraction. Various observers in different epidemics have recorded an unusual preva- lence of croupous pneumonia occurring simultaneously with cerebro-spinal fever. Bascome in his history of epidemics stated that " epidemic encepha- litis and malignant pneumonias prevailed in Germany in the sixteenth cen- tury" (Webber). Webber in his prize essay describes a variety of cerebro- spinal fever which he designates pneumonic, in which the cerebro-spinal axis is involved but slightly or not at all, and the brunt of the disease falls upon the respiratory organs. According to him. in certain epidemics the pneu- monic form has been common and in others infrequent. This fact is interest- ing taken in connection with the examination of the microbes of croupous pneumonia and cerebro-spinal fever, as detailed in our remarks under the head of etiology. Cutaneous Surface. — The features may be pallid, of normal appearance, or flushed in the first days of the disease, but in advanced cases they are CEREBROSPINAL FEVER. 439 pallid, as is the skin generally. A circumscribed patch of deep congestion often appears, as in sporadic meningitis, upon some part of them, as the forehead, cheek, or an ear, and after a short time disappears. The hyper- aemic streak, the tache cerSbrale of Trousseau, produced by drawing the fin- ger firmly across the surface, also appears as in other forms of meningitis if the temperature of the surface be not too much reduced. The following are the abnormal appearances of the skin most frequently observed: 1. Papilliform elevations, the so-called goose-skin, due to contrac- tions of the muscular fibres of the corium. This is not uncommon in the first weeks. 2. A dusky mottling, also common in the first and second weeks in grave cases, and most marked when the temperature is reduced. 3. Xumerous minute red points over a large part of the surface, bluish spots a few lines in diameter, due to extravasation of blood under the cuticle, resembling bruises in appearance, and large patches of the same color an inch or more in diameter, less common than the others, of irregular shape as well as size, and usually not more than two or three upon a patient. These last resemble bruises, and they may sometimes be such, received during the times of restlessness ; but ordinarily extravasations of this kind result entirely from the altered state of the blood. In New York in the epidemic of 1872 they were common, but since this epidemic, in the thirty-six cases which I have observed, I have rarely seen either the reddish points or the extravasations of blood. They were probably common in the epidemics in the first part of the century in this country, since the disease was desig- nated by the name " spotted fever " by the American physicians who wrote upon it at that time. That they are unusual in the European epidemics at the present time we infer from the fact that Yon Ziemssen expresses surprise that the disease should ever have been designated in America by such a title. 4. Herpes. This is common. It sometimes occurs as early as the second or third day, but in other instances not till toward the close of the first week or in the second. The number of herpetic eruptions varies from six or eight to clusters as large as or larger than the hand. This cutaneous disease evi- dently has a nervous origin, its vesicles occurring in most instances on those parts of the surface which are supplied by branches of the fifth pair of nerves. Its most common seat is upon the lips, but occasionally it appears upon the cheek, upon and around the ears, and upon the scalp. Erythema and roseola, both transient skin eruptions, occasionally appear, and in one instance, in my practice, erysipelas occurred. During the first days the skin is frequently dry ; afterward perspirations are not unusual, and free per- spirations sometimes occur, especially about the head, face, and neck. Urinary Organs. — In other forms of meningitis it is well known that the quantity of urine excreted is usually diminished, but in this disease it is normal, and it may be more than normal. Polyuria has been noticed in dif- ferent cases by various observers. Mosler observed a boy aged seven years who had an excessive secretion of urine, which dated back to an attack of cerebro-spinal fever in his third year. The polyuria is probably due to injury of the nervous centre, since physiological experiment has demon- strated that irritation of the central end of the vagus, of certain parts of the cerebellum, and of the walls of the fourth ventricle sometimes produces this effect. The urine occasionally contains a moderate amount of albumen, and in exceptional instances cylindrical casts and blood-corpuscles. Arthritic inflammation, apparently of a rheumatic character, has been occasionally observed. It is commonly slight, producing merely an oedema- tous appearance around one or more joints. Thus in one case which came under my notice, and which was subsequently fatal, the parents, who were poor, and were therefore without medical advice till the case was somewhat 440 CONSTITUTIONAL DISEASES. advanced, had already diagnosticated rheumatism on account of the puffiness which they had noticed around one of the wrists. The Special Senses. — Taste and smell are rarely affected, so far as is known, but it is possible that they are sometimes perverted, or even tempo- rarily lost, during the time of greatest stupor. In one case which I saw the sense of smell was entirely lost in one nostril, and I do not know whether it was ever fully restored. The affections of the eye and ear are important and of frequent occur- rence. Strabismus is common. It may occur at any period of the fever, continuing a few hours or several days, and it may appear and disappear several times before convalescence is established : occasionally it continues several weeks, after which the parallelism of the eyes is gradually and fully restored. In other instances it is permanent. Changes in the pupils are among the first and most noticeable of the initial symptoms, as I have already stated in describing the mode of com- mencement. These are dilatation, less frequently contraction, oscillation, inequality of size, feeble response to light, etc. Most patients present one or more of these abnormalities of the pupils, and they continue during the first and second weeks, and gradually abate if the course of the disease be favorable. Inflammatory hypersernia of the conjunctiva often occurs. It begins early, and now and then the conjunctivitis is so intense that con- siderable tumefaction of the lids results, with a free muco-purulent secre- tion. The false diagnosis has indeed been made of purulent ophthalmia in cases in which this affection of the lids was early and severe. But such intense inflammation is quite exceptional. More frequently there is a uni- form diffused redness of the conjunctiva, not so dusky as in typhus, and the injected vessels cannot be so readily distinguished as in that disease. In certain cases almost the whole eye (all, indeed, of the important con- stituents) becomes inflamed ; the media grow cloudy, the iris discolored, and the pupils uneven and filled up with fibrinous exudation. The deep struc- tures of the eye cannot, therefore, be readily explored by the ophthalmo- scope, but they are observed to be adherent to each other and covered by inflammatory exudation. They present a dusky-red or even a dark color when the inflammation is recent. Exceptionally the cornea ulcerates and the eye bursts, with the loss of more or less of the liquids and shrinking of the eye. " But ordinarily no ulceration occurs, and as the patient con- valesces the oedema of the lids, the hypersemia of the conjunctiva, the cloud- iness of the cornea and of the humors gradually abate and the exudation in the pupils is absorbed. The iris bulges forward, and the deep tissues of the eye, viewed through the vitreous humor, which before had a dusky-red color from hypersemia, now present a dull-white color." The lens itself, at first transparent, after a while becomes cataractous. Sight is lost totally and for ever. If the patient live, the volume of the eye diminishes, as the inflammation abates, to less than the normal size, even when there has been no rupture and escape of the fluids, and divergent strabismus is likely to occur. Prof. Knapp. whose description of the eye I have for the most part followed, says : c; The nature of the eye affection is a purulent choroiditis, probably metastatic." Fortunately, so general and destructive an inflammation of the eye as has been described above is comparatively rare. On the other hand, conjunctivitis of greater or less severity, and hyperemia of the optic disk, consequent upon the brain disease, are not unusual, but they subside, leaving the function of the organ unimpaired. " In some cases incurable blindness is noticed under the ophthalmoscope picture of optic nerve-atrophy, probably the sequence of choked disk " (Knapp). CEREBROSPINAL FEVER. 441 Inflammation of the middle ear, of a mild grade and subsiding without impairment of hearing, is common. The membrana tympani during its con- tinuance presents a dull-yellowish, and in places a reddish, hue. Occasion- ally a more severe otitis media occurs, ending in suppuration, perforation of the membrani tympani. and otorrhoea, which ceases after a variable time. But otitis media is not the most severe of the affections of the organs of hearing. Certain patients lose their hearing entirely, and never regain it, and that, too. with little otalgia, otorrhoea, or other local symptoms by which so grave a result can be prognosticated. This loss of hearing does not occur at the same period of the disease in all cases. Some of those who become deaf are able to hear as they emerge from the stupor of the disease, but lose this function during convalescence, while the majority are observed to be deaf as soon as the stupor abates and full consciousness returns. Two important facts have been observed in reference to the loss of hearing in these patients — to wit, it is bilateral and complete. "When first observed it is. in some, as stated above, complete, but in others partial, and when partial it gradually increases till after some days or weeks, when it becomes complete. I have the records of 10 cases of this loss of hearing, most of them occurring in my own practice in the epidemic of 1872, but a few of them detailed to me by the physicians who observed them in the same epidemic. According to these statistics, about 1 in every 10 patients became deaf, but in the milder form of cerebro-spinal meningitis, which has prevailed since 1872, the pro- portionate number thus affected has been less among my patients, and the same may be said in reference to the loss of sight: 1 of the 10 cases was a young lady, but the rest were children under the age of ten years. Prof. Knapp has examined 31 cases. " In all/' says he, " the deafness was bilateral, and, with 2 exceptions of faint perceptions of sound, complete. Among the 29 cases of total deafness there is only 1 who seemed to give some evidence of hearing afterward." The same author has recently informed me that further experience has confirmed his previous statement, that while the blindness produced by cerebro-spinal fever is in the majority of cases monolateral, but one case had come to his notice in which the deafness was on one side only. One theory attributes the loss of hearing to inflammatory lesions, either at the centre of audition within the brain or in the course of the auditory nerves before they enter the auditory foramina. The other theory, which is the better established of the two and must be accepted, attributes the loss of hearing to inflammatory disease of the ear, and especially of the labyrinth. Symptoms of Endemic or Naturalized Cerebro-spinal Fever. — The numerous monographs on this disease which have appeared during the last few years relate to its epidemic form, and no published observations, so far as I am aware, describe the character or symptoms which it presents or the changes which it undergoes when it occurs as an endemic or naturalized disease. The endemic disease must, of course, be observed in the cities or populous towns, for there is no rural locality, so far as I am aware, in which this disease is permanently established. In New York the naturalized disease appears to be accompanied by a less profound blood-change than occurs in epidemic cases. Although every year seeing a considerable number of cases, I have not in the last ten years seen one with the livid spots upon the surface, due to subcutaneous extravasation of blood, which were so common in the epidemic of 1872, and which have been so common in epidemics both in this country and in Europe that the term " spotted fever " was applied to the malady. Occasionally petechise occur in severe cases of the naturalized disease. Nature. — The theory that cerebro-spinal fever is a local disease, occur- 442 CONSTITUTIONAL DISEASES. ring epidemically, was commonly held in the first part of this century, but is now discarded. Job Wilson in 1815 considered it a form of influenza, and could see no utility in drawing a distinction between spotted fever and influ- enza. We at the present time can see no resemblance between the two, ex- cept that both occur as epidemics. The theory that cerebro-spinal fever is a peculiar local disease, occurring in epidemics, is more plausible than that which holds that it is a form of influenza. Even Niemeyer says that it presents no symptoms except such as are referable to the local affection. But the evi- dence is strong that cerebro-spinal fever is a constitutional malady with the meningitis as a local manifestation, just like measles with its bronchitis or scarlet fever with its pharyngitis. The abrupt and severe commencement, unlike that of those forms of meningitis which are known to be strictly local, and the early blood-change, as shown in certain cases by the appearance of the skin and extravasation under it, indicate a general disease. Constitutional diseases having prominent local symptoms and lesions are usually regarded at first as local. It is only as time goes on and they are more thoroughly studied and understood, and clinical observations multiply, that their constitutional nature is recognized. The theory that cerebro-spinal fever is a form of typhus once had advo- cates, but it is now so generally discarded as untenable and absurd that it would be a waste of time to consider the facts which differentiate the two maladies. Cerebro-spinal fever should therefore be considered as distinct from all other diseases, a malady sui generis, and in nosological writings it should be classified with those constitutional maladies which have specific causes. Although this disease ordinarily occurs in an epidemic form in localities widely separated from one another, and, after continuing a few weeks or months, totally disappears, perhaps never to return or not till after the lapse of years, nevertheless in localities it becomes established, so that it is proper to describe it as an endemic — a fact to which we have already referred as regards certain American cities. I do not know that it is endemic in any village or rural locality in this country. The large cities, with their promis- cuous population, foreign and native, their crowded tenement-houses, and their many sources of insalubrity, furnish in an eminent degree the condi- tions which are favorable for the development and perpetuation of the mi- crobic diseases. Those diseases which in the present state of our knowledge we have reason to believe are caused by micro-organisms, we should expect to prevail most where domiciles are crowded and filthy, and systems are enervated by impure air, hardships, and privation. Hence in New York City, in the crowded quarters of the poor, cerebro-spinal fever, like diphtheria, is seldom or never absent. 1872 1873 1874 1875 1876 1877 1878 1879 Deaths in New York from Cerebro- Spinal Fever. Number. 782 1880 290 1881 158 1882 146 1883 127 1884 116 1885 97 1886 108 1887 Number. . 170 . 461 . 238 . 223 . 210 . 202 . 223 . 203 It is seen that the greatest mortality was in the first year after the introduc- tion of the disease into the city, after which the number of deaths gradually diminished, year by year, till 1878, when the lowest mortality was reached. CEREBROSPINAL FEVER. 443 After 1S7S the mortality gradually increased till 1881, in which year the number of deaths was double that of any other year except 1872. The mortuary reports of Philadelphia likewise show that cerebro-spinal fever has remained in that city since its introduction in 1863, a period of twenty-five years, the annual deaths produced by it varying between 36, the minimum, in 1869 and 1870, and 384, the maximum, in 1864. In Providence also, as appears from Dr. Snow's reports, cerebro-spinal fever has caused an- nually more or fewer deaths since 1871. Therefore, we repeat, this fact may be added to the sum of our knowledge of this disease, that, once gaining a lodgement where the conditions are favorable for it, as in a large city, it may become established and remain an indefinite time. Anatomical Characters. — I have notes of the post-mortem appearances in 76 cases, published chiefly in British and American journals : 29 died within the first three days, 28 between the third and twenty-first days, and the dura- tion of the remaining 19 was unknown. These records furnish the data for the following remarks : The blood undergoes changes which are due in part to the inflammatory and in part to the constitutional and asthenic nature of the disease. The pro- portion of fibrin is increased in cases that are not speedily fatal, as it ordi- narily is in idiopathic inflammation. Analyses of the blood by Ames, Tourdes, and Maillot show a variable proportion of fibrin from three and four-tenths to more than six parts in one thousand. In sthenic cases accom- panied by a pretty general meningitis, cerebral and spinal, there is, after the fever has continued some days, the maximum amount of fibrin, while in the asthenic and suddenly fatal cases, with inflammation slight or in its com- mencement, the fibrin is but little increased. The most common abnormal appearance of the blood observed at autopsies is a dark color, with unusual fluidity and the presence of dark soft clots. Exceptionally bubbles of gas have been observed in the large vessels and the cavities of the heart. An unusually dark color of the blood, small and soft dark clots, and the presence of gas-bubbles, when only a few hours have elapsed 'after death, indicate a malignant form of the disease, in which the blood is early and profoundly altered. In certain cases this fluid is not so changed as to attract attention from its appearance. The points or patches of extravasated blood which are observed in and under the skin during life in some patients usually remain in the cadaver. When an incision is made through them the blood is seen to have been extravasated, not only in the layers of the skin, but also in the sub- cutaneous connective tissue. Extravasations of small extent are likewise sometimes observed upon and in thoracic and abdominal organs. In those who die after a sickness of a few hours or days — namely, in the stage of acute inflammatory congestion — the cranial sinuses are found engorged with blood and containing soft dark clots. The meninges envelop- ing the brain are also intensely hyperaemic in their entire extent in most cadavers, but in some cases the hyperaemia is limited to a portion of the meninges, while other portions appear nearly normal. In those cases which end fatally within a few hours this hyperaemia is ordinarily the only lesion of the meninges ; but if the case be more protracted, serum and fibrin are soon exuded from the vessels into the meshes of the pia mater, and under- neath this membrane over the surface of the brain. Pus-cells also occur mixed with the fibrin, sometimes so few that they are discovered only with the microscope, but in other cases in such quantity as to be much in excess of the fibrin and to be readily detected by the naked eye. Pus. which in these cases probably consists of white blood-corpuscles which have escaped with the fibrin from the meningeal vessels, often appears early in the attack. The arachnoid soon loses its transparency and polish, and presents a cloudy 44-4 COXSTITUTIOXAL DISEASES. appearance over a greater or less extent of its surface. The cloudiness is usually greatest along the course of the vessels in the sulci and depressions, and where the fibrinous exudation is greatest, but it occurs also in places where no such exudation is apparent to the naked eye. The exudation — serous, fibrinous, and purulent — occurs, as in other forms of meningitis, within the meshes of the pia mater, and underneath this mem- brane over the surface of the brain. The fibrin is raised from the surface of the brain with the meninges in making the autopsy. It is most abundant in the intergyral spaces, around the course of the vessels, over and around the optic commissure, pons Varolii, cerebellum, and medulla oblongata, and along the Sylvian fissures. It is most abundant in the depressions, where it some- times has the thickness of one-tenth to one-fourth of an inch, but it often extends over the convolutions so as to conceal them from view. Most other forms of meningitis have a local cause, and are therefore limited to a small extent of the meninges — as, for example, meningitis from tubercles or caries of the petrous portion of the temporal bone, in both of which it is commonly limited to the base of the brain ; or from accidents, when the meningitis commonly occurs upon the side or summit of the brain. The meningitis of cerebro-spinal fever, on the other hand, having a general or constitutional cause, occurs with nearly equal frequency upon all parts of the meningeal surface, except that it is perhaps most severe in the depres- sions, where the vascular supply is greatest. In cases of great severity the inflammatory exudation, fibrinous or purulent, or both, covers nearly or quite the entire surface of the brain. In those who die at an early stage of the attack the vessels of the brain, like those of the meninges, are hypersemic. so that numerous " puncta vas- culosa " appear upon its incised surface. At a later period this hyperaeruia, like that of the meninges, may disappear. If there be much effusion of serum within the ventricles and over the surface of the brain, the convolu- tions are liable to be flattened, and the pressure may be so great that the amount of blood circulating in the brain is reduced below the normal quan- tity. Thus, in the case of a child of three years who lived sixteen days, and was examined after death by Burdon-Sanderson. the ventricles contained a large amount of turbid serum and the brain-substance was everywhere pale and anaemic from compression. Cerebral ramolUssement occurs in certain cases. At one of the examina- tions in Charity Hospital, the patient having been only three days sick, the brain was found much softened. The dissection was made seven hours after death, so that the softening could not have been the result of decomposition. At one of the post-mortem examinations in Bellevue Hospital, softening of the fornix, corpus callosum, and septum lucidum was observed, and in another softening in the neighborhood of the subarachnoid space. In a case related by Dr. Moorman 1 it is stated that portions of the brain, medulla oblongata, and pons Varolii were softened. In a case observed by Dr. Uphani softening of the superior portion of the left cerebral hemisphere had occurred. Occasionally the whole brain is somewhat softened. Burdon-Sanderson, Rus- sell, and Githens each relate such a case. Moreover, the walls of the lateral ventricles are ordinarily more or less softened in fatal cases of cerebro-spinal fever, as they are in other forms of meningitis. In rare instances the brain is cedematous, as in a case published by Dr. Hutchinson. 2 In this case the patient was only four days sick and the whole brain was oedematous, serum escaping from its incised surface. The ventricles contain liquid, in some patients transparent serum, in others serum turbid and containing flocculi of fibrin or fibrin with pus. The 1 American Journal of the Medical Sciences, October, 1866. 2 Ibid., July, 1866. CEREBRO-SPIXAL FEVER. 445 liquids in the different ventricles, since they intercommunicate, are the same. The choroid plexus is either injected or it is infiltrated with fibrin and pus, With the abatement of the inflammation, absorption commences. The serum, from its nature, is readily absorbed, and the pus and fibrin more slowly by fatty degeneration and liquefaction. Occasionally the serum remains, and chronic hydrocephalus results. An infant who contracted the disease at the age of five months, and appeared to be convalescent, had, two months sub- sequently, great prominence of the anterior fontanel, and other symptoms indicating the presence of a considerable amount of effusion within the cranium. In another case, one year afterward, examination showed the enlargement of the head and prominence of the fontanel which characterize chronic hydrocephalus. A boy of ten years treated in Roosevelt Hospital in 1878 died three months after the commencement of cerebro-spinal fever. The records of the autopsy state : " Body a skeleton ; brain, dura mater, and pia mater appear normal, except a little thickening of latter at base of brain ; ventricles much enlarged and full of clear serum ; surface of walls of ven- tricles appears normal, but is soft ; spinal cord and membranes apparently normal ; heart, lungs, stomach, and intestines normal ; liver congested ; kid- neys pale." In this case, therefore, all the other lesions of the cerebro-spinal axis, except the serous effusion, had nearly disappeared. No post-mortem examinations, so far as I am aware, have yet revealed the state of the brain and its meninges in those who have had this malady at some former time, and have fully recovered. Whether there may not be some traces of it which are permanent, as opacity or adhesions, must be determined by future observations. The remarks made in reference to the cerebral apply, for the most part, also to the spinal meninges. There is at first intense hyperemia of the membranes, usually over the entire surface of the cord, soon followed by fibrinous, purulent, and serous exudation in the meshes of the pia mater and underneath this membrane. This exudation is sometimes confined to a por- tion of the meninges, more frequently that covering the posterior than the anterior aspect of the cord, and when it is general it is ordinarily thicker posteriorly than anteriorly. In severe cases nearly or quite the entire spinal pia mater may be infiltrated by inflammatory products. Thus, in the case of an infant that died of cerebro-spinal fever at the age of ten weeks, in the service of Dr. H. D. Chapin in the Out-door Department at Bellevue, the entire spinal cord was covered by a fibrino-purulent exudation, except a space about six lines in extent upon the anterior surface. No constant or uniform lesions occur in the organs of the trunk, and those observed are not distinctive of this disease. Hypostatic congestion of the lungs, bronchitis, atelectasis, and broncho-pneumonia are common. Pleuritic, endocardial, and pericardial inflammations have occasionally been observed, but are rare. Effusion of serum, sometimes blood-stained, occasion- ally occurs in the pleural and other serous cavities. The auricles and ven- tricles of the heart, as already stated, contain more or less blood, with soft dark clots in the more malignant and rapidly fatal cases, but larger and firmer in those which have been more protracted. The spleen is enlarged in less than half the patients. The absence of uniformity as regards the state of the spleen, the fact that in many it undergoes no appreciable change, is important, since this organ is so generally enlarged and softened in the infec- tious diseases. The stomach, intestines, and liver are sometimes more or less congested, but in other cases their appearance is normal. The agminate and solitary glands of the intestines have ordinarily been overlooked, but in cer- tain cases they have been found prominent. The kidneys are normal, or they exhibit the lesions of nephritis. In 1 of 8 autopsies made by Prof. Welch acute diffuse nephritis had been present, as shown by the state of the kidneys. 446 CONSTITUTIONAL DISEASES. In the case of a child of nine years treated by Dr. F. A. Burrall in the Presbyterian Hospital the urine was very albuminous and the kidneys pre- sented a fatty appearance. Anatomical changes in these organs, however, are not common, unless in slight degree, so that in most patients their, function is fully and properly performed. Prognosis. — Cerebro-spinal fever is justly regarded as one of the most dangerous maladies of childhood. It is dreaded not only on account of the great mortality which attends it, but also on account of its protracted course, the suffering which it causes, the possible permanent injury of the important organ which is chiefly involved, and the irreparable damage which the eye and ear often sustain. I have the records of the result in 52 cases which I attended or saw in consultation in the epidemic of 1872. Of these just one-half recovered. 16 of the 26 who died were hopelessly comatose within the first seven days, most of them dying within that time, and some even on the first and second days, while others of the 16 lingered into the second week and died without any sign of returning consciousness. The remaining 10, who subsequently died, but did not become comatose in the first week, were nevertheless seri- ously sick from the first day, but their symptoms, though severe, were not such as necessarily indicated a fatal result, so that there was some expecta- tion of a favorable ending till near death, which occurred for the most part from asthenia. One succumbed to purpura haemorrhagica, the hemorrhages occurring from the mucous surfaces. The patient died after a sickness of more than two months, in a state of extreme emaciation and prostration. The 26 who recovered convalesced slowly, and usually after many fluctuations. Their highest temperature and most severe and dangerous symptoms occurred in the first week. Most of them were several weeks under observation and treatment before they sufficiently recovered to be out of danger. The statis- tics of this epidemic therefore show — and the same is true of other epidemics — that the first week is the time of greatest danger, and if no fatal symp- toms are developed during this week, recovery is probable with proper thera- peutic measures and kind, intelligent, and efficient nursing, which is very important. Since 1872 I have seen a larger number, and have preserved records of 40 cases which I was able to follow to the close. Some were seen in consul- tation. Of these 40, 21 recovered and 19 died. Of the 19 fatal cases, 9 died in the first week, 5 in the second week, 1 in the third week, 1 on the twenty- fifth day, 1 on the thirty-first day, and 1 in the sixteenth week. This last patient, a boy of ten years, would, in my opinion, have recovered with better nursing. His death occurred from large bed-sores which extended to the bones, produced by lying a long time in one position on a hard bed when he was too weak to move, and often with soiled bedclothes underneath him. The remaining case of the 19 died after a prolonged sickness. There is probably no disease which falsifies the predictions of the phy- sician more frequently than cerebro-spinal fever. This is due partly to the severity of the cerebral symptoms in the commencement, which, did they occur in other forms of meningitis with which he is more familiar, would justify an unfavorable prognosis, and partly to the remissions and exacerba- tions, the occurrence alternately of symptoms of apparent convalescence and recrudescence or relapse, which characterize the course of this malady. Grave initial symptoms, which may appear to have a fatal augury, are often fol- lowed by such a remission that all danger seems past, and in a few hours later perhaps the symptoms are nearly or quite as grave as at first. Under the age of five years and over that of thirty the prognosis is less favorable than between these ages. An abrupt and violent commencement. CEREBROSPINAL FEVER. 447 profound stupor, convulsions, active delirium, and great elevation of tempera- ture are symptoms which should excite solicitude and render the prognosis guarded. " If the temperature remain above 105° F., death is probable, even with moderate stupor. Numerous and large petechial eruptions show a pro- foundly altered state of the blood, and are therefore a bad prognostic ; and so is continued albuminuria, since it shows great blood-change or nephritis, while other organs than the kidneys are probably so involved. In one case, a boy whom I examined nearly a year after the cerebro-spinal fever, the kidneys were still affected. He had anasarca of the face and extremities, with albu- minuria. Chronic Bright 's disease had occurred from the acute nephritis which complicated cerebro-spinal fever. Profound stupor, though a danger- ous svmptom, is not necessarily fatal so long as the patient can be aroused to partial consciousness and the pupils are responsive to light ; so long as it does not pass into actual coma it is less dangerous than active or maniacal delirium, which is likely to eventuate in this coma. A mild commencement with general mildness of symptoms, as the ability to comprehend and answer questions, moderate pain and muscular rigidity, some appetite, moderate emaciation, little vomiting, etc., justify a favorable prognosis, but even in such cases it should be guarded till convalescence is fully established. We may repeat and emphasize the important fact shown by the above statistics, that patients who live till the close of the second week without serious complications will probably recover. The danger after this period is, in most instances, from exhaustion and feeble action of the heart, result- ing from the impaired nutrition and the protracted course of the disease. Complications which most frequently pertain to the lungs increase greatly the gravity of many cases and contribute to the fatal ending. The fact that Webber in his prize essay describes a variety of cerebro-spinal fever which he designates pneumonic, and that those who make post-mortem examinations find that " oedema, hypostatic congestion of the lungs, bronchitis, atelectasis, and broncho-pneumonia are extremely common lesions in cerebro-spinal men- ingitis " (Welch), indicate a source of danger in addition to that located in the cerebro-spinal system. One close observer of an epidemic writes : " In all the fatal cases which came under my notice the most prominent symptoms which preceded death were those which indicate impairment and perversion of the respiratory functions. As the breathing became more hurried and difficult the general depression became more intense, the pulse became weaker and quicker, and the temperature of the skin more elevated." Parenchymatous degeneration of the liver and kidneys is another serious complication. The kidneys are probably more frequently, and to a greater extent, diseased than the liver. We have already stated that nephritis was present in 1 of the 8 cases examined by Prof. Welch. In the Revue medi- cate for June 3, 1882, M. Ernest Gandier published the case of a female who died comatose on the sixth day of cerebro-spinal fever. Examination of the urine had revealed the presence of " retractile albumen of Prof. Bouchard, attributable to renal lesions, and non-retractile albumen, consid- ered as an indication of some general infection of the system." Microscopic examination of the kidneys " showed considerable swelling and granular degeneration of the renal epithelial cells, with effusion of granular matter within the lumina of the tubules." We have seen from the case referred to above that the renal complication may persist and become chronic. Those who fully recover often exhibit symptoms, usually of a nervous character, as irritability of disposition, headache, etc., for months or years after conva- lescence is established. Diagnosis. — Cerebro-spinal fever, on account of the nature and severity 448 CONSTITUTIONAL DISEASES. of its symptoms and the suddenness of its onset, may be mistaken for scarlet fever, and vice versa. In one instance, to my knowledge, this mistake was made. High febrile movement, vomiting, convulsions, and stupor are common in the commencement of scarlet fever, and the same symptoms commonl} x usher in the severer forms of cerebro-spinal fever. It will aid in diagnosis to ascer- tain whether there be redness of the fauces, for this is present in the commence- ment of scarlet fever, and a few hours later the characteristic efflorescence appears on the skin. The diagnosis of cerebro-spinal fever from the common forms of menin- gitis is ordinarily not difficult, for while in the former the maximum inten- sity of symptoms occurs in the first days, in the latter there is gradual and progressive increase of symptoms from a comparatively mild commencement. Moreover, cases of ordinary or sporadic meningitis occurring at the age when cerebro-spinal fever is most frequent are commonly secondary 1 , being due to tubercles, caries of the petrous portion of the temporal bone, or other lesion, and are therefore preceded and accompanied by symptoms which are directly referable to the primary disease. We have seen how different it is in cerebro-spinal fever, which in most patients begins abruptly in a state of previous good health. Again, in cerebro-spinal fever after the second or third day hyperesthesia, retraction of the head, and other characteristic symptoms occur, which are either not present or are much less pronounced in ordinary meningitis. Some of the milder cases of cerebro-spinal fever might be mistaken for hysteria, but the pain in the head and elsewhere, the muscular rigidity, and especially the occurrence of more or less fever, enable us to make the diagnosis. Continued fever, typhus or typhoid, resembles cerebro-spinal fever in certain particulars, but it lacks the muscular contrac- tion and rigidity which characterize the latter. It does not usually begin so abruptly, with such severe symptoms, especially such severe headache, has less marked fluctuations, and a more definite duration. These facts in con- nection with the character of the prevailing epidemic will enable us to make the diagnosis. In one instance commencing retro-pharyngeal abscess, prob- ably associated with vertebral caries, was at first mistaken by me for cerebro- spinal fever. The patient was an infant, had a temperature of 104° F.. stiff- ness of the neck, with some retraction of the head, and cried from pain when the head was brought forward. The speedy occurrence of two large abscesses in other parts of the system, difficult deglutition, and noisy respi- ration, led to a digital exploration of the fauces, when the abscess was found and opened. Treatment. — Since, in epidemics of cerebro-spinal fever cases are more frequent and severe where antihygienic conditions exist, it is evident that measures looking to the removal of such conditions, measures designed to pro- cure pure air in the domicile, wholesome diet, and a quiet and regular mode of life — in fine, measures designed to produce the highest degree of health — are of the first importance for the prevention of the disease. Cleanliness of the streets and areas, as well as of the apartments, good sewerage and drain- age, the prompt removal of all refuse matter, avoidance of overcrowding — in a word, the strict observance of sanitary requirements in every particular — will, there can be little doubt from what we know of the causation and nature of cerebro-spinal fever, diminish the number and severity of the cases. The avoidance of fatigue and overwork and of mental excitement, the use of plain and wholesome diet, sufficient sleep, the utmost regularity in the mode of life, with the least possible exposure to depressing agencies, are the important pre- ventive measures which should be recommended during an epidemic of cere- bro-spinal fever. The enjoining of a quiet and regular mode of life as a preventive measure CEREBROSPINAL FEVER. 449 during the occurrence of an epidemic of cerebro-spinal fever is not inconsist- ent with the theory that the cause is a micro-organism. It is not unreason- able to suppose that the system may be more or less under the influence of the specific principle, and that this principle may obtain lodgement in the blood or tissues without result until some exciting cause occurs which depresses the system and disturbs the functions, when the resisting power fails and cerebro- spinal fever appears ; just as those exposed to Asiatic cholera may remain well until some imprudence in the diet or the mode of life causes an outbreak of the malady. Curative Treatment. — In the commencement of cerebro-spinal fever in- tense inflammatory congestion occurs of the cerebral and spinal meninges, and also to a certain extent of the brain and spinal cord. As regards treatment, the obvious indication is to reduce the hyperaemia of the vessels as quickly as possible and subdue or diminish the inflammation. For this purpose bags or bladders of ice should be immediately applied over the head and to the nucha, and constantly retained there as long as there is no complaint of chil- liness, no marked diminution of temperature, and the patient experiences some relief from the intense headache and other symptoms. Bran mixed with pounded ice produces a more uniform coldness and is sometimes more agree- able to the patient than the ice alone. The bag or bags should be about one-third full, so as to fit upon the head like a cap, and the nurse should be instructed to renew the ice as soon as it melts. In severe cases with marked elevation of temperature it is proper to apply cold over the dorsal and lum- bar vertebrae, as well as upon the head and nucha. A hot mustard foot-bath or a general warm bath in those cases in which convulsions are present or threatening, or in which there is delirium or great agitation or severe peripheral pains, is also useful, since it has a calmative effect and acts as a derivative from the hyperaemic nerve-centres. One writer states that he obtained marked benefit in a case by immersing the body to the neck in hot water. The abstraction of blood, usually by leeches applied to the temples, be- hind the ears, or along the spine, has been employed, but even in the com- mencement of the present century, when it was customary to bleed generally and locally in the treatment of inflammatory and febrile diseases, a majority of the American physicians, whose writings are extant, discountenanced the abstraction of blood in the treatment of this disease. Drs. Strong, Foot, and Miner, though under the influence of the Broussaisian doctrine, were good observers, and they soon abandoned the use of the lancet and leeches in the treatment of these patients for more sustaining measures. Strong 1 states that certain physicians employed venesection as a means of relieving the internal congestions, but, finding that the pulse became more frequent after a mode- rate loss of blood, they soon laid aside the lancet. Some experienced physi- cians of that period, however, continued to recommend and practise deple- tion, general as well as local, as for example, Dr. Gallop, who treated many cases in Vermont in the epidemic of 1811. Venesection in the treatment of cerebro-spinal fever is universally dis- carded at the present time in this country and Europe, but some intelligent physicians, as Sanderson and Niemeyer. approve of local bleeding in certain cases. It is. in my opinion, after examining the histories of many cases, uncer- tain whether the abstraction of blood should ever be recommended, but if it be prescribed it should be on the first day, when the hyperaemia is greatest. by the application of only a few leeches behind the ears, and never except when coma or convulsions are present or threatening and the patient is robust. The fact should not be forgotten that cerebro-spinal fever is in its nature 1 Medical and Physiological Register, 1811. 29 450 CONSTITUTIONAL DISEASES. asthenic and protracted, and that the intense inflammatory congestion of the nervous centres can ordinarily be relieved, if relieved at all, by the other measures recommended, which do not reduce the strength. The alarming symptoms which usher in an attack, the intense headache, restlessness, delir- ium, sometimes eclampsia or coma, seem to demand the most energetic treat- ment, and yet it is surprising to one who has his first experiences with this malady how patients under proper treatment, without the abstraction of blood, emerge from an apparently almost hopeless state and ultimately recover. There may be total unconsciousness, the pupils dilated like rings and insensible to light, the head intensely hot, tonic convulsions present or alternating with frequent clonic convulsions, and yet these symptoms, which in any other disease would be regarded as sufficient to justify the prognosis of certain death, may gradually pass off toward the close of the first or in the second week, and the case afterward progress favorably. In the New York epidemic of 1872 — previous to which physicians of this city had no personal expe- rience with cerebro- spinal fever — many cases were pronounced hopeless which ultimately did well without abstraction of blood. In a case occurring in the practice of Dr. Griswold the patient was comatose for three days, with pupils not responding or but very feebly responding to light, but he recovered with- out the abstraction of blood and with the remedies ordinarily employed. In a case which we will presently relate in speaking of another local treatment the patient was still unconscious in the third week, with pupils greatly dilated and insensible to light, and yet recovered without losing blood. Such cases show that the most urgent symptoms, such as seem to indicate the prompt employment of leeches in order to reduce the meningeal hyperaemia and the consecutive congestion of the nerve-centres, may be relieved and the patient recover without such depletion, and with the preservation of the blood, which is so much needed in the subsequent asthenic course of the malady. In only one case have I recommended the abstraction of blood, and this was so instructive that I will briefly relate it : A girl four years of age was seized on March 7, 1873, with vomiting, chilliness, and trembling, followed by severe general clonic convulsions lasting about fifteen minutes ; was semi- comatose ; pulse 132, and a few hours later 156 ; temperature 101i° F. ; respiration 44 ; eyes closed, pupils moderately dilated and feebly responsive to light ; dusky mottling of skin, constant tremulousness with twitching of limbs. Bromide of potassium was administered in hourly doses of four grains, ice applied to the head and nucha, and a hot mustard foot-bath followed by sinapisms to the nucha. On the following day, March 8th, she was partly conscious when aroused, but immediately relapsed into sleep ; head retracted ; bowels constipated ; pulse 136 ; temperature 102° ; vomited occasionally. It was thought proper, on account of the extreme stupor, to apply one leech to each temple, and the bites trickled slowly nearly five hours. The other treat- ment was continued. On the 9th the pulse was 180 — so feeble that it was counted with difficulty; temperature 101|°. The patient was evidently sink- ing. It was necessary to order whiskey in teaspoonful doses every two hours, with beef tea and other most nutritious drinks. Evening, pulse 172, still feeble. March 10th, pulse 180, barely perceptible; great hyperesthesia ; axillary temperature 100° ; axis of eyes directed downward. After this the patient gradually rallied for a time, the pulse becoming stronger and less frequent, but death finally occurred after nine weeks in a state of extreme emaciation and exhaustion. Slight convulsions occurred in the last hours. It is seen that in the above case, which may be regarded as typical, the patient passed into a state of extreme prostration after the application of the leeches, so that for three days I did not believe that she would live from hour to hour, and death occurred after an illness of nine weeks, apparently CEREBROSPINAL FEVER. 451 from sheer exhaustion. Experience like this, which corresponds with that of most other observers, shows the necessity of preserving the blood, and thereby the strength, however urgent the initial symptoms, inasmuch as cerebro-spinal fever in its subsequent course is attended by such marked asthenia. On May 3, 1878, a boy of ten years was admitted into one of the New York hospitals in the service of a prominent physician. It was stated that he had been four days sick with cerebro-spinal fever, and among other characteristic symptoms he had had delirium every night, and on May 2d delirium in the day-time, which had abated considerably after free epistaxis. In the hospital the application of ten leeches along the spine was ordered, but it does not appear to have diminished the delirium or any other symp- tom, and the following day the pulse was so frequent and feeble that active stimulation by brandy was resorted to. He had three strong convulsions on May 13th. which were relieved by ice to the head and nape of neck and by six minims of Magendie's solution. Severe pains occurred at times in the back and limbs, and on the 29th, one month after the commencement of the disease, the same pain frequently recurring, twelve leeches were ordered to be applied to the spine. On June 2d the limbs were flexed and quite stiff, and the effort to move them was attended by great pain. The pain in the back was also more constant, and in consequence sixteen leeches were applied to the spine. The next day there was no pain, but the patient was very stupid. On June 6th the records state that he was obviously losing strengh day by day — that his emaciation was extreme and his anaemia very marked. But he had very great vitality, and, although he had strabismus, bed-sores, incontinence of urine and feces, and extreme prostration, he lingered till August 1st, At the autopsy: " Body a skeleton; brain, dura mater, and pia mater appear normal, except a little thickening of latter at base of brain ; ventricles much enlarged and full of clear serum ; surface of walls of ven- tricles looks normal, but is soft ; spinal cord and membranes appear normal to the naked eye." No disease was discovered in other organs, except that the liver appeared congested and the kidneys pale. It can scarcely be doubted that although some temporary relief from the pain may have resulted to this patient by the repeated application of leeches, which diminished the menin- geal hyperemia, yet his chances for ultimate recovery would have been far better without such depletion. Therefore the histories of cases show that the result of abstraction of blood has been unsatisfactory, on account of the asthenic nature and protracted course of cerebro-spinal fever, and it should never be recommended as a remedial agent. Some benefit is apparently derived from the application of stimulating and moderately irritating lotions along the spine. A liniment consisting of equal parts of camphorated oil and turpentine briskly applied by friction with flannel up and down the spine till redness is produced, appears to cause some alleviation of the suffering, and it does not conflict with the use of the ice-bag. Dr. William H. Sutton of Dallas, Texas, has published the follow- ing interesting case, showing the benefit from stimulating and irritant appli- cations over the spine made in an unusual manner : A child aged three and a half years had been three weeks under treatment, through error of diagnosis, for supposed continued fever. When Dr. Sutton assumed charge of the case, November 20, 1877, the pupils were greatly dilated and insensible to light ; features pallid and pinched ; pulse 130 ; temperature 103° F. ; patient totally unconscious. November 21st, morning temperature 105°, pulse 140 ; evening temperature 101 i°, pulse 120. November 22d, morning temperature 106 J, pulse 160; restless; evening temperature 105?°, pulse 120; had not slept, except for moments, for nearly two weeks. A strip of flannel saturated with turpentine was placed over the spine from the neck to the sacrum, and 452 CONSTITUTIONAL DISEASES. a hot smoothing-iron was run up and down it, and eight drops of the fluid extract of ergot were given every three hours. Dr. Sutton adds : " The father stated to me that as soon as the application was finished the child fell asleep, and slept several hours — the first for two weeks — and the fever rapidly declined. From this time he began to improve, and gradually and fully recov- ered." The use of irritants and derivatives over the spine in the treatment of cerebro-spinal fever has been long and favorably known, but the mode of producing irritation in the above case was novel. Internal Treatment. — It will aid in the selection of the proper remedies to recall to mind the pathological state which we know to be present from the many autopsies which have been recorded. We have seen that the largest mortality, and consequently the most dangerous period, is in the first days, when there is intense, suddenly-developed inflammatory congestion of the meninges, with more or less secondary hyperseniia of the underlying brain and spinal cord, producing great headache, delirium, or somnolence, with exaggerated reflex irritability of the spinal cord, so that eclampsia is a com- mon and fatal complication. Fortunately, a remedy has been discovered in modern times (the bromide of potassium) which acts promptly and efficiently. It can be safely admin- istered in large and frequent doses to the youngest child. It is quickly elim- inated from the system through the kidneys and other emunctories in chil- dren, so as to prevent the occurrence of bromism, at least to the extent of causing any unpleasant consequences. It causes contraction of the minute vessels of the nervous centres so as to diminish the hypersemia, as shown by the experiments and observations of Dr. Putnam-Jacobi and others, and at the same time it diminishes, in a marked degree the reflex irritability of the spinal cord — two most beneficial and important effects of its use in this dis- ease. Many children by its timely employment are saved from the dangers of eclampsia, and by its sedative effect on the nervous system and contractile action on the capillaries it probably diminishes the intensity of the inflam- mation and the amount of exudation. I usually prescribe it, as recommended by Dr. Squibb, dissolved in simple cold water. In ordinary cases, not attended by eclampsia or marked symptoms which show that eclampsia is threatening, I generally prescribe at my first visit about four grains every two hours to a child of two years who has the usual restlessness and apparent headache, and six grains to a child of five years. If eclampsia occur, the bromide should be given more frequently, as every five or ten minutes, till it ceases. It is important to be able to determine when the quantity of the bromide administered should be diminished and when its use should be discontinued. I have very rarely observed bromism in children, and never to the extent of doing any serious harm, though for many years I have administered it in large and frequent doses whenever the occasion seemed to require it ; but the symptoms of bromism cannot readily be discriminated from those which may result from cerebro-spinal fever, such as muscular weakness, dilated pupils, with perhaps impaired vision, unsteady gait, nausea or vomiting, and abdominal pains. If the case progress favorably, frequent and large doses should, in my opinion, be given only in the first week, after which this agent should be given at longer intervals or in smaller doses. But during exacer- bations, which are liable to occur from time to time till the patient is well on the way to recovery, the use of the bromide in full doses is again indicated till the urgent symptoms begin to abate. Phenacetin is one of the most important, perhaps the most important, of the remedies for the early stages of the disease. I know no remedy which controls the headache and the fever more effectually than this, and without any detriment. Yet I prescribe it very sparingly, or not at all, after the first CEREBROSPINAL FEVER. 453 week or ten days, through fear of its depressing effect. I always prescribe it with caffeine, which being a cerebral excitant, counteracts the depressing- effects of the phenacetine. The following is the formula which I employ for the adult : R. 01. cinnamomi, gtt. x ; Phenacetina?, h)iv (gr. 80) ; Sodii bromidi, £iij ; Caffeina? alkaloid, gr. xx ; Sacch. lactis, 3J. — Misce. Divid. in chart No. x. Give to an adult one powder every four to six hours according to the headache and fever. To a child of twelve years, half a pow- der ; to a child of eight years, one-third of a powder. Recently the pharmacists of New York City have in stock a coated pill con- taining 3 grains of phenacetine and 1? grains of citrate of caffeine. A half of one of these pills can be given to a child of twelve years, and one-fourth of one to a child of six years. Ergot is another remedy, but I am not aware that I have observed any benefit from its use in this disease. Its effect is, I think, mostly on the lower part of the spinal system. If employed it should be given during the first and second weeks, when the congestion of the nervous centres is greatest. At a more advanced stage, when there is less congestion and the danger arises from the inflammatory products and structural changes, the time for the use of ergot is past, or if it is still of some service it is less needed than at first and should be given less frequently. The severe headache and restlessness which attend many cases require the occasional use of an opiate or the hydrate of chloral. Chloral in proper dose never fails to give quiet sleep, and it is supposed by some who have studied its therapeutic action that it diminishes the cerebral circulation. It is therefore a useful adjuvant to the bromide. Five grains usually suffice for a child of six to eight years. Chloral is especially useful in cases attended by eclampsia or by symptoms which threaten eclampsia, since it acts promptly and decidedly in diminishing reflex irritability. Formerly it was considered injudicious and unsafe to prescribe opiates in meningeal inflamma- tion, since it was supposed that they increased the liability to coma, but experience shows that they are sometimes very useful in this disease when administered in small or moderate doses, and without the risk which was once supposed to be incurred by their use. The thirty-second part of a grain of morphia administered at intervals of some hours was sufficient to relieve the suffering of one of my patients at the age of six years. Quinia apparently does not exert any marked controlling effect on the course of cerebro-spinal fever or its symptoms, although the paroxysmal cha- racter of the severe pains in many patients suggests the use of this agent as an antiperiodic. It was frequently prescribed by New York physicians in the epidemic of 1872, but I believe that the opinion was unanimous that it was not the proper remedy. I have prescribed it in large and small doses, in one instance giving fifteen grains to a child of thirteen years, but do not know that I have observed any benefit from its use in this malady. It may increase the hyperaemia of the meninges and the cerebro-spinal axis. When the acute stage has abated measures designed to remove the serum which sometimes remains, constituting a hydrocephalus, are indicated. For this purpose the iodide of potassium is probably more useful than any other agent. It is administered by some physicians early along with the bromide. in the same manner in which they have been in the habit of treating other forms of meningitis. I have prescribed it with the bromide and alone when the bromide was discontinued, but whether it produces any marked sorbefa- 454 CONSTITUTIONAL DISEASES. cient effect in this disease apart from the removal of serum seems to me doubtful. The result depends to a great extent on the nursing. The skill of the physician may be thwarted and the life of the patient lost by inefficient nursing. No other disease more urgently requires kind, intelligent, and con- stant attendance night and day on the part of the nurse. Not only should the medicines and nutriment be given punctually and regularly, but the great restlessness of the patient in the first days requires constant readjusting of the ice-bags, and during the long period of convalescence the utmost care is required to remove at once the excretions in order to prevent bed-sores, and to give the proper amount and kind of nutriment to prevent the emacia- tion and weakness from which many perish. The diet, from the beginning to the end of the malady, should be the most nutritious and such as is easily digested. It is necessary to give it in the liquid form, unless in mild cases in which the appetite may not be entirely lost. It is proper to aid the digestion by pepsin preparations. Nutritive enemata, consisting of beef tea or one of the extracts of beef, milk, and brandy, aid in averting the fatal prostration in protracted cases. After the acute stage has passed and the meningeal hyperemia has abated the alcoholic compounds in moderate doses, which in the beginning might be injurious, may now be useful, administered regularly by the mouth. The room should be dark, well ventilated, and quiet. All sympathizing friends who are not required in the nursing should be excluded. I know of no other disease in which this is so necessary, for mental excitement may produce dangerous aggravation of symptoms. We will close our remarks on this interesting disease by the report of a case from the pen of Dr. Augustus Caille, professor of the Post-Graduate Hospital, and one of the best clinical observers of New York : " C. V., a girl of German parentage, four years of age, was admitted to the Babies' wards January 29, 1894. She had become acutely ill four days previously, complaining of pain in the head, which was followed by vomiting and restlessness. When admitted to the hospital she was in a greatly emaciated state, with the head retracted. A diagnosis of cerebro- spinal meningitis was at once made, and the administration of mercury, quinia, and salicylate of sodium was contemplated in the order named, with the hope of counteracting with a few " specific " drugs the infection, the nature of which is still unknown. Calomel was given in one-quarter grain doses every three hours for two days. On the third and fourth days several five-grain doses of sulphate of quinine were administered in compound elixir of taraxacum and subsequently sodium salicylate, five grains four times a day in a watery solution, was given by mouth. An ice-cap was placed to the head, and a liquid diet was ordered. Constipation, a prominent symp- tom throughout the case, was overcome by means of compound licorice powder. The temperature was, as usual, very irregular, ranging from 101° to 105° F. " On February 8th the salicylate was discontinued and five grains of phenacetine were given night and morning, and a pepsin and hydrochloric- acid mixture was given several times during the day to aid digestion. From February 14th to 18th no medicine was given on account of vomiting. The child about this time remained for hours in complete opisthotonos. Hyper- esthesia was a prominent feature throughout the case, and contractures of different groups of muscles were noticed, usually with an elevation of tem- perature, but no eclamptic attacks. Oscillations of the pupils were noticed. The urine was free from abnormal constituents. " About February 20th a slight purulent discharge from the ear was ACUTE RHEUMATISM. 455 observed, and a few days later divergent squint. In the later stage of the disease warm baths were given daily, and bromide of potassium internally, together with a nutritious and easily digested diet. On March 10th the child was out of bed and able to move about, and in a few days it will be sent to its parents, presenting no evidence of the recent severe illness through which it has passed."' CHAPTER V. ACUTE RHEUMATISM. Rheumatism is a constitutional disease with a local manifestation — to wit, inflammation of the fibrous tissues, chiefly in and around the articula- tions, but occasionally in other parts, as the heart and nervous centres. It was formerly supposed to be rare in children, but more accurate observations show that it is scarcely less common during childhood than in adult life. In young patients, especially under the age of six or eight years, it is frequently overlooked, for the articular inflammations in such patients are commonly slight. In the last twenty-five years, during my connection with the chil- dren's class in the Bureau for the Relief of the Out-door Poor, I have exam- ined many children with rheumatism or the cardiac lesions resulting from rheumatism, and ordinarily I have found that few joints had been affected, and that there had been but little swelling of them or redness, and that the patients were usually not confined to bed, or even to the sitting posture, but had been able to walk about, though with restraint and complaint of pain or soreness. The parents in many instances supposed that their children were suffering from "growing pains," as they designated them. At the same time, with this mildness of symptoms the heart was becoming seriously and permanently crippled by endocarditis. Those who have attended my clinics will recollect that on some days as many as three or four children with cardiac lesions have been present whose histories show an overlooked rheu- matism of this mild type. Cases like the following are very common among the city poor : In January, 1871, a little girl three years old was presented, having dis- tinct aortic direct and mitral regurgitant murmurs. The mother was not aware that she had had rheumatism, but at the age of twenty months she had for several days pretty active febrile symptoms, which the physician attributed to some other ailment. In April, 1871, another girl, of the same age, was brought to the clinic, having a distinct mitral regurgitant murmur. The mother stated that she had been well till a month previously, when she was confined to her bed for a few days, having a high fever. She was attended by a homoeopathic physician, and the exact character of her sickness the mother was not able to state. Further medical advice was sought, as the child remained delicate, though her health was better than at first. There can be little doubt that the obscure fever in this case was rheumatic. In another child treated elsewhere, not old enough to relate the subjective symptoms, there was, in addition to an intense fever, evident pain in one foot or leg when the limb was moved. Still, the nature of the disease was not diagnos- ticated till some time after recovery, when a valvular murmur was acci- dentally discovered. Such histories, which are not rare, show that rheu- matism often occurs in young children, even infants, and they inculcate the 456 CONSTITUTIONAL DISEASES. important practical lesson that the disease at this age may be so obscure or latent as to be overlooked even by good diagnosticians. Some observers, meeting cases of valvular disease in children without the history of rheumatism, have concluded that rheumatism is not the chief cause of endocarditis at this age ; l but the explanation which I have given seems to me more in consonance with the facts. Scarlet fever not infrequently causes endocarditis, but this exanthem seldom occurs without detection, and it has been as often absent as has rheumatism from the histories as given by the parents of young children with valvular disease whom I have examined. Moreover, the endocarditis of scarlet fever is in many cases associated with, if it do not result from, scarlatinous rheumatism. Rheumatism in children is primary or secondary. The secondary form occurs chiefly in the declining stage of scarlet fever and variola. It is stated also to occur occasionally in new-born infants during epidemics of puerperal fever, but I have not observed such cases. Causes. — An inherited rheumatic diathesis is universally recognized as an important predisposing cause of this disease, so that it frequently occurs in different members of the same family. When the family history shows a strong predisposition to rheumatism, it occurs in the child from a slight exciting cause ; if no such predisposition exist, it only occurs through unusual circumstances of exposure. Investigations have been made in order to determine whether acute rheumatism is a microbic disease. Dr. Alfred Mantle of England made cultures from the serum of 7 and from the blood of 16 patients with acute rheumatism. He states that he made use of every precaution to prevent contamination by germs from without. The organisms obtained by Mantle in the cultures were a micrococcus and a small bacillus. He states that these organisms produced lactic-acid fermentation in sterilized milk. He believes that the microbes do not produce the symptoms of rheu- matism by their direct action, but by the ptomaines to which they give rise, and he raises the question whether lactic acid is not the chief ptomaine {Brit. Med. Jour., 1887). Popow states that the micrococci obtained by cul- tivation from the blood of rheumatic patients inoculated in rabbits caused in these animals the characteristic symptoms of rheumatism, and in their blood and synovial fluid he found the same cocci ( Wiener med. Presse, Jan. 29, 1888). Cornil and Babes have also related a fatal case of rheumatism in which mi- crococci and bacilli were found in the right knee. Wilson found bacilli in the pericardium* in two cases of rheumatic pericarditis. Petrone examined the serum taken from the knee-joint in three cases of acute rheumatism, and in all the specimens examined discovered microbes similar to those detected by Klebs in rheumatic endocarditis. Jaccoud relates the histories of two newly-born infants whose mothers at the time of their birth had acute rheu- matism. One of them twelve hours after birth, and the other three days after birth, ' ; were attacked with fever, rapid pulse, and well-marked rheu- matic swelling of several articulations." Under treatment one recovered in eight days and the other in a little more than two weeks. The above observations lend support to the theory that acute rheumatism is a micro- bic disease, and perhaps observations indicate that it is to a certain extent infectious. Children who have had one attack are especially liable to another, and when the diathesis is acquired slight exposures appear to be sufficient to cause the disease. It has heretofore been the common belief in the profession — and this opinion is also held by the laity — that exposure to cold is the usual excit- ing cause of rheumatism ; but if the disease have a microbic origin, it is a question whether or to what extent this theory is true. It is stated in support 1 Dr. A. Steffen, Jahrbuchfur Kinderh., 1870. ACUTE RHEUMATISM. 457 of it that rheumatism is most common in cold and changeable weather and in those who are most exposed to vicissitudes of temperature. Scarlatinous rheumatism has been alluded to above. Frequently during the course of scarlet fever inflammation of certain joints occurs which can- not be distinguished from that in the ordinary form of rheumatism, and in some of these instances endocarditis or pericarditis also occurs. Dr. Ashby is inclined to believe that scarlatinous rheumatism is produced by septic poisoning, but it sometimes occurs at such an early stage or in cases of such mildness that the conditions giving rise to ordinary sepsis do not seem to be present. It is therefore probable, in my opinion, that in some instances at least this articular affection occurring in scarlet fever is due to the direct action of the scarlatinous microbe or to a ptomaine or ptomaines produced by this microbe. Symptoms. — The commencement of acute idiopathic rheumatism is in most cases sudden ; occasionally fever and a degree of soreness or stiffness precede the articular affection for a few hours or days. The inflammation, slight at first, increases gradually, attaining its maximum intensity within one or two days. The joint is painful, red, hot, and swollen. The swelling is due to inflammatory oedema of the tissues surrounding the joint and effusion within the joint. As in all inflammations, the vascularity of the parts involved is increased, the synovial membrane loses, more or less, its lustre, and the effused fluid, which is mainly serum, has been found, in most of the cases in which an opportunity was presented for examining it, to contain a few leucocytes. Rarely fibrin is exuded, producing a rubbing sensation when the joint is moved, and perhaps impairing the mobility of the articular surfaces. Fortunately, however, in a large majority of cases the substance exuded both without and within the joint is mainly serum, and hence the rapid subsidence of the swell- ing when the inflammation ceases. The pain is commonly not severe when the child is quiet, but it is greatly increased if the joint be pressed or the limb moved. The joints of the extremities are most frequently the seat of rheumatic inflammation, but occasionally those of the trunk, as the intervertebral, the symphysis pubis, etc., are involved. As the inflammation abates in the artic- ulations first affected it reappears in others, unless the materies morbi have been eliminated from the system. It is seldom that more than two or three of the joints are in a state of active inflammation at the same time. The temperature in acute rheumatism is elevated two or three degrees above that of health, and the pulse varies from 120 to 140, its frequency de- pending on the age of the patient as well as the gravity of the disease. Per- spiration is a common symptom. The appetite is impaired, the tongue slightly coated, and the bowels constipated. The watery element of the urine is diminished, as in most febrile diseases, and there is not a corresponding reduc- tion in the solid elements, so that the urine is rendered more dense and its specific gravity is high. The amount of urea and coloring matter excreted from the kidneys is augmented during the active period of rheumatism, and the urine when it cools deposits urates. In ordinary cases there is no prom- inent symptom referable to the nervous system, with the exception of pain in the affected joint. Acute rheumatism, if only the articulations were involved, would be a dis- ease of little danger, however painful, but unfortunately in its proneness to produce specific inflammation of the sero-fibrous tissues the heart frequently becomes involved, less frequently the lungs and pleura, and in rare instances the cerebral or spinal meninges. The so-called cerebral rheumatism is attended by high fever, restlessness, headache, and sometimes delirium and coma. Twitching of the muscles and sometimes tonic or clonic spasms occur. Prof. 458 CONSTITUTIONAL DISEASES. Flint says : " In the majority of cases death takes place during coma. In some cases recovery sets in even after the appearance of very grave symptoms. In fatal cases no lesions of the brain or of the meninges can really be found. The symptoms seem to be referable to some profound infection or intoxication which acts upon the thermic and other nervous centres." This form of rheu- matism is certainly rare in childhood. Endocarditis is the most frequent of the heart inflammations occurring in rheumatism ; pericarditis, though less common, is not infrequent ; while in rare instances myocarditis occurs, usually associated with the other inflammations. Endocarditis is limited to the left side of the heart, and seldom continues long without engaging the valves, aortic or mitral, or both, causing their infiltration, fibroid degeneration, with consequent thickening, and sometimes adhesion. The valvular lesion thus produced is in most instances permanent, so impairing the action of the valves as to obstruct in greater or less degree the flow of blood through the orifice and allow its regurgitation. The mitral valve is more frequently affected than the aortic ; at least bruits produced by this lesion are more frequently in the mitral than aortic orifice, and when they are heard in both orifices they are commonly loudest in the mitral. This fact, noticed by different observers, I have repeatedly verified by observations in this city. I have preserved the records of 73 cases of valvular disease in children, and in most of them I was able to assign rheumatism as the cause, but it was in a large proportion of instances very slight, so as not to confine the patients to bed, and had been considered by the parents simply " growing pains," so that no treatment had been received. The statistics of different observers show that endocarditis in acute rheumatism occurs more frequently in chil- dren than in adults. The first sign of an endocardial inflammation is in most instances a systolic murmur produced in the mitral orifice. It can be heard on listening over the heart, and also over the left scapula. It indi- cates insufficiency of the mitral orifice and regurgitation of blood into the left auricle. In some cases the aortic valves are at the same time affected, and an aortic direct murmur occurs, synchronous with the mitral regurgi- tant. In rare instances the endocarditis extends to the aortic orifice, causing thickening of its valves and impairing their action, so that an aortic bruit results, while the mitral orifice is not affected, and therefore no mitral murmur occurs. Another cardiac bruit resulting from the endocarditis occasionally observed is a reduplication of the second sound, heard most distinctly at the apex. A diastolic sound sometimes follows this reduplication, and when it is well developed it constitutes the so-called presystolic murmur. It usually results from mitral stenosis caused by the endocarditis. Pericarditis is not so common in rheumatism as endocarditis, but it some- times occurs in children as well as in adults. It occasionally even precedes the affection of the joints, being the first in time of the rheumatic inflam- mations. It causes an increase in the fever, palpitation, quick and irregular pulse, restlessness, cardiac pain, and perhaps dyspnoea. At first a pericardial friction-sound may be detected, and subsequently, when sero-fibrinous exuda- tion has occurred, the area of dulness may be increased, with a muffling of the sounds of the heart. If the effusion of serum be moderate, the peri- cardial surfaces may become agglutinated early in the disease, or they may become agglutinated after the serum is absorbed, so as to prevent friction- sound. An adherent pericardium embarrasses the action of the heart, and is likely to lead eventually to hypertrophy. Tonsillitis occurs so frequently in children who have the rheumatic diathesis, and also so frequently during rheumatism, that Trousseau recognized a rheumatic form of the disease. ACUTE RHEUMATISM. 459 Bronchitis, pleurisy, and pneumonia also occasionally occur as complications of rheumatism. While the articular affections pertain to the clinical history of rheuma- tism, the internal inflammation, whether of the heart, lungs, pleura, or meninges, though similar as regards its pathological character, is properly considered as a complication. Acute rheumatism is so frequently complicated by one or the other of these affections that any disproportionate severity in the general symptoms, as compared with the inflammation of the joints, or any sudden and unexpected increase in the symptoms, should always lead the physician to examine thoroughly the condition of those organs which are most frequently affected. Inflammatory complications occur, as a rule, during the active period of rheumatism, when the inflammation is passing from joint to joint. If the general symptoms begin to improve and no new joints are involved, the lia- bility to complications is greatly diminished. Pathology. — The joints affected by rheumatism present various grades of inflammation, but in all typical cases, however intense the inflammation, suppuration does not occur. In a paper read before the London Medical Society, April 9, 1888, Dr. Money stated that when suppuration does occur in rheumatism the disease is complicated with septicaemia, and Sir Wm. MacCprmac and Dr. Ord expressed a similar opinion. Acuteness of sensation is increased over the inflamed joint. The ana- tomical changes in the joints have been sufficiently described in our remarks relating to the symptoms. Recently several writers have called attention to the fact that nodules occasionally occur under the skin in rheumatism. Lindmann relates two cases, an adult and a child, in which during the course of rheumatism numerous nodules appeared rapidly under the skin. They were about the size of a pea, hard, movable, and painful, but without red- ness. They disappeared during convalescence. Lindmann collated the records of 59 rheumatic cases in which nodules occurred. A majority of them were females, and 46 were children. These bodies usually appeared suddenly in the later stages of rheumatism, and varied from the size of a pin's head to that of an almond. They continued from a few days to a month or longer (Deutsche med. Woch., p. 519, 1888). Examination with the microscope shows that they consist of newly- formed connective tissue, such as re- sults from inflammation (Amer. Journ. of Med. Sci., Oct., 1888). Garrod states that these nodules and muscular atro- phy sometimes occur in the most simple forms of hydrarthrosis, and are usually attended by an increase in the reflexes, suggesting an excitability in the spinal cord (Lond. Lane, June 2, 1888). It is stated that Charcot and Parisot also attribute the occurrence of these nod- ules to an exaggerated excitability of the spinal cord. On the other hand, Mayer and Cuilleret observed two cases of nodules and atrophy of certain muscles following an attack of arthritis, and they think that a true myelitis had occurred to produce such a result, along with the constant peripheral irritation {Lyon medical, Apr. 29, 1888). Homan relates the case Fig. 60. 460 CONSTITUTIONAL DISEASES. of a patient aged eighteen years who had rheumatism of the muscles of the left leg from the hip to the ankle, lasting several weeks. In the latter part of his sickness the calf of the leg became unusually tender, and a hard nodule occurred in the muscular substance, and was accompanied by atrophy of the muscular fibres. The nodule gradually subsided and disappeared (St. Louis Courier of Med., March, 1888). The above observations, to which more might be added, show that the anatomical characters of acute rheumatism are not restricted to the joints and heart, but subcutaneous nodules, and more or less muscular atrophy, occasionally occur. Cheadle says the nodules occur mostly in the neighborhood of joints, and that they are rare in adults, but very common in children. They develop within a few days, and sometimes in successive crops, " but they usually take many weeks to subside." The above figure represents these nodules as seen by Dr. Cheadle in a boy of four years. Fig. 61. t- - -&H : . The woodcut (Fig. 61) shows the microscopic appearance of a nodule from a child of seven and a half years, as observed by Dr. Cheadle ; it exhibits the active cell-infiltration and proliferation of fibrous tissue. Duration ; Prognosis. — With proper treatment and without complica- tion the febrile action in a few days begins to abate, and the disease com- monly terminates within two weeks. Its duration is ordinarily shorter than in rheumatism of the adult. Fluctuations, however, are liable to occur. The disease may appear to be abating and the articular inflammations nearly cease when they return for a time, often without new exposure and without appreciable cause. The prognosis, even when cardiac inflammation has super- vened, is in most cases favorable, except so far as the lesion resulting from this inflammation is concerned, which being permanent may entail much sub- sequent suffering and occasion death after months or years. Indeed, what is most to be dreaded in cases of acute rheumatism is valvular disease or peri- cardial adhesion with its remoter consequences — namely, hypertrophy of heart, congestion and oedema of lungs, dropsies, etc. Secondary rheumatism occurring in scarlet fever is sometimes also com- plicated with, or rather coexists with, cardiac inflammation, pleuritis, or pneu- monitis, rendering the prognosis more unfavorable. In rare instances the acute symptoms of rheumatism abate, but the joints remain stiff and more or less swollen and painful when moved. The ACUTE RHEUMATISM. 461 acute has lapsed into a subacute or chronic rheumatism. Such a case, rep- resented in the accompanying figure (Fig. 62), was brought to the children's class in the Out-door Department at Belle vue Hos- pital in February. 1871. E.'H , a female three Fig. 62. and a half years old. had intermittent fever from the age of nine to fifteen months. From this time she remained well till the age of two years, when she was taken with acute rheumatism, commencing in her ankles and extending to other joints. The knee- and hip-joints on both sides have only par- tially recovered their mobility, and both legs and both thighs are permanently flexed, so that the gait is slow and unsteady. It is impossible to straighten either limb without causing great pain, and attempts to straighten the thigh produce the arch in the back very similar to that in coxalgia. Diagnosis. — This is not difficult in ordinary cases if a proper examination be made. In the commencement, if the affection of the joints be slight, rheumatism might be mistaken for remit- tent, typhoid, one of the eruptive fevers, or men- ingitis ; but on careful examination tenderness of one or more of the articulations will be observed, and probably some swelling. This tenderness is readily distinguished from the hyperesthesia which is common in the first stage of the essential fevers, and which is observed when pressure is made upon the chest or abdomen as well as upon the limbs, and is more marked between the joints than in them. Any doubt which may at first exist whether the patient may not have one of those diseases is soon dispelled, since their clinical history presents notable differences from that of rheumatism. I have known scrofulous arthritis or scrofulous osteitis near the joint present so close a resemblance to acute rheumatism as to be at first mistaken for it. In one instance this inflammation commenced nearly simultaneously in three joints, rendering the diagnosis at first very difficult. But scrofulous inflammation, as well as that from pyaemia, can be diagnosticated from rheu- matic disease of the joints by its greater persistence, less induration and sym- metry in the swelling, and by the history of the case. Chronic rheumatism may produce deformity similar to that from chronic scrofulous inflammation, as in the case mentioned above, but the rheumatic history, number of joints affected, bilateral character of the inflammation, good general health, etc. are sufficient to establish a clear diagnosis when the disease has been observed for some days. Treatment. — The treatment of acute rheumatism has undergone marked variations in the last thirty years. Its speedy cure is urgently demanded, on account of the imminent peril to the heart. From 1847 until a recent period the alkaline treatment, by the bicarbonate of potassium and bicarbonate of sodium, the tartrate of potassium and sodium, and the citrate of potassium, was commonly employed to the extent of rendering the urine alkaline in twelve or twenty-four hours. Statistics appeared to show that the duration of rheumatism was abridged by the alkaline treatment, and the liability to cardiac complications was diminished as soon as the urine became alkaline. Grarrod reported 50 cases in which the average duration was six or seven 462 CONSTITUTIONAL DISEASES. days under the alkaline treatment. Fuller in 1862 stated that in no single instance in 194 cases did cardiac complications occur when the alkaline treat- ment had been employed twenty-four hours. Dickinson's statistics also fur- nished strong evidence of the usefulness of alkalies in large doses, given so as to render the urine alkaline in twelve to twenty-four hours. He also stated that the alkaline treatment was inadequate unless employed so as to render the urine alkaline. More recently, the late Prof. Austin Flint considered the evidence conclusive in regard to the efficacy of the alkaline treatment of rheumatism, the doses employed being so large that the urine becomes alka- line in twenty-four hours. But since 1875 a new and, in acute cases of rheumatism, a very efficient remedy has come into use — to wit, salicylic acid, or its compound, salicylate of sodium. The sodium salicylate is most frequently employed. It may be given every two hours to adults in doses of ten to twenty grains, and to children in proportionate doses. But, although salicylic acid or salicylate of sodium acts almost as a specific in recent cases of rheumatism, relieving the pain and fever and diminishing the articular inflammation, it often pro- duces certain ill effects. It impairs digestion, causing nausea, and sometimes vomiting. It produces tinnitus aurium, and sometimes headache or vertigo, and occasionally albuminuria, as I have several times observed, so that it should not be employed longer than is required to control the rheumatism. The employment of salicylic acid or salicylate of sodium does not, apparently, prevent cardiac or other complications, and it is probably best to administer it in combination with, or alternately with, an alkali. The following formula is essentially that which has been employed in the Out-door Department at Bellevue with apparently excellent results : R. A cidi salicylic, ^ij-iij ; Pot as. acetat., J§ss ; Glycerini, ^j ; Aqufe, q. s. ad J; v. — Misce. Give one teaspoonful every two or three hours to a child of six years. An eligible vehicle for the sodium salicylate is the syrup of raspberry, as in the following formula : R. Sodii salicylat., ^iij ; Sodii bicarbonat, ,^ij ; ' Syr. rubi idsei, ^ij ; Aqure, 3 iij . — Misce. Give one teaspoonful every two or three hours to a child of six years. Since the oil of wintergreen contains a considerable amount of salicylic acid, it has been sometimes employed, as in the following formula: R. 01. gaultherise, 3J ; Sodii salicylat., ^iij ; Syr. simplic, J^iij ; Aqusp, ^vj. — Misce. Dose : A dessertspoonful to a child of five years. During the declining period of rheumatism and in convalescence quinine or some preparation of cinchona should be employed and the above medicine given less often. This tonic does indeed appear to exert a beneficial effect on the course of rheumatism, and is employed by some judicious and experienced physicians from the commencement. If there be a high temperature and a quick pulse, quinine administered in ERYSIPELAS. 463 an occasional large dose will be found very useful. Three to five grains may be given to a child of five years. Rheumatism impoverishes the blood, and the patient often begins to present an anaemic appearance, when he requires iron in addition to the vegetable tonic. The citrate of iron and quinine may then be employed. Secondary rheumatism requires sustaining treatment from the first. Such cases ordinarily do well without antirheumatic treatment, with the general supporting measures employed for the primary disease. Pneumonitis complicating rheumatism is best treated by moderate coun- ter-irritation and emollient poultices and the internal use of carbonate of am- monium or quinine. In pericarditis or endocarditis if, as is commonly the case, the movements of the heart be accelerated, aconite or the tincture or infusion of digitalis is demanded to the extent of reducing the number of pulsations to near the normal frequency. A child of six years can take three drops of the tincture or a large teaspoonful of the infusion, to be repeated, if necessary, in three hours till the reduction of the pulse is effected. Pa- tients often experience relief by the use of this agent from the palpitation and dyspnoea consequent upon the embarrassed movements of the heart. If the heart disease be severe and pulse feeble, quinine is also useful. The tinc- ture of strophanthus or that of spartein is sometimes prescribed as a substi- tute for the digitalis. The patient should be kept quiet in a room of uniform temperature, and not exposed to draughts of air. By such precautions the danger of compli- cations is greatly diminished. Repellant applications, as cold or irritants, should not be applied to the joints so long as the disease is acute, for they also increase the danger of complications. The affected joints should be envel- oped in flannel or cotton, and the pain, if intense, may be diminished by apply- ing flannel wrung out of warm water. If the disease become subacute or chronic, if the urates have disappeared from the urine, and the inflammation cease to pass from joint to joint, the tincture of iodine or moderately stimu- lating embrocations applied to the joints involve no danger and are useful. CHAPTER VI. ERYSIPELAS. The term " erysipelas " is applied to a constitutional or blood disease which is characterized by inflammation of the skin and subcutaneous connective tissue and a tendency to spread. It is accompanied by pungent and pricking heat, swelling, and subcutaneous infiltration. It involves especially the lymph vessels and spaces. The skin has a bright- red color and is swollen. Erysipelas occasionally occurs in childhood ; the cases which are met in this period present nearly the same features and pursue nearly the same course as in the adult. In infancy erysipelas is a common disease, and the following remarks relate chiefly to erysipelas occurring in this period of life. My sta- tistics are based on data derived mainly from the records of cases which oc- curred in this city, some in my own practice, and others in the practice of physicians known to be good observers. The points of chief interest in 41 cases are embraced in the following table. In addition to these cases, I have records of some which are designated septicaemia in which more or less erysipelas occurred at and extended from the umbilicus. 464 CONSTITUTIONAL DISEASES. Cases of Infantile Erysipelas. Age. Point of commencement. Parts affected. Duration. Result. 1 M. o months. Right knee. i Entire surface, except face and scalp. 5 weeks and 1 3 days. From a little above the knee to the 7 days. Recovered. 2 M. 2 years. Left knee. Recovered. 3 M. 10 months Elbow. Whole arm and forearm. Recovered. 4 F. 20 Below right knee. Entire leg, thigh, and trunk to the umbilicus. 7 days.. Recovered. 5 F. 9 Vulva. Abdomen, chest, and all the ex- tremities. 18 " Recovered. 6 M. 9 days. Genitals. Both lower extremities, abdomen to the umbilicus. 6 " Died. 7 F. 1 year. Vulva. Entire surface, except face. 6 weeks. Recovered. 8 F. 6 weeks. At or near the ear. Forehead and side of face. 1 week. Died in tetanic 9 9 months. Epigastric region. Trunk and lower extremities. 2 weeks. spasms. Died in tetanic spasms. 10 F. 10 At angle of mouth. Entire face and scalp. 10 days. Recovered. 11 F. 4 weeks. Vulva. Entire surface, except face. 3 weeks. Died. 12 F. 3 months. Vulva. Surface of abdomen to umbilicus and 2 " right lower extremity. Recovered. 13 F. 4 to 5 mos. Vulva. All the limbs and trunk, except the 3 to 4 weeks. chest. Trunk and both lower extremities. Died. 14 F. 5 months. From syphilitic sores around anus. 15 F. 3 Vulva. Entire trunk and both upper ex- 3 weeks, tremities. Recovered. 16 M. 8 Face near nostrils. Entire trunk and both upper ex- About 2 tremities. 1 weeks. Recovered. 17 F. 4 Vulva. Entire trunk and all the extremities. 1 week. Died. 18 F. 7 Knee. A portion of trunk and both lower 3 weeks, extremities. Recovered. 19 F. 6 Near the ear. Entire face and forehead. 10 days. Recovered. 20 M. 7 davs. Left eyelid. Left side of face. 3 " Died. 21 M. 14 " Genitals. Extended to knee, over abdomen to the chest. 4 " Died. 22 M. 3 months. Under the chin. Chin, left cheek, neck, left side of trunk, left thigh and leg. 23 F. 28 Right shoulder. Arm and forearm. lday. Died in con- vulsions. 24 F. 3 or 4 days. Vulva. Body and all the limbs. 12 days.' Died. 25 F. 3^ mos. Under left ear. Neck, chest, and arms. About 2 weeks. Died. 26 7 months. Below right knee. Trunk, neck, and head, and all the limbs. Both thighs and nearly entire trunk. 2 weeks. Died comatose. 27 F. 6 Vulva. 3 days. Died comatose. 28 M. 19 Near point of vaccination. Shoulder, arm, and forearm. 21 " Recovered. 29 M. 4 « Near point of vaccination. Chest and both upper limbs. 2 weeks. Recovered. 30 M. 2 " Near vaccine vesicle. Trunk and all the limbs. |l0days. | Died. 31 3 to 4 mos Near vaccine Arm, forearm, and shoulder on one 2 to 3 weeks. Died. vesicle. side. 32 F. 4 months. Near vaccine vesicle. Arm, forearm, and trunk. 2 months. Died. 33 M. 2 Near vaccine vesicle. Nearly entire surface. 1 week. Died with per- itonitis. 34 M. 5^ " Near point of vaccination. Arm and forearm. Recovered. ' M. 2K " Near point of vaccination. Arm. 7 days. Died probably of peritonitis. 36 M. 8 Near vaccine vesicle. Arm and forearm. 17 " Died. 37 5 Left foot. Leg, thigh, and lower part of trunk. 2 weeks. Died witb pneumonitis. 38 5 weeks. At one ear. Entire surface. 2 " Recovered. 39 2 months Left leg. Trunk and all the limbs. 2 " Recovered. 4(1 4 Near point of vaccination. Trunk and all the limbs. 2 " Died. 41 M. 14 Face. Trunk and all the limbs. 4 " Recovered. Age. — Of the above cases, 27 were under the age of six months, 9 from six months to twelve, and only 5 above the latter age. A large majority, therefore, of cases of infantile erysipelas occur in the first year of life. Point of Commencement. — In 58 cases in which I have ascertained the point of commencement it was in 13 cases the vulva, 17 the arm after EBYSIPELAS. 465 vaccination, 7 the leg. 6 the face, 3 the male genital organs, 3 at or near the ear. 1 the elbow. 1 the shoulder. 1 the nates, 1 the foot. In the adult, idio- pathic erysipelas commonly commences upon the face and affects only the face, ears, forehead, and scalp. On the other hand, in infantile erysipelas statistics show that the rash commences upon the face only in a small pro- portion of cases. 1 in 9, and that it rarely extends to the face when it com- mences in other parts. Causes. — The fact that erysipelas is infectious has led to many micro- scopic examinations in order to discover the nature of the microbe which causes it. In most instances some injury of the surface has occurred through which the poison is received — a scratch or abrasion or a slight cutaneous eruption. Many cases have been cited showing infectiousness. In my practice a child contracted it from lying in bed with one of the family who had facial erysipelas. The following cases were related before the Paris Academy in 1864 : Dr. Paintevin contracted erysipelas from two cases occur- ring in a hospital ward, and was visited by Dr. Testart of Gruise, a place free from ervsipelas. Three days after returning home this physician sickened with erysipelas. His servant, who waited on him, and a relative living twenty-four miles away, who called on him. also contracted the disease. The relative's wife was then seized with it, and also three members of a family who had called upon them. These last patients communicated the disease to a relative and two Sisters of Mercy who nursed them. These sisters, returning to the convent, infected others, among whom was the physician of the convent, who died. The physician's daughter also contracted it, the inflammation beginning in leech-bites which had been made over enlarged glands. Infectiousness has been shown not only by clinical experience, but also by experiments ; small tumors have been successfully inoculated with cultures of the erysipelatous cocci, but some of the patients thus treated have died. The attempt to remove tumors by inoculating them with the erysipelatous virus shows the highly infectious character of erysipelas, and certain small tumors have been removed by the erysipelas, while in other instances the result has been disastrous, death occurring. Fehleisen has discovered the specific microbe of erysipelas — to wit, a chain coccus designated the streptococcus erysipelatis. This streptococcus has been designated streptococcus erysipelatis, which he has cultivated, and by inoculating the cultures he has been able to reproduce erysipelas in tumors. More recently Meerovitch made microscopic examinations in thirty-one cases of erysipelas, and invariably found a large number of these streptococci in the affected skin, and in grave cases also a few in the blood. He detected this organism in abscesses and in fatal cases likewise in internal organs. The cultures made in meat bouillon preserved their vitality four or five months. It is now known that this organism sometimes passes from the maternal organism to the foetus through the uterine circulation. Ziegler says that the micrococcus which causes erysipelas enters the lymphatics and spreads chiefly by them. They are found, says he, in immense masses or swarms in the lymphatics, and from them they spread into the tissues, where they excite inflammation and often tissue-necrosis (Lond. Med. Recorder, Nov. 20, 1888). The blood may undergo certain changes which predispose to erysipelas or render the system less able to resist the micrococcus. Among the causes which produce this state of system, uncleanliness, residence in damp, dark, and crowded apartments, and defective alimentation hold a principal place. Hence this disease is more common in the poor quarters of a city than in the country, and in dispensary and hospital than in family practice. In a large proportion of cases there is an irritation or inflammation at 30 466 CONSTITUTIONAL DISEASES. some point, generally trivial, through which the streptococcus enters the system. Erysipelas therefore commonly begins at a simple ecthymatous or impetiginous eruption, around burns or suppurating sores or syphilitic erup- tions ; it frequently commences, as is seen by the above table, near the point of vaccination immediately after vaccination or when the pock is developed, or again when it has run its course and been detached. In erysipelas super- vening on vaccinia the streptococcus erysipelatis has probably been conveyed by dirty fingers or clothing. I might relate two instances in the practice of two physicians in which the old way of vaccinating with the scab produced severe erysipelas in children on whom it was used. The scabs probably con- tained the streptococcus erysipelatis. In a considerable proportion of cases it begins at the point where the skin is thin and delicate or where it unites with a mucous surface. Thus, I have records of cases in which it commenced at the external ear, commissure of the mouth, and at the vulva. Indeed, the frequency with which it commences at the vulva renders female infants more liable to it than males. In some instances erysipelas begins without any local exciting causes upon smooth and sound skin, even when there are sores upon various points of the surface. Erysipelas neonatorum is treated of in our remarks on Septicaemia of the New-born. Premonitory Symptoms. — Infantile erysipelas in certain cases has no premonitory stage, or, if present, it escapes notice. In other instances there are well-marked precursory symptoms, as drowsiness or restlessness, more or less fever, oppressed respiration, with perhaps vomiting and sudden twitch- ing of the limbs. In Cases 28 and 37 of the table, which occurred in my practice, the fever, restlessness, and dyspnoea were so great for three days before the appearance of the eruption as to cause much anxiety. In the adult erysipelatous patient pharyngitis often precedes the occurrence of the rash upon the skin. The same inflammation may be present in the premon- itory period of infantile erysipelas, as well as during the period of erysipe- latous eruption. The hurried and difficult respiration which is present in the commencement of some cases is probably due to an erysipelatous turgescence of the bronchial mucous membrane. Symptoms. — The patient with this disease is usually restless in conse- quence of the burning pain which accompanies the eruption. In severe cases there is little sleep, night or day, except from medicine. The sleep is short, and is often interrupted by sudden starting or twitching of the limbs. Con- vulsions may occur, but are not common. Fever is constantly present, and is proportionate to the extent and gravity of the erysipelas. I have notes of cases in which the pulse was more than 200 per minute, although other symptoms did not indicate immediate danger. The skin not affected by erysipelas is dry and hot, though not possessing the pungent heat of the inflamed portion ; face often flushed ; tongue moist and covered with a light fur ; stomach usually retentive. The state of the bowels varies : sometimes they are regular, sometimes variable, and in other cases the stools are green and more frequent than natural. I have records relating to the state of the bowels in 20 cases, as follows : In 7, regular ; in 9, loose ; in 2, constipated; in 1, constipated, then loose; and in 1, constipated, then regular. Diarrhoea, when present, is usually mild, requiring little or no treat- ment. The erysipelatous redness is not in all cases so pronounced as in the adult, but otherwise there is nothing peculiar in its appearance. In feeble infants with an impoverished state of the blood its color is pink, instead of the deep red which characterizes the inflammation in the robust. Points of vesication may occur where the inflammation is most severe, as in the adult, and subsequently the same desquamation and oedema. ERYSIPELAS. 467 If the infant be debilitated, there is great danger of the formation of abscesses around which the inflammation lingers after it has disappeared from every other part of the body. Sometimes also in very young infants gangrene occurs, especially in the genital organs in the male. Several of these cases have been related to me, all under the age of a month or six weeks, and all fatal. Occasionally the sloughing is so great as to denude the testicle. A noteworthy feature of erysipelas in infants is its proneness to return. When it has been progressively subsiding and hope is entertained of its speedy disappearance, it not infrequently is suddenly relighted from some unknown cause, travelling again over the same or parts of the same surface. In one case the disease, arising from vaccination, extended three times over the arm and forearm ; and in another case a second time over both legs and a considerable part of the trunk. The internal inflammations which most frequently complicate erysipelas and give rise to symptoms which are superadded to those pertaining to the erysipelas are pharyngitis and peritonitis, and more rarely broncho-pneumonia or enteritis. In a case which I examined after death in the Nursery and Child's Hospital, and in which, the erysipelatous inflammation having extended over the abdomen, the lesions of peritonitis were present, it appeared from the thinness of the abdominal walls that the inflammation had extended through them from the external to the internal surface or from the skin to the peritoneum. Prognosis. — Erysipelas is much more fatal in infancy than in adult life. In the death-statistics of this city for three years I find 80 deaths from ery- sipelas of infants under the age of one year, to 83 deaths from this disease above that age. Age greatly influences the prognosis. Infants under the age of three weeks usually die ; from the age of three weeks to six months the result is doubtful ; while above the age of six months a majority recover with correct treatment. It will be seen by the foregoing table that 7 infants under the age of six weeks had erysipelas, and 6 died ; from the age of six weeks to six months, 6 recovered and 9 died; and above the age of six months, 9 recov- ered and 4 died. With the exception of a case of the so-called umbilical erysipelas, the youngest child who recovered of whom I have obtained information was three weeks old. In this case the rash extended nearly over the entire surface, be- ginning with the face. Case 38 of the table, treated by myself, was very similar as regards the extent of the erysipelatous eruption and the result. This infant was five weeks old. It is scarcely necessary to state that erysipelas is more favorable when it affects the limbs than when it invades the head, neck, or body ; when it spreads slowly than rapidly ; when it is superficial than when phlegmonous. In those cases in which the connective tissue is much involved the infant is not always safe after the disease has run its course ; he sometimes dies exhausted from the discharge of abscesses ; I have records of two such cases. Duration. — In 16 cases that recovered the erysipelas terminated within the first week in 2, the second week in 6, the third week in 5, fourth week in 1, and in 2 cases it lasted five and six weeks. The average duration was fifteen days. In 19 fatal cases, 10 died within the first week, 5 the second week, 3 the third week, and 1 in the fourth week. The average duration of fatal cases was about ten days. Modes of Death. — Death occurs in different ways : in chronic or tonic convulsions followed by coma, from exhaustion, and from internal inflamma- tion, that from exhaustion being probably the most common. Pathological Anatomy. — The blood doubtless in this disease under- goes certain pathological alterations previously to the occurrence of the erup- 468 CONSTITUTIONAL DISEASES. tion, but the exact changes are not known. Our knowledge of the morbid anatomy of erysipelas relates chiefly to the local affections, which, with the exception of the inflammation of the skin, are not constant, and may there- fore be regarded as complications. The cutaneous inflammation affects all the structures of the skin, and in greater or less degree also the subcutaneous con- nective tissue. The inflammation is accompanied by more or less serous effusion or oedema. The not infrequent occurrence of peritonitis in connection with erysipelas has long been known. In Heberden's Epitome Morborum Puerilium the ana- tomical character of erysipelas is expressed in one sentence : " When the body has been opened after death the intestines have been found glued together and covered with coagulable lymph."' Since Herberden's time nearly all who have written on diseases of infancy and childhood have mentioned peritonitis as one of the most common complications of erysipelas. Underwood says: "Upon examining several bodies after death the contents of the body have frequently been found glued together and their surface covered with inflammatory exu- dation exactly similar to that of those who have died of puerperal fever." Similar remarks in reference to the frequency of peritonitis in this disease are made by recent writers. The statistics in reference to erysipelas as well as peritonitis show that in infants in hospital practice, and in those affected by erysipelas during epi- demics of puerperal fever, peritonitis is a not infrequent complication. On the other hand, as we commonly meet cases of infantile erysipelas occurring spo- radically in private practice, abdominal distention and tenderness are not suf- ficient to indicate peritonitis. In only one of the cases embraced in the fore- going table was a post-mortem examination made, and in that there had been no peritonitis. The occurrence of pharyngitis in connection with erysipelas has been already mentioned. Enteritis has been alluded to as another complication in infants. Diar- rhoea has been stated to be a symptom in certain cases, and it has been found to be dependent on enteritis of a mild grade. Billard made post-mortem exam- inations of 16 infants who died of erysipelas, and " found in 2 gastro-enteritis, in 10 enteritis, in 3 pneumonia complicated with enteritis and cerebral conges- tion, and in 1 pleuro-pneumonia." Prophylaxis. — A patient with erysipelas should be isolated, and the bed- ding and linen worn by him should be placed in boiling water as soon as re- moved. No one should be allowed to occupy the bed or room when vacated by the patient until it has been thoroughly disinfected. Treatment. — The external treatment has varied greatly, but those agents are now most employed which have soothing or antiseptic properties. Among them we may mention iodoform in collodion. Scarification and leeching, formerly employed, have been abandoned as pernicious, and astringents, as alum and sugar of lead, are now known to be inefficacious. I have obtained the best results by applying the following ointment over the inflamed surface every three or four hours : R. Ichthvol, 3j ; Ung. aquse rosse, Sjj. — Misce. On this side of the Atlantic great uniformity prevails as regards the in- ternal treatment of erysipelas. Sustaining measures are prescribed, and the tincture of the chloride of iron is the tonic generally preferred. Whatever the intensity of the febrile reaction and the stage of the disease, if there be no intestinal complication ferruginous or other tonics should be administered. CRETINISM. 469 The largest doses of the tincture of the chloride of iron given in any of the cases in the above table were in Case No. 4 — namely, ten drops every two hours — and this patient recovered in seven days from a pretty severe attack. Probably, however, nothing is gained by such large doses, and they may irritate the intestinal surface and increase the liability to enteritis, which, we have seen, complicates a certain proportion of cases. Four drops may be given every three hours to a child from one to two years of age. Instead of the iron, or in addition to it, one of the preparations of cinchona may be prescribed. Erysipelas being an asthenic disease, it is very important that the diet should be highly nutritious and easily digested. Milk, perhaps peptonized, should be given freely, and the various meat peptones are also useful. Brandy or wine is also required. If vomiting be a pronounced symptom, it may be necessary to employ rectal alimentation. CHAPTER VII. CRETINISM (MYXCEDEMA). The term cretinism has long been employed to designate a remarkable disease which is endemic in certain localities in both hemispheres, and also occurs in a sporadic form in places widely separated. It was regarded as a disease mainly of infancy and childhood until 1873, when Sir William Gull published his observations on what he designated " a cretinoid state super- vening in adult life in women," and Ord gave it the name myxoedema, which is still retained to designate cases which commence in adult life. I shall apply the term cretinism to cases which begin in infancy or child- hood or come under observation as cretins during these periods. It is known that a large proportion of cretins manifest symptoms of the disease in infancy, or at so early an age that their cretinism is properly regarded as congenital. Thus in his instructive paper on this malady, read before the New York Academy of Medicine, Dr. Crary relates the case of a female in whom the symptoms had continued during the entire life ; and at the age of five years, when the child was not larger than an infant of ten months, and different physicians had examined her, the correct diagnosis was first made. The cretinism in this case, as in many others having a late diagnosis, was evidently congenital. We shall see hereafter that many of these dwarfs suffering from cretinism have been treated for months by prominent physi- cians for chronic Bright's disease. Cretinism occurs in many places widely separated in the Alpine chain, which traverses Switzerland, Piedmont, and Lombardy ; upon the northern slopes of the Apennines and southern slopes of the Pyrenees ; in Savoy ; along the banks of the Danube and Traun in Wurtemberg ; in the Black Forest ; in the valley of Ojat, Russia ; Irkutsk, Siberia ; on both slopes of the Himalaya ; and in parts of Cochin China and Burmah. In the Western hemisphere cretinism occurs along the valley of the Magdalena River ; in certain parts of New England, New York, Ohio. California ; but in no part of the Western hemisphere have cases been numerous, so far as I can learn. Although cretinism occurs over greater and smaller areas in so many localities, sufficient investigations have not been made to determine the influ- ence of climate, soil, altitude, or the habits and conditions of the people bearing upon its causation. I have not been able to ascertain that any abnormal state of either parent or in their mode of life acts as a predisposing or exciting cause of cretinism in their children. In this country only one in a family or circle of relatives 470 CONSTITUTIONAL DISEASES. is, as a rule, affected. But the fact that it is endemic in certain localities for a long series of years encourages the belief that the local cause or causes, which seem to act by destroying the thyroid gland or antagonizing its func- tion, will yet be discovered. No other disease presents to our consideration more anatomical characters than this. Prudden and Delafield say : " The most marked and constant lesion in this disease is an atrophic condition of the thyroid gland. The parenchyma is more or less completely replaced by the fibrillar connective tissue and by new-formed reticular tissue, resembling the lymphatic tissue of the lymph-nodes. The fat-tissues may be atrophic, and the subcutaneous tissue has been shown in some, but not in all the cases, to contain an unusual amount of mucin. In certain patients the fibres of the upper or external part of the corium are crowded apart by fluid." Among the anatomical characters pertaining to the circulatory system may be mentioned diminution of the relative number of red corpuscles, also of the haemoglobin ; white corpuscles normal ; hypertrophy of left ventricle ; intestinal myocarditis, endarteritis ; atheromatous and amyloid degenerations. The patient is liable to headaches, anaphrodisia, rheumatoid pains, low tem- perature (95° to 98°), pulse weak and slow, respiration 17, urine of low spe- cific gravity, 1008-1014, diminution of urea ; sometimes the presence of albumen in small amount, with a few hyaline and granular casts ; has variable appetite ; constipation ; frequent and painful micturition. The body of the cretin is always short and thick. When fully devel- oped its height is from 3 i to 4 J feet; its cutaneous and subcutaneous circu- lation is slow, and the action of the heart is generally not strong ; sutures and fontanelles of the cranium slow in closing ; the teeth grow slowly and blacken and decay early. The patient has atrophy of the hair-follicles ; many have a dry and scaly scalp, which supports a coarse growth of hair coming down low on the forehead, but the hair is absent or scanty upon the axillae and pubes ; expression of face dull ; it is large and broad, with the usual lines, depressions, and prominences wanting ; eyelids cool, smooth, and dry, appearing thickened, so as sometimes to nearly obstruct vision by their swelling and approximation to each other ; nose swollen, short, and flattened ; lips large, thick, and pendulous, and of a dark violet color ; tongue large, thick, protruding, and only partially covered by the lips ; it is moved with difficulty, so that the partaking of solid food, or even liquid food in severe cases, is not easy, and it is in some patients regurgitated. The fact that there is the appearance of general oedema, and yet the pitting or pressure is very slight, has been alluded to by various writers. The explanation of this given by Delafield and Prudden has been, I believe, generally accepted : " The fat- tissues may be atrophic, and the subcutaneous tissue has been shown in some, though not all of the cases, to contain an unusual amount of mucin. In some cases the fibres of the upper layers of the corium are crowded apart by fluid." The small size of the interspaces in the superficial part of the corium and the viscidity of mucin afford explanation of the fact to which we allude. Hectic spots occasionally occur over the malar bones, and sometimes parts of the surface, especially the hands and face, have a yellowish or mahogany color or that like Addison's disease. As is seen in all the illustrations, the skin of the abdomen is pendulous and flabby and the swelling of the breasts nearly or quite conceals the nipples. Breathing through the nostrils is slow, and if for any reason it is accelerated, dyspnoea results. The swelling of the Schneiderian surface embarrasses respiration through the nostrils, and snoring during sleep is common. A muco-sanguinolent or reddish-brown stain, occur- ring during sleep, is sometimes observed upon the pillow, having oozed from the nostrils or mouth. CRETINISM. 471 Warm weather is useful to these cases, and during the heat of summer certain cases may improve. The general paresis is such that some patients are scarcely able to stand without support, even at the age of four or five years. Bramwell says that the walking, or waddling as he expresses it, is like that of the hippopotamus. Cretinism affects equally body and mind ; it arrests bodily and mental growth and development. While at the age of four or five years the cretin can scarcely stand or walk without support, at the same time his speech lacks intelligence and sound and consecutive thought, and is likely to be indistinct or monosyllabic. Cretinism, when it pursues its normal course uninfluenced by medicine, is chronic. It may continue many years, with occasional amelioration of some of the symptoms, but only for a brief time. Death occurs in a comatose state. If the patient reach adult life, he is still physically and mentally de- generate till the close of life. Diagnosis. — Cretinism has such pronounced anatomical and physiological characters that the diagnosis is easy when the physician has once observed a case. Yet in many instances a mistaken diagnosis has been made because the physician is not familiar with it and the disease is in its earty stages. It has been and is most frequently mistaken for chronic Bright's disease. The gen- eral oedema in the one from mucin, and in the other from serum; the albumen and occasional casts in the urine and the general weakness which occur in both diseases have led to cretinism being mistaken for Bright's disease, and vice versa. The oedema not pitting, not affected by gravitation or but slightly affected, no perspiration, with a rough and dry skin, coarse, " wiry " and scanty hair, and other diagnostic symptoms which are related in this paper suffice for the exclusion of Bright's disease. The following case of congenital cretinism was presented by J. P. West, M. D., of Bellaire, Ohio, to the Eastern Ohio Medical Society, July 10, 1894, and January 8, 1895 : July 10, 1894 : A congenital cretin, now seventeen and a half months old, was born and has lived about a mile from Bellaire, on a hill four hundred feet above the Ohio River. She is the third of four children ; the other three are boys. The oldest died, when six months old, of cholera infantum. The second child is four years old, and the youngest nine weeks. These are very healthy children. The father, a farmer, is twenty-seven and the mother twenty-two years old, both being healthy. There is no history of any hereditary disease nor of goitre, nor is there any goitre in the vicinity. The labor was normal, the child small, weighing about six pounds. For the first few months nothing appeared wrong with the baby, although the mother saw she was slower about noticing things than her other children had been, and would lie unnat- urally quiet for long periods, often paying no attention whatever to her voice or to any noise. As time passed she showed no desire to sit alone and seldom a desire to raise her head. Her mouth was always open, her tongue protruding ; she took no notice of her surroundings, and it was with the greatest difficulty that her attention could be attracted. She was now about nine months old, and it was evident to the pa- rents there was something wrong, but it was believed she would outgrow it. When seventeen months old she weighed fourteen and a half pounds and was twenty-three inches in height. Her skin is thick, harsh, dry, and yellowish. Over her shoulders and arms there is some roughness and peeling of the skin ; this often occurs on the feet also. The head is flat, with a low forehead and prominent parietal eminences. The anterior fontanel widely open ; at times flat, at others full. Her hair coarse, rough, and scanty ; eyes dull ; the lids red and puffy, and cover the lower half of the cornea ; nose is broad and flat ; mouth always open ; lips very thick : neck short and thick ; no thyroid gland felt ; chest rather narrow ; a small swelling can be felt where each rib joins its cartilage ; abdomen full, prominent, and hard : umbilicus protruding ; abdominal organs normal : the hands short and stubby : legs short, thick, and bowed ; joints of the extremities somewhat enlarged ; some lor- 472 CONSTITUTIONAL DISEASES. dosis ; temperature varies from 97f° to 99° F. in the rectum ; breathing almost always noisy, as if there were naso-pharyngeal obstruction ; respiration 24 ; pulse 96. I have never heard her cry but once, when it was most peculiar and distress- ing. When crying she first becomes very restless, then opens her mouth wide, shuts her eyes tight, gets very red in the face, and emits a sound resembling a grunting cough. This sound is repeated again and again, from twenty to forty seconds apart ; the face in the interval is held firmly in the position just described. Her laugh, which I have never heard, is said to be as peculiar as her cry. Is good-natured ■ can be made to laugh, and seldom cries ; often lies perfectly still ; breathes slowly and quietly, and cannot be aroused. Occasionally, when laugh- ing or crying, or even when still, she almost strangles ; becomes blue in the face, and it is only with difficulty she can be brought to her normal condition. This occurs without recognizable cause, may be repeated two or three times in a day, or may not occur for a week at a time ; seldom sweats, and never freely ; takes but little food, and that milk ; is very costive. On July 20, 1894, she was put on Crary's glycerin extract of the thyroid gland, one and a half drops three times a day. After taking this two weeks she became feverish and fretful, and the dose was diminished, and stopped entirely from August 4th to 7th, then was begun again and kept up until August 23d. From this time until the present she has taken almost uninterruptedly one grain of the pow- dered thyroid twice a day. In the latter part of August she was sweating so pro- fusely about the head, particularly when asleep, that only one grain daily was given during the first ten days of September, but as this had no effect on the sweating, she was put back on the two grains. On October 15th and again on December 10th three one-grain doses were tried, but she could not tolerate this amount, and we continued with the two grains. For three weeks in July she took fluid extract of cascara sagrada for the constipation, after which she had no trouble with her bowels. On September 20th she was ordered five- to ten-drop doses of cod-liver oil and a small teaspoonful of cream three times a day. This treatment was continued until the latter part of November, when it was thought best to discontinue it, as the sweating had ceased and she was becoming quite fat. The child had not been under treatment quite four weeks before some improve- ment could be noticed. Her skin was not quite so thick and yellowish, her lips and tongue not so large, and her attention more easily attracted. During August there was a gradual and very perceptible change, and a new growth of hair appeared. On September 20th I noted that there was a considerable growth of new hair, which covered most of the scalp, was finer, and not harsh and wiry like the old ; on the sides of the head dark-brown, much darker than on the other parts of the head. She plays most of the time and notices everything said to her and given her. She will lie on the floor for an hour playing with her feet and trying to put them in her mouth. She turns her head quickly when spoken to, and looks at one intelligently. October 1st : Is twenty-five inches in height. Weighs sixteen and a half pounds. Her abdomen has lost two and a half inches and her chest gained one and a half. The anterior fontanel is one-third smaller ; skin not so yellowish nor so thick. There is a little peeling over the knees and front of legs. She holds the head up with but little effort, has a pleasant expression, smiles, and is easily made to laugh. The cry and laugh have lost their former peculiarities and are now perfectly natural. The eyelids are swollen but little, her lips are not so large, and the tongue is very seldom out of the mouth. A few hard papules are scattered over her face. Her hands are not quite so " spade-like,' 1 but she retains her stumpy look. November 1st : The improvement noted above has continued, and she has gained in every way. All the old hair is gone. The head is not so flat nor square, the fontanel only one-third its former size. The tongue no longer protrudes, and the mouth is assuming a much better shape. The skin is smooth, soft, and clear. She eats and sleeps well, and plays most of the time, knows all the family, and exhibits considerable jealousy toward her younger brother. January 8, 1895 : Her improvement has been steady and rapid. There is no evidence now that would indicate that this child was a cretin, except her height. She is several inches shorter than she should be and still looks somewhat stumpy. Notice that her skin is as soft and clear as any child's. Her hair is plentiful, soft, and silky, while before it was scanty and wiry. The expression of her face is bright, and she knows all that goes on about her. She will try to cough and CBETIXISM. 473 sneeze, and do many other things when told. Her eyelids are no longer swollen and baggy. Her tongue is perfectly normal, and her mouth anything but repul- sive. During her waking hours she is continually on the move. I call your atten- tion, particularly, to her abdomen and umbilicus, and the changes that have taken place here. The abdomen is not larger than it should be and the umbilical hernia, J lilt; 11 IS llUL ictigci Liictii it biiuuiu uc ciiju. tiic u.111 Fjn±^a>± nciiua present at first, is gone. On October 1st she cut her two lower incisor teeth, the November 27th and the second ..December 7th, the two upper first upper incisor on Fig. 63. Fig. 64. Case of cretinism described above. The same ease after six months' treatment with the thyroid extract. lateral incisors in the middle of December, and the two lower the latter part of the month. She began sitting alone the middle of November, and now can stand by holding to a chair. She cannot crawl, but you would be surprised to see how fast she can go across a room by rolling over and over. This table will afford an idea of her improvement : Weight Height Neck Chest . Abdomen Circumference of head Ear to ear Nose to occiput . . . 474 CONSTITUTIONAL DISEASES. Treatment. — The remarkable fact has been established by many obser- vations that the thyroid gland contains some substance which, administered to cretins, exerts a curative effect. Without this ductless gland, which until recently was supposed to be superfluous, it now appears that man would be reduced to a state of feebleness and imbecility. There is no branch of the human race which does not have more mental activity, and which is not more competent to reduce and utilize the forces of nature, than the cretin, so that if we all lacked this substance which the thyroid gland contributes to the system, and which elevates and energizes the action of the brain. — if, in other words, all human beings were cretins, the condition of the race would be deplorable. By the use of the thyroid gland as a medicine taken by the mouth or by subcutaneous injection the prominent symptoms of cretinism gradually dis- appear, and the patient approaches more and more the normal state of devel- opment and growth. The temperature, pulse, and respiration become more normal. In most cases gradual improvement occurs under correct treatment in the many particulars in which the disease manifests itself. Since the thyroid gland has been recognized as the efficient curative agent of cretinism, it has been employed in various ways. Murray's original preparation is most used. It contains one drachm of the expressed juice, one drachm of glycerin, and one-half of 1 per cent, of the aqueous solu- tion of carbolic acid. Five to fifteen minims are injected two or three times daily under the skin. A flushed face, pain when the remedy is inserted, which is by preference in the lumbar region, indicate that the remedy should be discontinued. In all cases of the use of the glycerin extract the glands are carefully cleaned, minced, and 24 grains are added to 1 drachm of gly- cerin, and after maceration with the glycerin the mixture is allowed to stand, after which it is filtered by compression. Full antiseptic precautions are used in the process of preparing the gland, and the glycerin is sterilized previously, and diseased glands are rejected. The medicine when prepared should be kept from heat and light. At the beginning of treatment the dose of this preparation should be for an adult 5 drops three times daily, with a gradual increase to 15 drops. In the treatment of infants 1 drop of the above, three times daily, is sufficient at first, and the maximum amount attained by gradual increase should be perhaps 4 drops four times daily. In the opinion of Dr. Crary this medicine prepared from the thyroid glands of lambs is more effectual than that from older sheep. Case. — Eelated by Dr. G. W. Crary, D. D. : Female, aged five years, born in Boston of New England parentage ; an only child. The mother has had an irri- table and rapid heart, and is anaemic. During the period of her gestation, ending with the birth of the child, she was constantly nauseated. She had also tonsillitis for five weeks, and a broken rib by an accident in the third month of gestation. The birth was instrumental and the cord was around the neck. The child at birth was apparently normal, weighing eight pounds. The first symptoms of cretinism were noticed at the age of three months. The tongue was apparently thick and she was pronounced tongue-tied. She weighs at five years fifteen pounds ; has chronic constipation. At the age of four months she cried much, and had attacks of dyspnoea ; at six months ceased to grow and lost weight : at eight months the abnormal development in different ways was first noticed : the swollen and pro- truding tongue, swelling of the cheek, lack of bodily and mental development, were apparent, but the disease was not diagnosticated until after the age of five years. At this time the child was of the size of a ten months' infant. The following symptoms indicated clearly the nature of the disease : Slight mental perception ; a lighted match did not attract attention ; loud noises caused her to turn, but she could not locate them ; no response to the call of her name ; disposition good ; when placed upon her back turned with difficulty upon her face CRETINISM. 475 and abdomen ; -when sitting upon the floor usually fell prostrate without effort to prevent falling : hair of scalp thin and coarse, but present upon forehead and sides of face ; temperature 97°-9S° ; anaemic. "We will now relate the mode of treatment : " I have used the glycerin extract in all cases, and make it of a strength of 24 grams of the thyroid gland of the lamb to 1 drachm of glycerin. The glands are carefully cleaned, minced, and after maceration with the glycerin the mixture is allowed to stand for three or four days, after which it is filtered under pres- sure as required for use." One drop, three times daily, of the above medicine was at first adminis- tered. This was gradually increased until 4 drops were given, and the tem- perature arose to 99°. On September 19th the appearance was better, with more notice of objects. On September 27th, 5 drops were taken and the temperature was normal ; swelling of body, face, and lips much reduced ; tongue swells and more movable, and could be kept within the lips, but not within the closed jaws ; skin soft and more moist ; bowels normal ; is brighter, and turns her head in the direction of the voice. On October 5th and 6th the quantity administered of the extract was 15 to 16 drops daily, and her temperature was 101°. The dose was therefore reduced to 3 drops three times daily, but she was far advanced toward recovery. October 16th, improvement of body and mind continues. The circumfer- ences of the head, face, upper extremities, and upper part of the trunk have diminished. Dr. Crary states that the effects of the thyroid administration may be summed up as follows : Increased metabolism, shown by — 1. Elevation of temperature ; 2. Increased appetite, with more complete absorption of nitrogenous food; 3. Loss of weight, with nitrogen excreted in excess of that taken in the food ; 4. Growth of skeleton in the very young ; 5. Marked improvement in body-nutrition generally ; 6. Increased activity of mucous membrane, skin, and kidneys. If the patient has recovered or is well on the way to recovery, still the medicine should not be omitted entirely, but may be given in less frequent doses. SECTION IV. MALFORMATIONS AND DEFORMITIES. CHAPTER I. THE DIGESTIVE ORGANS. Lips and Palate. Atresia Oris, Microstoma, small mouth, congenital or acquired, requires treatment either by dilatation or operation. Dilatation is a slow and tedious process, and must be persevered in for a long period to effect satisfactory results. The tendency to contraction is very great. In general it is better to enlarge the mouth laterally, and draw the mucous membrane over the Fig. 65. Fig. 66. Cicatricial contraction of mouth. Large mouth ; pendulous growths near ear. wound and attach it to the margin of the skin. If union is secured, the result will be satisfactory. If it fail at any point, the operation may be repeated. Macrostoma, or congenital enlargement of the mouth, is due to a failure of union of the superior maxillary and the frontal, nasal, and external nasal processes. It is usually unilateral and can readily be remedied by carefully paring the edges and uniting them by suture. Fig. 67. Fig. 68. Fig. 69. V ; Showing the development of the intermaxillary. Harelip, congenital cicatrix. Harelip as slight notch. Harelip is a congenital non-union of the central, or of the central with 476 THE DIGESTIVE ORGANS. 477 the lateral portion of the upper lip, cleft corresponding with the junction of the intermaxillary or of the maxillary and intermaxillary bones (Fig. 67) ; it is most common in males and is frequently hereditary ; it may be single, double, or complicated. The fissure may be a slight cicatrix, the first indication of harelip (Fig. 68), or a short notch (Fig. 69) : but in general it extends to within a little of the nostril, and is often continuous with it (Fig. 70) : when double it may be of Fig. 70. Fig. 71. Uncomplicated double harelip. Fig. 72. the same size on each side (Fig. 71), or there may be a short notch on one side and an extensive one on the other ; the substance of the lip al- ways varies much in such cases, be- ing thick and fleshy in some and in others thin and defective in all re- ■*&"■■ spects. and the breadth of the gap Harelip as deep fissure on usually varies in accordance with right side, these characters. There is always, even in the worst cases of double cleft, an intermediate portion of lip which may be broad or narrow, long or short, thin or of the natural thickness of the lip, but generally it is deficient. The general rules of treatment are : (1) If the infant is feeble, delay operation until after the third month ; (2) if healthy and the cleft single, operate, if it is desired, immediately ; (3) if there is no special urgency, delay till from the third to the sixth month (the comparative mortality in the different periods favors the latter course) ; (4) when there is inability to take food operate at the earliest moment ; (5) defer the operation if diarrhoea or eruptive diseases are present ; (6) the midsummer months are very unfavorable ; (7) if the harelip is double, wait until the child is two or three years old, unless the conditions render an earlier operation necessary ; (8) chloroform is not necessary in infants : (9) cleanse the mouth, gums, lips, and nose with boric-acid solution. The stages of the operation are : (1) The infant, having a sheet wrapped around its body so as to enclose its arms, should be held upright in the arms of an experienced assistant, and its head firmly grasped by a second assistant (Fig. 72) ; the older child should recline with its head raised ; (2) separate thoroughly all adhe- sions to the gums, so that the two flaps move freely ; (3) make section of the edges of the cleft with strong scissors or with the knife, and in such form as will most completely obliterate deform- ity when the flaps are placed in perfect apposition ; (4) close the wound with harelip pins if the tension is great, and with silver-wire suture if it is but slight ; introduce the suture or pins so deeply as to reach, but not to pene- trate, the mucous membrane. Thomas of Birmingham restores the cleft into the nostril several days before completing the operation. The flaps rarely require any other support until the sutures or pins are removed. Partial fissure of the lip is best treated by two incisions which meet at a point above the tip of the fissure, and extend into each flap without dividing the margins (Figs. 73, 74) ; the double flap thus formed is depressed, the apex presenting downward, and the wound then becomes diamond-shaped. On closing the wound there is a pouting of the lip which gradually disap- pears, leaving no deformity. Single harelip may occur on either side, and may vary in extent from a >per£ lip: position for young patient. 478 MALFORMATIONS AND DEFORMITIES. slight indentation to a complete division into the nostril. The two sides of the cleft differ in their regularity, being on different levels and variously bevelled at the angles. If the knife is used, enter it at the angle and cut Fig. 73. Fig. 74. Fig. 75. Nelaton's operation for partial harelip. Operation for single harelip. away a sufficient portion to make the margin straight and secure easy and perfect adjustment ; at the free border (Fig. 75) turn the edge inward to the cleft, to avoid the notch in the lip and save a portion of the mucous mem- brane. If the scissors are preferred, the same section can be made. If the free borders are irregular and round, the method of saving the parings should be adopted — namely, make an incision from A B (Fig. 76) through the thick- ness of the lip down to the mucous membrane, but not through it, and turn the flap back ; on the other side transfix the lip at C and separate a flap as far as Z>, dividing it at E ; bring the two sides together and attach the flap, E, C, Fig. Fig. 77. Fig. 78. Collis's operation for harelip. Malgaigne's operation for harelip. to J. by a suture, and the flap, E, D : to B ; apply two intermediate sutures, and the result will be a lip nearly double the depth (Fig. 77) of that obtained by the ordinary method ; the same result follows if the two portions, pared off the sides of the cleft, remain attached to each other (Fig. 78), as well as to the free edge of the lip, and are turned downward and the two sides are united as before. This method is peculiarly appropriate to clefts which do Fig. 79. Fig. 80. Harelip : Giraldes's method. not extend through the whole depth of the lip, but terminate at some dis- tance from the nostril. In cases of very extensive cleft, or with a projection of one portion of THE DIGESTIVE ORGANS. 479 the jaw. the following operation is advised : Cut flaps on either side (Fig. 79) and leave them attached, one, C, by the lower, and the other, J., by the upper end. the incision being carried around the nose as far as may be deemed necessary, E ; the flap attached by its lower end, C, is then turned downward so that its red edge forms the border of the lip, while the other, JL, is drawn upward toward the nostril, and they are thus dovetailed together (Fig. 80) with interrupted suture. In some cases the continuity of the lip border may best be preserved by the following method : Remove the edge of one of the borders clearly throughout ; on the other cut a flap with its pedicle below ; bring the edges together so that the flap is applied from below upward upon the notch. If the flaps in any case do not promptly unite and the edges continue to granu- late, they should be maintained in apposition for the purpose of securing union by granulation. Double harelip may exist with or without defect in the bone. When complicated with fissure of the hard palate, the best-conducted operations are very liable to fail. If the clefts are limited to the lips (Fig. 81), and there is not severe tension, operate upon both sides at the same time (Fig. 82) ; but Fig. 81. Fig. 82. Double harelip. if the traction upon the parts is great, operate upon one side at a time, mak- ing a central flap, which can be attached at the sides and to the angles of the flaps (Fig. 82) ; first make the incisions, B and A ; then pare the edges of the projecting mass C; turn the flaps, A and B, downward and unite them. The result is good (Fig. 82). If the intermaxillary bone has not formed ossific union, it projects more or less, according to its attachments to the septum nasi. Except when it is a mere pendulous mass from the tip of the nose, efforts should be made to save it, both because it contains the sacs of the incisor teeth, and its presence is necessary to maintain the form of the upper jaw and lip. In the slighter cases of projection of the intermaxillary bone it is merely necessary to frac- ture its attachment to the septum and press the mass back into position, or, if it be too large to fill the gap, the exuberant parts must be pared away at the sides, the adjacent sides of the superior maxillary bones refreshed, and any teeth projecting across the cleft removed. A wedge-shaped piece maybe cut from the septum, which allows the mass to recede more readily into the cleft (Fig. 83) ; a suture may be applied to the sides of this notch to retain the depressed bone in place. The bone has been retained in position by silver sutures passed through it and the adjoin- ing hard palate, but three teeth were destroyed by the penetration of their sacs. The bone has been successfully held in position by at once uniting the clefts in the soft tissues. When the flaps are insufficient to close the cleft, they may be dissected away from the cheek to such an extent as to admit of their easy approximation. If the process is tedious, it should be divided into 480 MALFORMATIONS AND DEFORMITIES. stages, dealing first with the projecting intermaxillary bone, and then with the soft parts. When the mass is merely suspended from the tip of the nose, Fig. 83. Fig. 84. Fig. 85. Before operation. Front view. Side view : after operation. it must be removed by careful dissection with strong scissors, the soft parts being retained and so placed as to form a columna nasi or to fill the gap in the lip (Fig. 84). The result is very favorable (Fig. 85). The use of an oesophageal tube to feed the child after operation may be employed to prevent the contact of food with the wound. Hypertrophy of the mucous glands is characterized by dulous portions of tissue appearing on either side of the 86), and is due to an increase of the glands of the part and membrane. Make a straight or elliptical incision in the line the submucous tissue ; close the incision with fine sutures. Hypertrophy of the lip generally occurs in scrofulous sists in chronic thickening of the deep structures. It may two elevated pen- middle line (Fig. not of the mucous of the lip ; excise subjects and con- result from a con- Fig. 86. Fig. 87. Hypertrophy of mucous glands of lips (Bryant ). Hypertrophy of lip (Buck). genital enlargement of capillaries constituting a nsevus (Fig. 87), and then has a raspberry discoloration, is flabby, pendulous, and contains hard knots in its substance. Operate as follows : Remove a V-shaped patch, equidistant from the angles of the mouth, and having its apex low down in the median line under the chin ; divide the mucous membrane along the line of its reflection from the jaw on either side of the wound; bring the opposite edges of the wound together and secure them in exact coaptation by pin-sutures inserted at equal distances from each other below the lip-border ; between every two pin-sutures add a silver wire, and on the vermilion border fine thread sutures, one being on its buccal surface ; when union is complete, a second operation is required to reduce the thickness of the lip. This is effected by two parallel incisions, including one-third of the thickness of the lip and penetrating deeply into its substance. The raspberry color must be destroyed by the galvano- cautery. THE DIGESTIVE ORGANS. 481 The Tongue. Tongue-tie is a congenital malformation in which the fraenum linguae extends too far forward toward the point of the tongue, and remains rather below its natural height, measured from the floor of the mouth ; protrusion is hindered, and where the defect is great the tongue cannot be applied against the roof of the mouth ; the slight form is harmless, but the severe form presents a great obstacle to sucking ; in the latter case it is advisable to operate. Division has been followed by fatal hemorrhage from the ranine arteries, but carefully performed it is without danger and painless ; pass the first and second fingers of the left hand, palm downward, under the tip of the tongue on either side of the fraenum, and put it well on the stretch ; snip the edge of the fraenum with blunt-pointed scissors below the fingers, thus escaping the ranine arteries, which run along the lower surface of the tongue ; push the tongue upward against the roof of the mouth, and divide further, if necessary ; this method is preferable to the use of the cleft in the handle of the ordinary director. Hypertrophy of the tongue is usually congenital, and may be noticed immediately after birth, or may appear later, being uncertain in its rate of growth ; when fully developed the tongue protrudes, with constant dribbling of saliva, and causes deformity ■ Fig. 88. (Fig. 88) of the jaw. The treatment by pressure and astringents may first be attempted, as follows : Apply daily cupri sulph. 9j to aq. Jj on lint, and compress with a bandage. If these means fail, removal is the only alternative. Excision is very dangerous when the organ is large, owing to hemorrhage ; the knife, ligature, ecraseur, or galvano-cautery may be employed ; when the knife is used the flaps may be made by transfixing the tongue laterally or vertically ; the former method is, in general, preferable, as the thickness of the tongue is thereby much more reduced. The head being supported against the breast of an assist- Hypertrophy of the ant, who retracts the angles of the mouth, seize the tongue tongue (Buck), with forceps on its edges, and draw it well forward ; pass a strong ligature transversely through the back part of the tongue with which to draw the organ forward ; transfix the tongue from side to side at the point where excision is to be completed, and cut forward and downward through its under sur- face, making the lower flap ; form the upper flap by cutting in a reverse direction, backward and downward, to the point where the first section had commenced ; ligate the arteries and secure the flaps in contact with sutures ; recovery with a flattened tongue and good speech results. A vertical incision may be required, in order to remove a V-shaped portion of sufficient size, and bring together the lateral flaps so as to form a new tip, which shall fall within the teeth ; the patient, anaesthetized, being placed with the head elevated and held by an assistant, pass the knife through the substance of the tongue external to the middle line, to avoid the ranine artery ; cut out a flap, and tie all the bleeding vessels ; pass a strong ligature through this flap to prevent the tongue falling back ; enter the knife at the same point ; carry it across the middle lines, dividing the ranine arteries, which must be tied before the flap is finally separated ; close the wound with strong sutures thus : Introduce theue sutures into the lateral flaps, and on tying them the tip of the tongue assumes a natural appear- ance. Removal by the ecraseur involves less immediate risk from hemorrhage, but is liable to be followed by dangerous inflammatory swelling. If employed, proceed thus : Pass the chain of a very stout instrument through the substance of the tongue at the same point as in excision by the knife, and when it has worked its way outward a little, pass a second chain and work it at the same time toward the opposite side. 31 482 MALFORMATIONS AND DEFORMITIES. Angeioma, vascular tumor, may be venous or arterial ; the former is common, the latter rare. Venous angeiomas are generally congenital, may be single or multiple ; usually appear on the anterior part of the dorsum, projecting slightly above the surface, thinning the mucous membrane over them, and showing a dull blue or livid color ; in some the contents may be pressed out, and in others the mass feels tense and elastic like a thin cyst filled with fluid ; they are usually quite painless, seldom very large, and not inconvenient except from their bulk and occasional liability to bleed. They may diminish and disappear, or increase, or undergo warty degeneration. They are composed of numerous anastomosing vessels, or are cavernous. The treatment is destruction by the actual or galvano-cautery, the latter being preferable. The point of one of the platinum instruments, at a dull- red heat, should be made to penetrate deeply into the substance of the growth, and moved in all directions through it until it has been completely broken up ; repeat the operation if necessary. Papillomata, warty tumors, occur, usually, on the dorsum within the papillary area, and are then due to hypertrophy of the natural papillae ; they may grow on the under surface. They may be mistaken for condylomata or warty carcinomata ; the history of the case is the guide to a correct diag- nosis in the first class, and the age of the patient and the induration of the base determine the latter. In children the hypertrophied papillae may be destroyed by the solid nitrate of silver ; the larger pedunculated growth may be removed with scissors or the ligature ; the larger papillomata should be removed with the knife or scissors. The Palate. Congenital Defects of the Palate. — Fissure or cleft of the palate, as a congenital defect, may involve : (1) only the ovula, 1 (Fig. 90) ; (2) the soft Fig, 89. Mouth-gag. palate, 2 (Fig. 90); (3) the hard palate as far forward as the middle of the palate process of the superior maxillae or through the palate bones only (Fig. 91) ; (4) the alveolar ridge entire with the cleft of the palate (Fig. 92) ; (5) cleft or notch of the alveolar ridge with entire cleft of palate ; (6) double cleft of the alveolar ridge, with fissure from each running backward and in- ward and joining behind the intermaxillary bones, becoming continuous with a median fissure. There are also many grades of separation of the fissure. Usually the cleft in the palate is narrower in front and widens toward the velum, but in some the gap THE DIGESTIVE ORGANS. 483 will be very wide and in others very narrow, though complete from alveolus to uvula. In partial clefts the breadth is often much greater than is apparent from its extent, in some instances giving the greatest breadth met with. Fig. 90. Fig. 91. Fig. 92. Large fissure. Fissure of soft and hard palate. Slight fissure. The operations undertaken for the relief of fissured palate are staphylor- rhaphy and uranoplasty, the former being an operation on the soft, and the latter on the hard palate. If the uvula alone is bifid and the voice unaffected, it is better not to in- terfere with the fissure. As the articulation, however, is generally affected, closure by suture is the rule of treatment ; the operation may be performed at any age, but when circumstances are unfavorable to an early operation, it is better to defer it until the child is at least three or four years old, or even until adult life. If the patient is a child, chloroform should be given and the gag inserted (Fig. 93). Staphylorrhaphy, suture of the soft palate, is an operation which the surgeon need have no hesitation of undertaking when the cleft is limited. The child being properly supported by an assistant, clean the mouth with boric acid. First seize one point of the cleft with long spring forceps, draw it for- ward, transfix it near its inner border with a narrow, sharp knife on a long handle, and freely cut upward or down- ward and remove the mucous Fig. 93. membrane along the whole of its inner margin (Fig. 94) ; make the same section on the opposite side and divide the angle of union last. When the cleft extends for- ward through the whole of the velum, or even to a slight extent into palate bones, the operation is more complicated, for every at- tempt to bring the edges of the fissure together is opposed by the combined actions of the levator and tensor palati muscles on either side, drawing directly away from the median line at which the edges of the fissure should meet ; the muscles must therefore be divided to ensure success. The relaxation of the tissues of the fissured velum may generally be sufficiently secured by means of incisions made with strong curved scissors, so as to divide the posterior pillar of the palate just where it begins to spread out into the velum ; in some cases an additional stroke or two of the scissors is necessary to divide a band Whitehead's gag and tongue-depressor. 484 MALFORMATIONS AXD DEFORMITIES. Fig. 94. of firm tissue extending above and behind the soft palate. The division of the muscles is also effected as follows : Pass a suture through one section of the soft palate at the root of the uvula, secure the ends by a knot, and have it held outside the mouth ; repeat a similar suture on the opposite side 5 draw one of the sutures firmly, holding one-half of the soft palate to its opposite side, so as to stretch this section of the palate toward the median line ; recognize the hamular process in the substance of the soft palate internal and a very little posterior to the last molar tooth ; intro- duce the point of a thin, narrow knife fixed in a long handle, the blade down, a little in front and to the inner side of this process, and carry it up- ward, backward, and somewhat inward, until the point is seen in the gap, having passed through the entire thickness of the soft palate, and cut par- tially, if not wholly, the tendon of the tensor palati : raise the handle of the knife, depressing its point, and as the blade is drawn forward make it cut downward, so as to pass through a consider- able section of a circle on the posterior surface of the palate, by which the division of the greater portion of the levator palati is effected ; complete its section as the knife is withdrawn (Fig. 96). If the muscle is properly divided, all movements of the palate cease, and it becomes pendulous and flaccid : if there be any further resistance, reintroduce the knife and divide the fibres more freely. The divisions of the muscles may be made a day or two before the operation for closing the fissure, and thus avoid the bleed- ing : or the muscles may be divided after paring the edges, and inserting the sutures, the palate being put on the stretch by means of the threads held in the hand ; lateral incisions through the soft parts completely dividing the soft palate from its lateral attachments wili allow the two halves to fall together. The edges of the fissures should now be thoroughly denuded of mucous mem- brane. The suture selected should be silkworm-gut or Chinese silk, made antiseptic. First decide how many sutures will be required, and observe the points at which they should be inserted to correspond on each side ; the sutures in each needle should be at least one yard in length, and each suture should be doubled for its whole length before being passed ; with the needle in the right hand and a pair of long spring forceps in the left, push the point of the needle through the soft palate Showing the paring of the edges of fissures after the introduction of the sutures. Fig. 95. Fig. 96. Fig. Passing the suture. Sedillot's operation for staphylorrhaphy. Incisions to relieve tension. on the patient's left side, as near to its anterior margin as practicable ; seize one thread of the suture and draw it forward ; pass the needle on the opposite side with a double thread, the loop of which should be drawn out ; the needles being removed, the single thread of the one side is passed through the loop of the other, the looped thread withdrawn from the palate carrying the single suture through THE DIGESTIVE ORGANS. 485 the opposite side (Fig. 95) ; repeat until the requisite number, three or four, is inserted ; tie each separately, and not too tightly, to allow for swelling ; a slip- knot ( Fig. 95) to bring the edges together, and a second knot over that, are suffi- cient (Fig. 96) : the ends should not be cut off very close. A perforated shot may be passed over the suture, and compressed to prevent slipping. If wire is used, it must be applied with the wire adjuster, be nicely twisted, and cut closely. The after-treatment must be carefully attended to ; the diet should be liquid ; no con- versation should be allowed ; the sutures may be removed after about eight days. To relieve tension, the soft palate may be incised (Fig. 96), or by the side cuts, B (Fig. 97). subsequently gaping so as to appear as arches. Uranoplasty, closure of fissure of the hard palate, may be undertaken at any age. yet as the real object of the operation is to enable the patient to articulate plainly and intelligibly, and as a child does not commence to articu- late, as a rule, before twelve months old, nor to pronounce many words before two years of age, the reasons are strong against its performance prior to this latter period of life, for the child is now in a much more favorable condition to undergo the operation, and less liable to succumb to the effects of the loss of blood. The early treatment, therefore, is the proper nourishment of the infant until it reaches the requisite age, and the mother's milk is the only food that should be given for the first six or eight weeks ; if the child cannot nurse, owing to the extent of the cleft, it must be hand-fed with her milk. The operation, whatever may be the extent of the fissure, consists in dissect- ing up the membrane covering the hard palate, quite back to the alveolar processes, including the periosteum, so as to form muco-periosteal flaps. The result will be successful in any case where the patient is fairly healthy and the parts can be brought together without undue tension. The closure is effected not only by these soft tissues, but also by bone subsequently repro- duced in the periosteal layer. As the success of the operation depends upon immediate union of the edges of the flaps, examine the patient carefully to ascertain if he is in a condition of health to justify the expectation of union by first intention ; if there are any signs of disordered health or defective power, as pustules, herpes, excoriated lips or nostrils, the operation should be postponed. The operation may be completed at one or at several sittings ; unless there are circumstances of peculiar difficulty in the case, which will make the operation either unusually tedious or will necessitate such an exten- sive division of the soft parts as would endanger the flaps, the whole cleft should be closed at one operation. In an ordinary case of cleft of the hard and soft palate proceed as follows : Place the patient, etherized, in a good light ; introduce the gag previously fitted to the mouth (Fig. 93) ; or, if the cleft is through the alveolar process also, select a gag which has no central roof portion. Operate first on the soft palate ; pare the edges of the cleft from below upward, the point of the uvula being held with for- ceps, b (Fig. 88), to render it tense ; apply the sutures from below upward, passing them, if possible, completely through both sides to avoid the loops described, and fastening each after the next is passed ; relieve the undue tension by longitudinal incisions on either side parallel with the cleft and just internal to the hamular process, avoiding the post-palatine foramen, or cut the muscles, seizing with the forceps, b (Fig. 88), the palato-pharyngeus muscles and dividing them with the scis- sors, f (Fig. 88), low down, and also the levator palati of both sides. When the soft palate has been closed and the point in the velum has been reached where the sutures can no longer be fastened, from the amount of tension, proceed to operate on the hard palate if the condition of the patient do not forbid it. Separate the soft tissues from the bone, commencing at the edge of the cleft and dissecting out- ward to the alveolar process, or, which may be preferable, from the alveolar border toward the fissure, as follows : Make an inscision close to and parallel with the alveolar ridge, from a point opposite the last molar tooth forward to the canine, and separate the flaps from the bone by means of the periosteotome, lu i (Fig. 88), commencing at the incisors and proceeding inward to the edge of the gap, avoid- 486 MALFORMATIONS AND DEFORMITIES. ing bruising the flaps ; these flaps should now fall inward and downward and meet in the median line without the slightest traction ; if the edges do not readily meet, the flaps have not been sufficiently detached, and search m-ust be made for the point preventing descent, which should be freely liberated ; pare the edges with a sharp knife so that two entire and fresh raw surfaces are brought accurately in con- tact ; pass the sutures as in closure of the soft palate. No special treatment is required, except to avoid giving warm food until Fig. 98. Fig. 99. A, preliminary puncture with awl to give line for chisel; B, incision through bone completed by chisel ; C, holes bored through hard and soft palates for sutures : D, junction of hard and soft palates ; E, E, lateral openings subsequently filled up by granulation. the day after the operation, and to abstain from looking at the palate ; give first iced milk, and afterward, for a fortnight, such food as eggs, milk, rice milk, cream custard, stewed fruit, arrow-root, soup, beef-tea, pounded meat with wine, brandy, or malt liquors ; children and delicate young persons should be kept in bed for a week, when practicable ; the sutures should remain three weeks or a month in children, and be removed under an anaesthetic. The following method of operating has given excellent results : Holes are drilled with a curved brad-awl through the margin of the hard palate (Fig. 98) for the passage of the threads, while the palate itself is then cut through with a chisel in a line parallel to and about half an inch from the cleft, B ; such step being facilitated by previously drilling the bone, A; this loosening of the margins of the hard palate allows the borders of the cleft to be brought together along its whole length after the margins have been pared and the stitches twisted (Fig. 99). It frequently happens that under the most favorable circumstances a small aper- ture will remain ; these openings are not unlike those slight congenital defects which appear in the palate as orifices, or which result from syphilitic caries ; they may be closed by subsequent operations or with a metal plate or with a hard-rubber obturator. Contracted soft palate frequently results from successful closure of the cleft, and leads to imperfect speech. With a view to lengthen the curtain or relieve the tension upon it, several operations have been performed : (1) The inner borders of the palato- pharyngeus muscles have been pared and united, but the operation had the effect of compelling the patient to breathe entirely through the mouth, without im- proving speech. (2) The attachments of the palate to the sides of the fauces, together with the anterior and posterior pillars, may be divided as follows : Pass a spatula behind the soft palate, 1, 2 (Fig. 100), both to steady and draw it forward ; then transfix the soft palate by a sharp-pointed bistoury by the side of the spatula and at the inner edge of the harnu- lar process, 1, 4, and cut through the free margin of Contraction of soft palate. the palate to (Fig. 100), dividing the tensor palati, palato-glossus, and THE DIGESTIVE ORGANS. 487 palato-pharyngeus muscles ; retraction follows, 3 ; sutures are now passed through the sides of the flap from before backward, thus hemming the mucous membrane, 5 ; this operation is extremely simple, comparatively pain- less, and has always resulted in some, and in many instances marked, im- provements of the Voice. (3) Dissection of the palato-pharyngeus muscles to form flaps in connection with a raised portion of the mucous membrane of the prevertebral region was attempted, but not completed. Careful anti- sepsis must be practised. The Rectum. Imperforate rectum is caused by a membranous partition which may be just within the anus or an inch or more above ; it varies in thickness, but is usually thin ; the symptoms are retention of the meconium and vomiting. Examination with the finger or probe or a small elastic catheter or bougie determines its nature ; if the membrane is thick, it may not be possible to decide whether the intestine is continuous above till an incision is made, but if it is thin it will bulge down upon the finger, especially when the child cries. Delay the operation a day or two, until the meconium dilates the lower part of the intestine ; if the septum is thin, break it down with the end of the little finger ; if thick, puncture with a sharp-pointed bistoury, the blade being wrapped with thread, and cautiously carried into the passage on a grooved director or along the finger ; enlarge the puncture by a crucial in- cision ; dilate with the end of the little finger ; pass the finger, or a bougie of suitable size, daily, for several months. Absence of the rectum may be partial, which is most common, or com- plete, the anus being normal. When only partially absent, the other portion usually terminates in a cul-de-sac at a greater or less distance from the sur- face of the body, or it may be prolonged as a narrow tube or imperforate cord, and blended with adjacent parts ; if wholly absent, the canal may open in some abnormal situation. The diagnosis is made by examination with the finger or a bougie. If the occlusion is not thick, it is only necessary to incise the in- tervening tissues and dilate. If the part is very thick and hard, dilate the anus, if necessary add lateral incisions ; separate the mucous membrane, and draw down the rectum ; cut off that portion including the septum, and attach the margin by suture to the skin. If the rectum is wholly absent and the bowel cannot be reached by dissection, a last resort is to make an artificial anus in the left groin. The Anus. Contraction of the anus may be due to a congenital narrowing of the lower part of the rectum and the anus, or of the anal orifice alone, or the in- tegument may extend partially over the anus ; the situation and form of the anus are generally normal, but the orifice is puckered or plicated ; the narrow- ing may be slight or only admit the passage of a probe. The symptoms are absence of meconium and progressive, painful tension of the abdomen, and vomiting. The treatment is dilatation : Select a graduated bougie, the tip of which readily passes the contraction ; inject a little oil to lubricate the parts ; or, if there are feces in the rectum, move the bowels first with an enema; place the patient on the back with the thighs well flexed ; warm and oil the bougie, and pass it gently but firmly into the constriction ; repeat the ope- ration, daily, until the part is enlarged to at least its normal calibre ; the finger may be substituted for the bougie when the stricture is sufficiently dilated. If the narrowing is extreme and very rigid and unvarying, incise the lateral surfaces on a director, and in the direction of the tuber ischii, to such a depth as to 488 MALFORMATIONS AND DEFORMITIES. allow the passage of the feces ; if the first incisions are not sufficiently deep, repeat them ; but it is necessary to divide only slightly or partially the sphincter. If the narrowing is due to extension of the integument, incise it in several places on the director, and dilate daily with a bougie or with the little finger. Imperforate anus is generally caused by a lamina of fibro-cellular tissue, usually thin and transparent, permitting the meconium to be seen through it, and forming a small, roundish prominence, which is most distinct when the child cries or strains ; the bulging membrane gives to the finger a doughy feeling and sense of obscure fluctuation ; on pressure it recedes, but reappears on removal of the finger ; the membrane may be very thick and dense, espe- cially at the circumference, when the protrusion will be less prominent. The nature of the affection is apparent on inspection. If the membrane is thin, incise it at once ; if it is thick, and there is a doubt as to the continuation of the rectum, delay a day or two for the rectum to become distended; then, while the child is held on its back on the knees of an assistant, the thighs strongly flexed, make a crucial incision through the membrane, the point of intersection of the incisions being the centre of the anus ; remove the inter- vening flaps with scissors, and dilate the opening daily with the finger or a bougie. Absence of the anus is characterized by the obliteration of every trace of the orifice, the perineal raphe extending from the scrotum to the point of the coccyx without interruption, and the space of the anus being occupied with cellulo-fibrous tissue ; there are no external signs by which the location, or even existence, of the rectum can certainly be ascertained ; if it is present, and near the perineum, fluctuation may sometimes be detected by the finger in the perineum, or by pushing firmly up in the direction of the rectum, while with the left hand firm pressure is made upon the anterior walls of the abdo- men inward and down toward the finger in the perineum. If by these manip- ulations the presence of the rectum is detected, an operation will afford the desired relief. The patient being held by the assistant, as before described, and, if necessary, the sound introduced, make an incision in the median line from a point near the scrotum to the extremity of the coccyx (Fig, 101), through the skin and superficial fascia ; repeat the incision, but of gradually diminishing length, carefully feeling before each stroke to ascertain by fluctu- ation the presence of the blind sac of the rectum, and also the position of the bladder or vagina ; if the rectum is not found in the middle line, search pos- teriorly, as the extremity is sometimes displaced from the centre ; the bowel will be detected as a fluctuating tumor, more or less elastic, and of a dark- brown color ; when recognized, seize it with strong-toothed forceps, or pass a needle armed with a double ligature through it and gently draw it down- Fig. 101. Fig. 102. W Incision for imperforate anus. Bowel attached to external wound. ward ; adhesions may be broken up with the fingers, or the knife, or scissors ; when brought down to a level with the integument, open the cul-de-sac lon- gitudinally, empty its contents, thoroughly cleanse the part, and unite the margin, by six points of suture (Fig. 102), to the integument of the corre- THE URINARY BLADDER. 489 spending edges of the perineal wound in the exact situation of the anus ; the mucous membrane should overlap the external skin, to prevent the escape of fecal matters into the cellular tissue ; close the wound anteriorly and poste- riorly by suture ; bind the child's legs together with a bandage, and apply antiseptic dressings to the wound ; tendency to undue contraction must be counteracted by dilatation. CHAPTEE II. THE UKIXAKY BLADDER Extroversion of the bladder is a congenital malformation, occurring chiefly in males, in which the anterior portion and the parietes of the abdo- men are absent, so that the posterior and lower part of the bladder protrudes under the pressure of the viscera from behind as a round red tumor covered by mucous membrane, in which the orifice of the ureters can be seen. The linea alba bifurcates at the upper angle, but is continued on either side of the ossa pubis, forming a triangle 5 the pubic bones are not united by a symphysis ; the penis is small, the ureter and corpus spongiosum are deficient in their whole extent, and the only remnant of the urethra is a groove lined by mucous membrane on the dorsum of the penis ; the glans penis is full and large. This deformity leads to painful and distressing results, owing to the con- stant flow of urine over the groin and thighs, but it is in no respect danger- ous to life. The treatment may be palliative, by the application of an appa- ratus to collect the urine, of which there are many kinds. But even the best fitting does not always obviate the gradual soaking by the urine of the skin of the abdomen, groins, and perineum, and hence operations have been devised to relieve the disgusting deformity. Efforts have been made (1) to open com- munication between the ureters and the rectum, but the operation is very dan- gerous, and has not given satisfactory results ; (2) to cover the exposed sur- face ; some of these operations have been very successful, and have become legitimate by the approval of good authority. The following operations are advised : Make an umbilical flap, 1 (Fig. 106), and turn it down over the bladder ; then make two flaps from the groin, one on either side (Fig. 103), and slide them over the central flap, and attach them in Fig. 103. Fig. 104. Wood's operation for extroverted bladder outline of incisions. Wood's operation : flaps applied. 490 MALFORMATIONS AND DEFORMITIES. the median line (Fig. 104) ; the result is, the skin surface of the middle flap presents- to the bladder, and the raw surface is covered by the raw surfaces of the lateral the new wound is left to cicatrize. Or dissect off the mucous membrane of Fig. 305. Fig. 106. # Bigelow's operation. the exposed bladder ; make lateral flaps from both inguinal regions (Figs. 105, 106) ; unite them upon the median line and transversely above it, the points a, a, a, and b, b, being brought together, as the skin more readily yields in a direction obliquely upward ; the result is perfect (Fig. 106). CHAPTER III. THE EXTREMITIES. Fig. 107. The Upper Extremities. A supernumerary digit (Fig. 107) appears in many forms, and should be treated according to the peculiarities. (1) If it is attached loosely or by a narrow pedicle, divide the pedicle close to its point of attachment to the skin, so that no remains may be left ; hemorrhage must be carefully suppressed. (2) If it is more developed and articulates with the sides of the metacarpal or phalangeal bone which is common to it and another digit, operate early, and so arrange the incision as to leave as small a cicatrix as possible. (3) In cases where the additional digit is connected to the head of a phalangeal or metacarpal bone the removal is likely to involve the opening of the joint of the adjacent phalanx ; removal is advisable only in case the additional phalanx impairs the function of the other. (4) If the supernumerary digit is fully developed, having its own phalangeal and metacarpal bones, removal is rarely advisable, but if required must be taken away so as to leave as little deformity and impairment as possible. (5) There may be fusion of digits, or even of hands (Fig. 120), in which no operation is desirable. Supernumerary thumb. THE EXTREMITIES. 491 The union of digits, webbed, may be congenital, when it is generally sym- metrical ; or it may be the result of injuries and burns. The uniting medium may be the skin only, or the skin and deeper tissues, and even the bone. The two apposing digits may be united throughout their entire length or only in part. Webbed toes do not require treatment. When the union is partial and does not involve the interspace at the cleft, divide the connecting Fig. 108. Fig. 109. Apparent fusion of the hands. Seton inserted. tissue, and maintain the fingers apart until cicatrization is complete. When the union of the cleft is complete there is great difficulty in preventing reunion after division. Introduce a seton at the base of the cleft (Fig. 109) and allow it to remain until the opening becomes permanent, when the remainder of the web may be divided. India-rubber tubing introduced at the same point and tied to a band around the wrist makes a good seton. Make two flaps of the web, ; for the posterior make an Fig. 110. If the septum is very dense, operate as follows anterior and posterior, but reversed (Figs. 110, 1-11] Fig. 111. Fig. 112. Diagram of flaps in operation for webbed finger, with thick septum. Operation for webbed finger : a, the lines of the two incisions uniting, so as to divide the web and leave a flap on each side ; b, the flaps detached from the op- posite fingers to those to which they are adherent ; c, the flaps applied to the fingers and covering in the raw and exposed surfaces (Erichsen). incision along the dorsal aspect of one finger the length of the web, and transverse incisions at either extremity to the middle of the dorsum of the other finger ; repeat the operation on the palmar surface, but make the longitudinal incision along the palmar surface of the finger which forms the base of the posterior flap ; dissect the 492 MALFORMATIONS AND DEFORMITIES. two flaps and turn them back 5 separate the fingers, which now have each a flap, one attached upon the dorsal and the other upon the palmar surface (Fig. 112) ; apply the flaps to their respective fingers ; the union of these flaps effectually separates the fingers. Maunder advises to separate the web along one finger, unite its margins, and thus form a flap for the apposed digit : close the wound left upon the other finger by a piece of skin transplanted from the hip, the hand being bound to the part until adhesion has taken place. Flexion of the phalangeal joints, so as to permanently distort the fingers, may be congenital or acquired. When the deformity can be overcome by division of contracted tendons or fascia, this operation must be performed and suitable splints applied. If, however, the conditions are unfavorable to tenotomy, the affected joint should be exsected. In extreme cases amputa- tion is the only successful remedy. The Knee. Genu valgum (knock-knee ; in-knee) is very common in children suf- fering from rickets. It is usually (Fig. 11-i) bilateral. Various opinions have been given by writers as to the precise local changes which take place. Formerly the deformity was believed to be due to a relaxation of the inter- nal lateral ligaments. Later, it was ascribed to an overgrowth of the internal condyle of the femurs. Recently, Humphrey has contended that the exter- nal condyle has ceased to grow as rapidly as the internal condyle, owing to undue pressure in bearing the weight of the body. The truth is, that these and other conditions exist in varying degrees. There is, pre- ceding the deformity at the knee, a noticeable weakness of the ankle and a disposition to a flat foot. This instability of the ankle and foot is due to impairment of the attachments of the ligaments to bones undergoing rachitic changes. The tendency of the foot would be to turn outward in walking, and thus change the bearing of the lower end of the femur upon the tibia in such manner that the weight of the body would fall most directly upon the outer condyle. The result would be diminished growth of the external and increased growth of the inner condyle of the femur. Noble Smith Fig. 114. (Surg, of Deformities) concludes from his examinations that the change is in the internal condyle of the tibia, and not in that of the femur. There is also a change in the axis of the femur, an inward curve forming in the lower third (Fig. 113), which, according to Mac- ewen. causes the internal condyle to descend still lower. In general, bilateral knock-knee is arrested before the knees Fig. 113. Extreme genu valgum (from a photo- Femur curved by rickets. graph). interfere with each other in walking, but in extreme cases they may pass each THE EXTREMITIES. 493 other. Instead of bilateral knock-knee, one knee may be valgus and the other bowed. Owen says : " The explanation of this association is from the mother carrying the child always on one arm. whilst she throws the other arm around the knees to make them fit into the hollow of her waist. Thus, if the child be carried always upon the left arm, the left leg will be valgus, while the right will be bowed.' ' In the early stages of this deformity it may be difficult to determine the fact of a commencing change. The most marked general symptom will be a complaint of fatigue and pains in the knee after exercise. If, now, the child is placed on the back, the internal condyles will be too prominent. If the knees are brought together, it will be noticed that the ankles do not readily touch, and the degree of separation shows the extent of the change at the knees. Attempts at adduction and abduction of the feet prove that the internal part of the joint is unnaturally lax and movable. The treatment will depend upon the stage of progress of the disease. When rickets is found to exist and the child is not walking, the tendency to knock-knee is so slight that no other precaution is required than to pro- tect the child from wrong positions, and by skilled massage, with forcible straightening of the leg, overcome any tendency to deformity. If, however, the deformity increases, a lateral splint, or two if both knees are involved, should be applied, which may be of wood and well padded so as to fit the leg. When applied it should extend from the hip to the foot along the outside of the limb (Fig. 115). The patient must not walk. The splint should be removed daily, and the limb rubbed, stretched, and compressed outward at the knee. By perseverance the deformity, if slight, may be overcome. If both knees are slightly valgus, Owen recommends that a flat pillow be fixed between the knees and the ankles tied together by a handkerchief Fig. 115. Fig. 116. Splint for knock-knee (Owen). Simple treatment of double knock-knee (Owen), or strap (Fig. 116) ; this method should be carried on day and night, and to prevent rotation of the tibiae a sand-bag may be kept across the knees. If the child is of a more advanced age, it may not be required to pre- vent the exercise of walking, but the necessity of proper support at the knees will be increased. An effective apparatus is that which is so arranged as to gently but firmly compress the inner surface of the knee outward to steel splints 494 MALFORMATIONS AND DEFORMITIES. having a joint at the knee and attached to shoes. Truehart has devised a very useful splint of this kind (Fig. 117). If the case appears as a confirmed knock-knee, and the child has recovered from the attack of rickets, the treatment assumes an altogether new character. We have then to consider the propriety of an Fig. 117. operation to correct the deformity. The methods now adopted, and the success which is assured, mark one of the great advances of modern sur- gery. Osteotomy as applied to the correction of genu valgum is an illustration of the great capabilities of antiseptic surgery. Though the Fig. 119. Fig. 118. a a, line of Ogton's in- cision ; bb, Reeves's ; b c, Macewen's. Apparatus for knock-knees. Drawing illustrating Dr. Ogston's ope- ration : right limb shows line of sec- tion of the inner condyle of the femur; left, inner condyle brought to required position (Bryant). knee-joint is to be entered directly with a rude instrument, either a saw or a chisel, the operation may be undertaken with comparative certainty of success. Barker and Owen have reported fatal cases, but with proper pre- cautions and antisepsis the chances are altogether favorable. There are several methods of procedure : Section of the internal condyle may be made with a view to its replacement and reunion on a higher level (Figs. 118 and 119). The condyle may be separated with a saw (Ogston) or with a chisel (Reeves). Section with a saw is much the more difficult opera- tion, but with antiseptic precaution it has proved very successful. The ope- ration with the saw is as follows : Flex the knee as far as possible and turn the thigh outward ; introduce a long and strong tenotome knife three and a half inches above the tip of the internal condyle on the inner side of the thigh, and as far back as the opposite ridge of bone running between the linea aspera and the condyle ; carry the blade forward, downward, and outward over the front of the femur, with its cutting edge directed to the bone ; when its point is felt under the skin, in the groove between the con- dyles where the patella would normally have been lying in the flexed position, divide the soft parts and periosteum by withdrawing the knife ; through the cut thus made introduce a narrow saw and divide the condyle nearly to the popliteal space ; now forcibly straighten the knee, and the remaining attachments of the con- dyle will be readily fractured (Fig. 119). Section with the chisel is free from the objections which apply to those methods involving a more or less free opening of the knee-joint: THE EXTREMITIES. 495 Introduce an antiseptic scalpel above the most prominent part of the internal tuberosity, and divide the soft parts and periosteum ; insert by the side of the knife an antiseptic chisel, and with a few strokes of the mallet penetrate the condyle to its greatest depth, but only as far as the cartilage covering it 5 the direction of the chisel should be first toward the intereondyloid groove, then the chisel should be partially withdrawn, and its direction altered forward and backward until the con- dyle is loosened, but not separated. Straighten the limb, breaking off the divided condyle, and pushing it upward with the head of the tibia (Fig. 119) ; close the in- cision, and apply an immovable apparatus, as gypsum, and retain it for three or four weeks in children, when passive motion must be begun and persevered in until the functions of the joint are completely restored. Macewen accomplishes the purpose by partly dividing, with a mallet and chisel, the femur at the base of the condyles, then fracturing it and straighten- ing the limb. He makes the incision at the base of the internal condyle (Fig. 120), but most operators prefer to operate from the outer side of the Fig. 120. Appearance of limbs before and after Macewen's operation. limb. Macewen's operation is the more simple, and, as the joint is not inter- fered with, it is the safer. The results are quite as good as Ogston's or Reeves's operation, as will be seen in the illustration (Fig. 120). Genu extrorsum (out-knee) is the result of a bending outward of the femur and tibia without inequality in the condyles of the femur. It may exist on one side and knock-knee on the other. In this case the knock-knee has caused the bow-leg by changing the axis of the trunk from its centre to the axis of the thigh of the affected limb. Out-knee is believed to be caused in many rachitic children by the position which they assume in sitting, with their legs abducted and rotated outward (Wright), the knees being unsup- ported. The treatment should protect the limbs from the weight of the body and from any position assumed by the child liable to increase the deformity, and at the same time existing curvatures should be overcome. While the general treatment for rickets is pursued, bathing in warm salt water, rubbing the entire body with the hands, and such manipulation of the curved bones as will tend to straighten them are very useful. In these efforts to straighten the bones no strain should be placed on the knee, lest the internal lateral liga- ments be weakened. All the force must be applied to the individual bone. If the deformity is firmly established and the child has recovered, osteot- omy must be practised with the usual antiseptic precautions. When out- knee is due chiefly to the bending of one bone, as the femur or tibia, it will be sufficient to straighten that bone (Fig. 113). But in the more marked cases both the femur and tibia must be straightened to secure the required results. 496 MALFORMATIONS AXD DEFORMITIES. The Leg. Bow-leg proper is a curvature of the tibia and fibula, without any change in the femur. It conies on insidiously, even before the child has begun to walk. The habit of sitting with the legs crossed, like a tailor, gives an inclination to the tibia. Wright states that if the feet are crossed one over the other, the curve will be most marked at the lower third of the tibia, and the leg which rests upon the other will have more of an anterior and less of an external curve (Fig. 121) than its fellow. The treatment must, as in instances already given, tend to prevent the deform- ity and correct those that have taken place. Bathing, rubbing, and straightening the /'/ / fim / *T| \\ affected bones must be persevered in until II ^&m ^SF \ t ^ ie cnnc ^ nas recovered. The mechanical LLmr ^^0 ^iy \3# appliances should maintain an equable pres- Bow-legs (Ashby and Wright). sure on the curvatures. Owen's apparatus is very useful and easily adjusted, as will be seen by the illustrations (Figs. 122, 123). A more expensive apparatus may be employed for children who are walking (Fig. 124). Two upright steel Fig. 122. Fig. 123. Fig. 124. Simple apparatus for bow -legs (Owen). Apparatus for rickets. stems are fastened below to a shoe and terminated above in the calf-band ; a leather bandage is passed around the stems and tightly laced in front over the arc of the curvature (or), or a strap is passed over the arc of the curva- ture and fastened to a spur suspended from the calf-band behind (c), the points of resistance being in either case the heel of the shoe (6) and the posterior trough of the calf-band (c). It should be borne in mind that after the child has recovered from rickets, and begun to resume active exercise, there is a strong tendency to the cor- rection of slight curvatures of the tibia, due to the action of the muscles. If, however, the curvature is great (Fig. 125) the tendency will rather be in the direction of increased deformity. The only radical cure of the latter cases is straightening the curved bones by osteotomy (Fig. 126). The ope- ration is very simple : Prepare the limb by washing and shaving, and irrigate the wound during the THE EXTREMITIES. 497 operation with the bichloride solution. Select an osteotomy chisel (Fig. 127) and mallet : make a longitudinal incision down to the bone with the scalpel ; now apply Fig. 125. Fig. 126. Result of osteotomy for bow- (Ashhurst) the cutting edge of the chisel transversely, and with repeated blows of the mallet nearly divide the bone ; then fracture the remaining portion ; ap- ply a catgut drain and close the wound with the continuous su- Fig. 127. ture ; straighten the limb, apply iodoform gauze, and finish with plaster-of-Paris dressing extending from the foot to the hip. The Feet. Distortions of the feet may be due to spasmodic action of one class of muscles, the antagonizing muscles acting normally, or to paralysis of one class, the opposing mus- cles being healthy. Careful examination of each case will determine whether spasm or paralysis is the cause ; but in general congenital cases are caused by spasm, and non-con- genital by paralysis. The general rule of treatment is to endeavor to overcome by appliances those deformities which readily yield to manipulation and are caused by paralysis, and to divide contracted tendons in those which do not yield readily and are caused by spasm. The object of treatment is the restoration of form and function, and the means to be employed are physiological, mechanical, and operative. Adams very justly remarks : " The scientific treatment of severe deformities can only be accomplished by a judicious combination of these three methods, and many of the failures are due to the want of this combination of principles too frequently considered antagonistic to each other." Selecting talipes-equino-varus, the most frequent ex- ample of club-foot, the rules of treatment as regards Macewen's chisel, the adoption of the several methods are as follows : (1) If no obstacle exists to the perfect restoration of form by gentle application of force, the defect may be remedied by the manipulations of the nurse, aided, in more marked cases if necessary, by simple mechanical appliances, as rub- ber plaster, a boot with springs. (2) If the foot can be nearly but not quite restored to its natural form by the hand, the heel remaining somewhat ele- vated so as to limit or prevent flexion at the ankle-joint, tenotomy is justi- 32 498 MALFORMATIONS AM) DEFORMITIES. fiable, as it greatly hastens the cure. (3) In more severe grades tenotomy is indispensably necessary ; these cases are recognized by the following fea- tures : namely, the foot cannot be fully everted or brought to a straight line with the leg by manipulation, and in the attempt to effect this the inner malleolus does not become prominent. (4) The os calcis either cannot be depressed at all or only to a slight degree, so that after the partial ever- sion of the foot little or no flexion at the ankle-joint can be obtained. The following summary of principles of treatment of congenital club-foot, laid down by Little (of London), deserves attention : 1. Whether the case promises favor- ably for mechanical treatment only, or needs, as the majority of cases do need, ope- rative interference, commence the treatment as soon after birth as practicable. 2. Reduce the distortion from the state of a compound one (varus) to the simpler form (equinus) by first curing the inversion of the foot and the tendency to involution of the sole. 3. Avoid the slightest undue pressure upon prominent points of the leg and foot by careful padding of the hollow parts, and by using only gentle pressure with any bandage ; avoid obstruction of the returning blood from the limb. 4. Re- move splint and bandage daily, practise gentle movements of the foot in the desired direction, endeavor to prevent the part remaining for an instant unsupported and liable to fall back into the deformed position, until it is found that the foot, on re- moval of the bandage, retains a perfectly good position and flexibility. 5. Never permit the child to be placed on the feet or to walk until the form and movements are complete, whatever may be the age of the patient. The only apparatus neces- sary to carry out this treatment is a splint of tin or pasteboard so adapted to the external parts as to leave a space between the foot and splint when bandages are applied, or rubber plaster applied to the anterior part of the foot and passing up Talipes equinus (Fig. 128) is usually congenital. There are also vari- The treatment is operative and mechanical. The ous degrees of varus Fig. 128. Talipes Equinm G T1EMANN & CO Club-foot shoe. Congenital Club-foot. tendo Achillis and plantaris may alone require division, or, in addition, the plantar fascia must be cut, as when the arch of the foot is strongly contracted ; the foot should usually be brought into position at once and retained by splints or the gypsum dressing. In gen- eral it will be more advantageous; especially if the child is walking, to apply, within a week or two after the operation, the club-foot shoe. There are many varieties, as Sayre's, Shaffer's, Taylor's. The Sayre shoe (Fig. 129) generally gives satisfaction. Its construction and modes of action are as follows : A cushioned iron cap to receive the heel, the leather covering of which is carried over the instep and ankle THE EXTREMITIES. 499 and fastened by lacing ; elastic tubing, X, to go in front of the ankle-joint further to secure the heel in position, and fastening at C, an iron hook on outside of heel-cap ; sole of shoe, p -^q D. cushioned, and laced securely in front of the medio-tarsal articulation ; ball-and-socket joint, E, connecting sole with heel ; elevated plate of iron, F. properly cushioned, to make pressure against base of first metatarsal bone ; steel bars, G. connecting the shoe with strap, H, to go round the calf; joint, K, opposite the ankle ; stationary hooks, L, opposite the toes, for attaching the India-rubber muscles, 3f. 31. M. These India-rubber tubes have chains attached, and are for the purpose of making flexion and eversion. Or the following more simple apparatus may be used : The sole of the strong leather shoe is of metal, with the joint near the heel, allowing lateral motion ; a durable spiral spring, a (Fig. 130), draws the foot outward by a constant, elastic, and easy traction ; this pressure is increased or decreased at will by fastening the spring in a series of sockets, c. The single outside upright steel bar, with joints at the ankle, is fastened round the limb below the knee- joint, and so constructed that the screw at the ankle-joint forces the foot flat upon the floor, the foot in almost all cases being turned under as indicated (Fig. 129) ; the spiral spring, d, at- tached to a catgut cord and fastened near the toes Club-foot apparatus, upon the outside of the foot, elevates the toes and stretches the tendo Achillis, thus drawing the foot to its natural position. Talipes calcaneus (Fig. 131) is both a congenital and non-congenital affection. In congenital cases the deformity consists in the position of the Fig. 131. Fig. 132. Acquired Congenital Talipes calcaneus. foot being an exaggerated degree of flexion, owing to paralysis of the calf. In acquired cases there is paralysis of the muscles of the calf and the exten- sors of the toes. In congenital cases the treatment required is passive exercise and the use of a soft padded splint applied in front of the leg and foot. If there is much contraction of the anterior muscles, the tendons of the tibialis anticus, extensor proprius pollicis, extensor lon-us aigitorum, and peroneus tertius may require to be divided. The apparatus has a steel spiral spring, placed on a pivot and playing between brackets of the leg and ankle-stem to depress the front part of the foot by e^en son ; there is not so much danger of falling with this apparatus when descending stairs. Or, instead of the spring, there may be an elastic band attached to the heel of he shoe below and to the ring above, which constantly tends to elevate the Shoe for calcaneus. 500 MALFORMATIONS AND DEFORMITIES. Non-congenital calcaneus is usually the result of infantile paralysis, and as a consequence tenotomy is seldom required ; palliative treatment alone must be attempted by the application of a proper shoe. Fig. 133. Congenital Varus. Club-foot— three grades of severity. Talipes varus, usually also equinus, in its severe form has the following external characters (Fig. 133) : namely, the anterior portion of the foot is turned inward, forming a right angle ; the sole looks directly backward and the dorsum forward ; the inner border looks directly upward and the outer directly downward. The first stage of treatment consists in correcting the varus by turning the foot outward into a straight position or by bringing the sole squarely downward ; the second stage consists in overcoming the eleva- tion of the heel, equinus, if that exist. If the foot can be brought around nearly straight with comparative ease, the effort should be made by manipu- lation and bandaging to correct the deformity. This may be effected by many methods : (1) Apply a strip of adhesive plaster around the anterior part of the foot, commencing on the dorsum and passing around the inside, then across the sole to the outside, and then, while the foot Fig. 134. Fig. 135. is turned strongly outward, up the outside of the leg to the knee : over this dressing apply a roller band- age ; repeat the dressing every sec- ond day (Fig. 134). (2)^ Apply a splint adapted to the outside of the limb (Little), with a foot-piece at an angle with the foot, and, beginning at the upper part, bandage the leg and foot to the splint (Fig. 135) ; change the dressing every second day, giving to the foot strong trac- tion externally. (3) Give the pa- tient chloroform, and, after forcing the foot outward fifteen minutes, apply a gypsum bandage (Ogston) ; repeat the dressing weekly. In cases which require tenotomy divide the tibialis anticus and posticus, and, if neces- sary, also the tendo Achillis and flexor longus digitorum ; after the healing of the wounds apply the club-foot shoe. The removal of a triangular mass from the tarsus (Colley) on the outside has been successfully practised in severe cases ; the steps of the operation and the results will be understood by the illustrations (Figs ; 136, 137, 138). Phelps has succeeded in overcoming severe forms of varus by incisions dividing all of the con- tracted tissues on the inside of the foot. These extensive operations are to be resorted to when milder methods have failed, and in older children. Hopkins of Philadelphia has recently successfully corrected inveterate Mode of stretching foot in talipes varus, by strapping. Varus treated by bandage. THE EXTREMITIES. 501 talipes varus by the artificial production of Pott's fracture deformity. He operated as follows : After tenotomy of the tendo Achillis, though the equinus element was almost absent, an incision two inches long was carried down to within half an inch of the Fig. 136. Fig. 137. Fig. 138. Foot before operation. Bones removed. Foot after operation (Bryant). external malleolus. The fibula, having been stripped of periosteum, was exposed and three-eighths of an inch of its shaft excised with cutting forceps, the lower section being three-fourths of an inch above the lower end of the bone. Forcible abduction of the foot brought the sole beneath and a little beyond. A few strands Fig. 139. Fig. 140. m The case before and after operation. of drainage were placed in the wound ; the limb was dressed antiseptically and placed upon an internal straight splint. A plaster-of-Paris dressing was applied fourteen days later, when a scanty serous oozing had ceased and the wounds were healed. The child showed no inflammatory reaction after the operation : indeed, none was to be expected, for the shaft of the fibula was not more than an eighth of an inch in diameter (Figs. 139, 140). Talipes valgus (Fig. 141) is rarely congenital. Marked cases, without rigid muscular contraction, may be cured mechanically in a few months with- out tenotomy, but severe cases demand a combination of operative, mechani- cal, and physiological means. The tendons requiring division in the slighter 502 MALFORMATIONS AND DEFORMITIES. cases are the peronei and extensor longus, and the tendo Achillis if involved ; in very severe cases the tibialis anticus and the extensor pollicis must also be Congenital Club-foot. Acquired divided. The mechanical treatment of slight cases in which the tendo Achillis is not divided is as follows : A convex pad of vulcanized India-rubber is placed inside of the boot in the normal situation of the arch of the foot which it is intended to support ; it should extend half way across the sole of the foot, and rise on the inner side so as to sup- port the navicular bone ; the heel should be raised on the inner side about a quarter of an inch, so as to twist the foot inward and throw the weight on the outer side. In more severe cases it is necessary to add a steel support, attached to the outer side of the boot and carried up to the calf of the leg, where it is connected with a semi- circular steel plate and a strap which encircles the leg ; a free joint should corre- spond with the ankle, and a leather strap attached to the inner side of the boot should pass across the ankle-joint and buckle outside the steel support. In the most severe cases, after tenotomy is performed a shoe must be applied which effectually brings the foot by degrees into position. The shoe and spring of Royal "Whitman are very effectual in accomplishing this result. Hollow club-foot (pes cavus) (Fig. 142), is due to paralysis of the inter- ossei muscles, the short flexor, and adductor of the great toe ; the first phalanges are extended upon the metatarsal bones, and the last two pha- Fig. 142. Hollow club-foot, pes cavus (Erichsen). laDges flexed upon the first; the posterior extremities of the first phalanges are subluxated upon the heads of the metatarsal bones ; then the curve of the plantar arch becomes increased and the plantar arch shortened ; then certain articulations and their ligaments become deformed as in all club-feet. From the position of the toes and from the increased arch of the foot the whole pressure in walking is borne upon the heel and upon the skin covering THE EXTREMITIES. 503 the unnaturally prominent heads of the metatarsal bones, which latter become tender in consequence, especially that over the great toe. The treat- ment consists in : 1. stimulation of paralyzed muscles by faradization ; 2, the division of the tendons of those muscles which their tonic contraction maintain and increase the deformity. The muscles more often divided are the extensor of the great toe, the tendo Achillis, and in addition a very tight band of the inner division of the plantar fascia. The Scarpa shoe may be used after the operation, having hinges across the middle and rack-and- Fig. 143. Fig. 144. Congenital hypertrophy of toes and foot. (Plantar aspect.) (Dorsal aspect.) pinion movement, so that the depressed heads of the metatarsal bones may be raised by the anterior half of the sole. Congenital hypertrophy of toes and foot (Figs. 143, 144) is occasionally met with. The only remedy is the adaptation of suitable apparatus to meet the deficiency of the foot. PART IV. SECTION I. DISEASES OF THE BLOOD. By Frederic M. Warner, M. D. CHAPTER I. MEL.ENA NEONATORUM. Hemorrhage from the gastro-intestinal surface occurs in children from various causes. It is a common symptom of intussusception in infants. It occurs from dysentery and purpura and from the syphilitic dyscrasia. It has been observed in polypus of the rectum and in anal fissures. In rare instances it occurs from the irritation of lumbrici, from foreign substances which have been swallowed, and from the ulceration of typhoid fever. Intes- tinal hemorrhage from such causes is a symptom of constitutional or local disease. But in newly-born infants it sometimes occurs without other symp- toms or without other appreciable disease, and therefore is regarded as an essential malady. Melaena neonatorum was mentioned by Storck in 1750, and various writers at different times alluded to it or briefly described it prior to 1825. It 1825 it was more fully treated of by Hesse than by any of his predeces- sors. 1 The monograph published by him was valuable, as it contained his own observations and those of contemporary physicians communicated to him, as well as the investigations of his predecessors. Dr. Kahn-Escher of Zurich (1835), Meisner (1838), Kiwisch (1841), Rumpe (1841), Hoffman (1842), and Helmbrecht (1843) published memoirs or related cases of melaena. Several of the best-known authors on diseases of children, long recognized as authorities in this branch of practice, have also written on intestinal hemorrhage, as Billard, Yogel, Eilliet and Barthez, Barrier, Bou- chut. West, Eustace Smith, and Goodhart, so that the literature of this dis- ease is no longer meagre. Age. — In the statistics of Billard, embracing 15 cases, 8 were between the ages of one and six days, 4 between the ages of six and eight days, and 3 between the ages of ten and eighteen days. Of 20 cases embraced in the memoir of Rilliet and Barthez, 9 were at or under the age of thirty -six hours when the hemorrhage began. 5 between the ages of two and four days, 2 1 Annalen von Pierer, 1825, Heft 6. 504 MELJSNA NEONATORUM. 505 between six and eleven days, and 2 at the ages of fifteen and twenty weeks. Of 50 cases collated by Croom 1 from various sources, gastro-intestinal hem- orrhage took place in 30 between the first and sixth days, in 8 between the sixth and eighth days, in 4 between the eighth and twelfth days, and in 8 between the twelfth and eighteenth days. The bleeding began in 6 within the first twenty-four hours. These statistics, which correspond with those of other observers, show that in a large majority of cases the hemorrhage occurs within the first twenty-four hours. Hsematemesis also takes place along with the intestinal hemorrhage in a considerable proportion of cases. Etiology. — The cause of melasna of the newly-born is involved in some obscurity. To a considerable extent the causes are the same as in hemor- rhage from the umbilicus, which we have treated of in a foregoing page. A predisposition to this and other forms of hemorrhage is sometimes inherited. Dr. Rahn-Escher states that the mothers sometimes have digestive ailments or other forms of ill-health, which he thinks produce atony of the vessels in their infants. The bleeding infant sometimes belongs to a family of bleeders and inherits hemophilia. In the Medical Times and Gazette for October, 1880, Dr. Croom relates 4 cases in which there appeared to be an hereditary tendency to bleeding. In 1 of the cases the father was subject to hemorrhages ; in another the pressure of the forceps produced extensive ecchymoses on both sides of the head. We have stated in our remarks on umbilical hemorrhage that newly-born infants affected by syphilis are very liable to intestinal and other forms of hemorrhage from the dyscrasia present or from anatomi- cal changes in the walls of the minute vessels, or, as is probable, from both causes. Our article on umbilical hemorrhage contains the statistics of Mracek. who at the autopsies of 160 syphilitic infants observed internal hemorrhages in 42, but in only 4 of these was extravasated blood present in the intestines. But the majority of the neonati who have gastro-intestinal hemorrhage do not appear to have any inherited dyscrasia or taint of system. Certainly the instances are exceptional in which the infants belong to families of " bleeders " or have the syphilitic dyscrasia. We must look for other causes apart from these. Billard attributes melsena of the newly-born to conges- tion of the vessels. Says he: " I have examined 15 cases of passive intes- tinal hemorrhage Most of them were remarkable for the plethoric condition of their bodies and the general congestion of their integuments, .... In all the large abdominal vessels, the liver, spleen, lungs, and heart were considerably engorged with blood." He adds : " It cannot be too strongly recommended to accoucheurs to allow the umbilical cord to bleed when a child is observed to be in a state of asphyxia ; for it has already been seen what serious effects follow from a superabundance of blood in young infants." 2 Vogel says : '.' The turgescence of the mesenteric arteries and their systems of capillaries, seen even in the physiological state, and produced by the sudden closure of the umbilical arteries, so important in the foetus, and which arise directly from the hypogastric arteries, may be looked upon as a cause of this disease. An especial thinness of the walls or friability of the affected system of vessels must certainly play a part here, because otherwise this, in reality, very rare form of hemorrhage would have to occur much more frequently. The closure of the ductus venosus Arantii, and especially that of the branch of the umbilical vein opening into the portal vein, deserves more frequent and stricter investigation to explain this hemorrhage." Rilliet and Barthez attach but little importance to the causes of melsena assigned by writers who preceded them, but state that it is easy to conceive 1 Medical Times and Gaz., Oct., 1880. 2 Treatise on the Diseases of hi/ants. 506 DISEASES OF THE BLOOD. that hyperemia of the intestinal tube, which is normal in the newly-born r might be increased by atony of the vessels or impeded abdominal circulation, through arrest of the circulation in the portal vein, so that hemorrhage would be likely to occur. Incomplete establishment of respiration, in which congestion of organs occurs, and especially of the intestines, they regard as a predisposing cause. They admit hereditary influence in certain cases, as when a parent has been subject to hemorrhage. M. Bouchut l makes three groups of cases of melsena, according to the supposed etiology, as follows : First, nielama from purpura ; second, from passive congestion, the result of compression at birth ; third, from acute or chronic inflammation of the gas- trointestinal surface. Dr. West believes that tedious and difficult labor, in which the head of the child is compressed and abdomen injured, is an occa- sional cause of intestinal hemorrhage. The tardy and difficult establishment of respiration he also thinks may be a predisposing cause, but he adds : " Very often no reason can be assigned for it." In two post-mortem examinations which he made no adequate cause was discovered. Braun 2 mentions among the probable causes congestion of mesenteric vessels, pressure during birth, heredity, intra-uterine malnutrition. Steiner 3 believes that intestinal hemor- rage occurs sometimes from a round perforating ulcer due to fatty degene- ration of the arteries. Hecker, Buhl, Spiegelberg, and Leopold Landau relate cases, six in all, in which abscesses or ulcers were observed in the stomach or duodenum, or in both. Landau expresses the opinion that these lesions occurring in the gastro-duodenal surface are produced by small embo- lisms. Keinhold 4 relates the case of an infant born May 15th who had hamiateniesis and melaena on the first day, and died May 17th. There was apparently epigastric tenderness. All the organs were ansemic. and the stomach contained seven or eight ulcers with edges slightly raised. No em- boli could be discovered, but the umbilical vein contained a brownish-red clot. On the other hand, J. Halliday Croom, lecturer on midwifery and dis- eases of women at the School of Medicine, Edinburgh, made the autopsy of a child that died of melsena at the age of half a day. The gastrointes- tinal surface was carefully examined, and no abscess, ulcer, or erosion was discovered, but some congestion was observed in the lower part of the intes- tine. He alludes to another case, described by Helmbrecht, in which the only apparent morbid condition was congestion of the rectum. In another case, observed by Dr. Croom, an infant of three weeks, previously well, died of haematemesis and melaena. Both auricles contained firm clots, and in the aorta was a clot partly decolorized. The only abnormal appearance in the digestive tract was capillary injection of the duodenal surface. 5 In a case reported by Schutze, 6 no ulceration of the intestinal mucous membrane was discovered at the autopsy, but the mouth, pharynx, oesophagus, trachea, stomach, bronchi, lower part of ileum, and larger intestine were full of a dark tea-colored fluid ; there were ecchymoses of the dura mater, and the lungs were emphysematous. Epstein of Prague 7 in an interesting monograph on melaena neonatorum states that hemorrhage occurs in the newly-born from various causes — from disturbance of the circulation leading to congestion, from disease of the ves- sels, and from disease of the blood itself. In infants born partly asphyxiated after tedious labor, or in weakly infants with atelectasis, Epstein says that hyperemia, hemorrhagic erosions, ulcerations, and actual hemorrhage of the gastro-intestinal surface are likely to occur. He believes that the most com- 1 Traite pratique des Maladies des Nouveaux-nes. - Compendium des Kinderkeilkunde, Vienna, 1871. 3 Diseases of Children. 4 Deutsche med. Woch., No. 28, 1881. 5 Medical Times and Gaz., Oct., 1880. 6 Centralblattf. Gyndkol., No. 9, 1894. 7 Allgem. Wien. med. Zeit, No. 49, 1882. SIMPLE OB SECONDARY ANJEMIA. 507 mon cause of nielaena is temporary congestion of the finer capillary vessels. When the surface of the stomach has been sprinkled with ecchymoses, small gastric ulcers have been present, caused by emboli in the gastro-duodenal vessels, resulting from thrombi in the umbilical vein. From the above quite numerous observations we are able to affirm that hemorrhage from the stomach and intestines in the newly-born occurs from different causes, prominent among which are — 1st, haemophilia ; 2d, inherited syphilis ; 3d, congestion of the gastro-intestinal surface ; 4th, ulcers occur- ring especially in the stomach, whether produced by emboli resulting from thrombosis in the umbilical vein or from other causes. Diagnosis. — If the infant vomit blood, the nipple of the mother or wet-nurse should be inspected, for a considerable amount of blood is some- times drawn by suction from the nipple. If no abrasion or sore be dis- covered upon or around the nipple or upon the lips or in the mouth of the infant, we may assume that hemorrhage is occurring from the stomach or upper part of the intestines of the infant. The presence of blood upon the diaper without any fissure upon the anus or external source of its occurrence is evidence of intestinal hemorrhage. The blood is dark and more or less changed by digestion or the action of the intestinal secretions if it have lain some time in the intestines. The pallor of the infant and increasing feeble- ness are evidence of the loss of blood. But in one instance myself and two other physicians were deceived by a midwife who had loosely ligated the umbilical cord, so that fatal hemorrhage occurred from it. The case was reported as one of intestinal hemorrhage, and was recorded as such in the statistics of the Health Board. The source of the hemorrhage was ascer- tained by a post-mortem examination which we were fortunate in obtaining. The gastro-intestinal surface was normal except its extreme bloodlessness and pallor. Prognosis.— The prognosis is in most instances unfavorable, but if the infant be strong and the amount of hemorrhage small, we may hold out some encouragement of a favorable result. It is possible, indeed, that a consider- able amount of blood may be lost and the infant recover. But weakly infants who have an abundant hemorrhage sink rapidly. If the bleeding do not cease in twenty-four hours, death will probably be the result. Treatment. — The child should be nourished at the breast if possible, and a little ice-water be given with a spoon along with the breast-milk. If the infant do not have breast-milk, peptonized milk may be employed. The food, of whatever kind, should be given cool. It has been recommended to apply the ice-bag over the abdomen while warm applications are made to the extremities. One grain of tannic or gallic acid dissolved in cool water may be given every hour, or one or two drops of turpentine. If the child exhibit signs of failing strength, a few drops of brandy should be given at short intervals in cold peptonized milk. CHAPTER II. SIMPLE OR SECONDARY ANEMIA. By simple anaemia we mean a condition resulting almost invariably as a consequence of previously existing disease, excepting, of course, post-hemor- rhagic anaemia, whereby the composition of the blood is greatly altered, re- sulting in the impoverishment of the vital fluid and the impairment of its 508 DISEASES OF THE BLOOD. function. Should this condition be regarded as a symptom or as a disease? Unquestionably the latter, characterized as it is by certain anatomical appear- ances and a train of well-marked symptoms. In children simple anaemia is one of the most important pathological con- ditions we meet, frequently encountered, complicating many other states, in- fluencing other and grave diseases, always of much significance. In common with the other blood-diseases, it is characterized by a diminution in the amount of haemoglobin, which normally constitutes about 90 per cent, of the bulk of the red cells. The red blood-globules may be only slightly reduced in num- ber, they may even be numerically normal, and in very badly-nourished chil- dren there is a lessening in the whole amount of blood. Let us revert briefly to a consideration of the corpuscular elements of the blood, and the relationship of their state or condition to this affection. The red blood-cells are the means by which oxygen is carried to the tissues ; they vary in number from four and a half to five millions per cubic millimetre in the healthy adult ; at birth the number is greater ; within a short time it is rapidly reduced. (Plate III. Fig. 1.) Nucleated blood-cells, which are normally found in the red marrow, are probably intermediate between the red blood-cells and the marrow-cells ; these are not found in the blood of healthy adults, though present in the blood of children up to two or three years of age and in the foetus. According to Erlich, 1 they may be found in the blood of patients suffering from all varieties of anaemia ; they are a little larger than the ordinary red blood-cells and con- tain one or more nuclei. The white blood-corpuscles are larger and fewer than the red blood-cells in number, being about from eight to fifteen thousand per cubic millimetre normally, although this amount may be greatly increased without affecting the health. > The blood of children contains double and sometimes treble the adult number of white blood-cells, and in exceptional cases even a greater number, and then there is great likelihood that this condition of leukocytosis may be mistaken for leukaemia. Infants at the breast are said to have present in the blood a greater per- centage of leukocytes than those fed on cow's milk, Personally I have not been able to demonstrate this, although I have many times examined the blood of infants for the purpose of comparison. It is an undoubted fact that in all cases of anaemia the amount of haemoglobin is diminished, the sole exception being in pernicious anaemia, where the haemoglobin commonly equals or ex- ceeds the percentage of red blood-cells, and this may be demonstrated by means of the haemoglobinometer — an instrument which, as its name indicates, registers accurately the percentage of haemoglobin in the specimen of blood. The simplest instrument for practical use is the one devised by Gowers. In simple anaemia the percentage of haemoglobin is diminished to a much greater extent than that of the red blood-globules. (Plate III. Fig. 2.) In studying any of the blood diseases much may be learned by examina- tion of the blood — 1, for the haemoglobin as I have above suggested; and 2, by the microscope, for a determination of the rough proportion between the red and white cells, their color, shape, and size, as well as those of the blood-plaques, the presence of nucleated blood-cells or of foreign bodies, such as the Plas- modium malarise. This latter method is simple, and is readily managed by any one with a microscope with ordinary lenses. For the more exact determination, how- ever, of the relation between the red and white corpuscles special apparatus is required. For this purpose the Thoma-Zeiss haemacytometer is in common 1 Berliner klinische Wochenschrift, 1880, p. 405. PLATE 111. Fig. 1. Fig. 2. f®%®% or JP C Blood in Anaemia. o- o0 ° o n o°oOg°o co ° o°or° 00 1 o o°o O°0~ o M ° o J»©50o ( o Blood in Chlorosis, (x 300.) Blood in Acute Lymphatic Leukaemia. (x 300.) SIMPLE OR SECONDARY ANJEMIA. 509 use. and is very simple and easily managed. It consists practically of a slide with a centrally depressed disk, which is divided into microscopic squares. Upon this surface properly diluted blood is dropped, the cells being counted within the given space, and as the dilution is a standard one, the total number of white and red corpuscles per cubic millimetre is easy to calculate. In various wasting diseases accompanied by great changes in the blood a condition is sometimes obtained in which marked alterations in the shapes of the red corpuscles occur ; they become variously distorted, and may even take upon themselves amoeboid movements. This is sometimes the case in simple anaemia, but is more characteristic of the condition known as pernicious anaemia. Etiology. — The causes which lead to the condition of simple anaemia in children are various, chief among them being malnutrition, secondary to graver diseases, such as scarlatina and inherited disease, tuberculosis, syphilis, im- proper and scanty food, faulty hygiene, including lack of fresh air ; and Haig, 1 who has investigated this subject pretty thoroughly, thinks that severe anaemia is sometimes caused by a condition of uric-acidaemia. This I believe to be often the case. Rachford, 2 as the result of the examination of the blood of 166 school- girls, has been led to the conclusion that pronounced anaemia without apparent cause is strongly suggestive of concealed tuberculosis, and that anaemia in apparently non-tubercular girls coming from tubercular stock is very probably due to a deep-seated and hidden glandular tuberculosis. Symptoms. — We have seen that in anaemia — 1, the haemoglobin is reduced, and 2, the red blood-cells may or may not be diminished in number, while the total bulk of the blood may or may not remain practically the same. There- fore, the initial symptom to which our attention is apt to be called in this dis- ease is referable to this condition — pallor, ranging all the way from almost marble whiteness to dusky yellow ; pallor of skin ; pallor of all visible mucous surfaces ; certain portions of the body become markedly blanched, the ears, nose, and nails. In some cases the cheeks may be bright red in color, while the conjunctiva, the lips, gums, and roof of mouth betray a waxen whiteness. In other cases the temperature is normal ; in others an irregular pyrexia may develop, the pulse may be full and soft or small and weak, with the heart's action irregu- lar, while a venous hum may commonly be heard over the jugulars. Leu- korrhcea may develop in very young female children, and catarrh of the respi- ratory mucous membranes is of common occurrence. When the anaemia is secondary to and dependent upon other disease — such as rickets, for example — it is often the first symptom noticed. There is a peculiar puffiness of face, hands, and feet, resembling the oedema of acute Bright's disease. Patients complain of neuralgic pains, the most important and characteristic of which was first pointed out by Flint in cases of so-called spinal irritation, where pressure over the cervical and dorsal vertebrae causes intercostal and cervico-occipital pains, with perhaps the association of nausea, vomiting, palpitation, and a nervous cough. With these symptoms great weakness and prostration are of frequent occur- rence, associated with loss of appetite and obstinate constipation, which latter condition has been believed by Sir Andrew Clarke and some other observers to be one of the causes of the disease, by poisoning the patient from absorption of ptomaines from the impacted intestinal canal. Diagnosis. — The diagnosis must be made from chlorosis, pernicious anaemia, leukaemia, beginning pulmonary tuberculosis, and acute Bright's disease. 1 Uric Acid, p. 218. 2 Transactions of the American Pediatric Society, 1S92. 510 DISEASES OF THE BLOOD. From Chlorosis. — The age of the patient, as this is an exceedingly rare affection in young children ; also the hue of the skin in chlorotic patients is unmistakable, the typical greenish pallor — particularly true of brunettes — being entirely different from the yellow-white or muddy color of simple anaemia. (Plate III. Fig. 3.) From Pernicious Anaemia. — A microscopic examination of the blood in this latter condition is essential. The red blood-corpuscles are rapidly reduced in number ; they may reach only one-fifth or one-sixth of the nor- mal amount, while, on the other hand, the percentage of haemoglobin is relatively high. The red blood-cells are either much larger than normal or much smaller, and may take upon themselves irregular forms. Nucleated blood-cells are constantly present. The white blood-corpuscles are also diminished, but not to a corresponding degree with the red cells. From Leukaemia. — In the ansemia of infants leukocytosis is apt to occur, and it is due to this fact that errors in diagnosis are of common occurrence. The composition of the blood, however, is very characteristic. In leukaemia (a rare affection in infants) a constant, steady increase in the number of the white cells obtains, while there is a like steady decrease in the number of red cells. In leukocytosis the number of white blood-corpuscles varies greatly at different times. In leukaemia we have the enlarged liver, spleen, and lymph- atic glands, which of course are absent in anaemia, except in a form which has been described by Von Jaksch, 1 and which he calls anaemia infantum or pseudo-leukaemia. From Beginning Pulmonary Tuberculosis. — By means of the physical signs and characteristic range of temperature. From Acute Brighfs Disease. — By means of the presence or absence of casts and other symptoms marking this affection. Treatment. — In considering the treatment of this affection our object is primarily to increase the amount of haemoglobin contained in the blood. When the patient is the victim of inherited disease, syphilis or tuberculosis, medication appropriate to the systemic poison, together with the best possible hygienic conditions — fresh air, abundance of fatty food and expressed beef- juice (the nearest approach to the administration of haemoglobin at our com- mand), and regular exercise, preferably in the open air — will be of benefit. About the only two drugs which seem to be of efficacy in the treatment of anaemia in young children are iron and arsenic. Iron. — The blood of man contains one part of iron to two hundred and fifty parts of red blood-globules. In health a mixed diet contains sufficient iron for all purposes ; but when the percentage of haemoglobin falls below the normal amount, experience proves that the exhibition of iron in many cases promptly arrests this fall and restores the normal balance. Forchheimer 2 insists upon the intestinal tract as the principal place of origin of the haemoglobin, and believes that, excluding the origin of anaemias, the reduction of haemoglobin is due to either diminished formation, excessive destruction, or both. Therefore he treats all cases of simple anaemia, charac- terized, of course by a lessening of the amount of haemoglobin, by intestinal antiseptics. I believe that anaemias of intestinal origin, such as undoubtedly exist, may rationally be treated on this principle, but only those. The same observer believes that the good effect obtained by the employment of iron in anaemia is partly due to its ability to prevent the formation of albuminous products not compatible with haemoglobin formation. Be this as it may. the good effects produced in the treatment of anaemia with iron is too old a story to repeat, except to emphasize the fact of its value with a word of caution 1 Annals of Universal Medical Science, 1890, vol. ii. pp. E. 12. 2 "Ansemia in Children," Transactions of the Pediatric Society, vol. v. PRIMARY ANAEMIA. 511 against its abuse. I believe that the best effects are obtained by the adminis- tration of small doses, for in this way it acts in the double capacity of a sto- machic tonic and a blood reconstructive. In large doses it quickly exhausts the gastric glands by over-stimulation, and it is then, of necessity, discontinued. Arsenic, in combination with iron or alone, in proportionately larger doses than adults will bear, is of great importance, and especially useful in chronic eases. It acts by increasing the appetite, promoting digestion, and improv- ing the body nutrition. In the anaemia of the uric-acid condition — which is. although of frequent occurrence in young children, commonly overlooked, and which may have resisted iron given in the usual way for a long time — brilliant results will sometimes be obtained by the administration of the salicylate of soda. Dr. Augustus Caille has published statistics regarding the value of the employment of inhalations of nascent ozone in the anaemia of children, which he deems considerable. I have used oxygen in a number of cases, and believe that it has been of service. Exercise in the open air, regularly, is probably equal in value with either. The treatment is therefore thus summed up : Eelieve, if possible, the constitutional cause of the anaemia ; in addition, give iron and arsenic sparingly, in tonic doses ; plenty of good nutritious food and systematic exercise in the open air. CHAPTER III. PKIMARY ANAEMIA. Leukaemia (Leucocythsemia), A disease characterized by a steadily progressive increase in the number of white blood-corpuscles, and a diminution in the number of red blood-cells. In many cases the spleen becomes very greatly increased in size, and in others the lymphatics become enlarged, and marked changes may take place in the bone-marrow. Etiology. — The origin of the disease is obscure. Tuberculosis, syphilis, malaria, anything which tends to seriously alter the bodily nutrition, predis- poses to the disease. According to the observations of Cameron (published in 1888) and those of Sanger (in 1891), intra-uterine transmission of leukaemia from mother to child does not take place. It is of rare occurrence in chil- dren, but is in many cases overlooked when actually present. It may follow the exanthemata. Morbid Anatomy. — The spleen is generally more or less enlarged in the splenic variety of the disease ; it may be so large as to seriously interfere with the functions of other organs. The lesions consist of a hyperplasia : on section the spleen is dark red in color, with occasional hemorrhagic infarc- tions. The lymphatic glands also undergo a hyperplasia, whitish or grayish- red on section ; the liver is generally large. The medulla of the bones may be gelatinous and red, or white from the number of leucocytes. The blood- changes are very marked. Normally, the proportion of white and red blood- cells is 1 to 500 ; in this disease the white cells may equal or exceed the red blood-cells in number. In acute lymphatic leuksemia the white cells are chiefly lymphocytes — small cells about the size of red blood-globules, nearly filled with a single nucleus. (Plate III., Fig. 4.) 512 DISEASES OF THE BLOOD. In leuksemia linealis the colorless cells are much larger than the red blood-cells. In the splenic variety of the disease there are present large colorless cells, which do not occur in normal blood, and which differ from the other large white cells in the fact that they contain a fine granular mass in the nucleus. Blood-plaques may or may not be present. The Charcot-Neu- mann crystals readily separate out from the blood. (Plate IV. Fig. 1.) Symptoms. — The disease begins insidiously. The most characteristic symptoms are the blood-changes, aside from which occur extreme pallor, en- largement and tenderness of the spleen, enlargement of the lymphatic glands, in which caseation and suppuration may take place but rarely. When the disease affects the medulla there may be tenderness on pressure over the shafts of the long bones, over the sternum, and over the spinal column. Hemorrhages may occur from the gums and the nose frequently — haematemesis or haematuria rarely ; cerebral hemorrhage may take place. Nausea, vomiting, and diarrhoea are of constant occurrence. Jaundice and accumulation of fluid in the peritoneal and pleural cavities occur, and we have also the symptoms of anaemia — faintness, dizziness, and headache. A slight elevation of temperature is pretty constant, but at times it may be absent. Diagnosis. — An examination of the blood can alone reveal the presence of leukaemia, but this is characteristic and unmistakable. Prognosis. — A fatal termination is the rule ; exceptionally patients have recovered, but when this occurs a relapse after a longer or shorter time is to be looked for. Treatment. — Arsenic, iron, inhalations of oxygen, and in some cases, where seemingly indicated by an early history of malarial influences, quinine, are all, at times, of benefit, arsenic probably being of more real utility than any other drug. Pure air and good food are essential. There is seldom, however, prolonged benefit from any line of treatment. Excision of the spleen has been performed, but is not to be advised. Pseudo -leukaemia (Lymphatic Anaemia ; Hodgkin's Disease) consists in a hyperplasia of the lymphatic tissues wherever situated in the body, notably in the lymphatic glands and spleen ; frequently the liver is in- volved, associated with anaemia and pyrexia, and generally progressing to a fatal termination. Etiology. — Generally occurs during youth — very frequently, however, in childhood. A majority of the cases are in males. As a rule, the affection begins in an insidious manner from no assignable cause. It has been ascribed to syphilitic or tubercular antecedents. In other cases, however, local irritation, due to chronic disease of the ear, a decayed tooth, or naso- pharyngeal catarrh, gives rise to disease of the adjacent lymphatic glands, from which the glands in various parts of the body become affected. The main pathological change is an increase in the lymphatic tissue in various organs of the body. Morbid Anatomy. — The cervical glands are most frequently primarily involved, the axillary next, and then the inguinal. Of the deep glands, the thoracic, notably the bronchial, are most often enlarged. The glands, at first distinct, later become amalgamated into masses. The spleen is generally of large size, due to an increase in the lymphatic tissue, but this condition is not constant. The liver may be larger than normal, together with the kidney, due to the same lymphatic increase. The blood-changes are not constant. In the early stage of the affection there is no change ; later, how- ever, when the anaemia has become marked, the blood is characteristic of PLATE IV. Fig. 1. Fig. Bloocl in Leukaemia Lineal is. (x 400.) Chareot-Neumann Crystal? in Leuksemic Bloocl. (x 300.) Fig. 3. Bloocl in Pernicious Anaemia, (x 300.) PRIMARY ANEMIA. 513 this condition, thin and watery, with a diminution in the number of red cells, the white corpuscles remaining at about the normal number. Occasionally the latter become greatly increased and true leuksemia may supervene. Symptoms. — The first symptom noticed is an enlargement of the cervical glands. They may remain in this condition unchanged for months or years, or they may grow larger rapidly, fusing together in great masses. At the same time the axillary glands increase in size, followed by the inguinal, these bodies taking upon themselves like changes. Glands deeply situated now become enlarged, as is demonstrated by the mechanical effects produced by the pressure of the larger veins upon the blood-vessels, bronchi, nerves, etc. Anaemia, intense and progressive, supervenes, associated with more or less fever and prostration ; pain, caused in part by poverty of the blood, in part by pressure on nerves ; constipation ; sometimes great difficulty in swallow- ing ; hoarseness, caused by pressure upon the larynx itself or upon the pneu- mogastric ; nausea and vomiting. Diagnosis. — This affection must be differentiated from tuberculous and scrofulous glands, from simple adenitis and leukaemia — from the two former by the family history, the course of the glandular enlargement in groups, then splenic enlargement, and the non-liability to suppuration ; from simple adenitis by the rapid subsidence of the latter under appropriate treatment ; and from leukaemia by an examination of the blood. Prognosis. — Lymphatic anasmia progresses almost always steadily to a fatal termination. Occasionally a case recovers, but it is the exception. The disease lasts from three months to three or four years. Cases have been reported of longer duration of the disease than this, but this, of course, depends upon the rapidity with which the lymphatic tissue increases, and whether the masses which are formed affect vital parts early or late. Treatment. — If the diagnosis is made early in the disease, extirpation of the glands affected gives the most hopeful chance for recovery. The usual tonic treatment of cod-liver oil, iron, and arsenic, as in most of the blood diseases, generally betters the condition somewhat. Salt-water baths, iodide of potassium, inunction of iodide of lead and lanolin, good diet, and fresh air are all useful. Pressure effects must be treated as occasion demands. Splenic Anaemia, an affection of which the essential factor is an enlargement of the spleen, associated with a waxen olive complexion. Etiology. — Enlargement of the spleen is of frequent occurrence in young children, and is generally caused, primarily, by syphilis, tuberculosis, malarial poisoning, and rachitis. Morbid Anatomy. — The principal pathological changes occur in the spleen, which is found to be large, smooth, and dense in consistency, red in color on section ; there is a hyperplasia of the fibrous tissue and a correspond- ing decrease in the amount of the normal adenoid substance. The number of red blood-cells is found to be greatly diminished, while the white blood- corpuscles in some cases are increased in number, and in others they remain about the same. Symptoms. — The peculiar pallor which accompanies this affection is often the first symptom noticed, and the large, smooth, firm mass appearing below the free border of the ribs and pushing out into the abdominal region, some- times occupying the whole of the left side. Vomiting and diarrhoea occur frequently in the course of the disease, diminishing the strength and lower- ing the vitality of the patient ; catarrhal troubles, notably bronchitis or broncho-pneumonia, often bring the case to a fatal termination. 33 514 DISEASES OF THE BLOOD. Diagnosis. — In all cases of anaemia in young children attention should be at once directed to the spleen ; the enlargement of this organ, from its position, mobility, hardness, and smoothness,, is not difficult of detection, while an examination of the blood, which should always be made in these cases, will seem to differentiate it from leukaemia. In pernicious anaemia the spleen is not particularly enlarged, and the disease differs essentially from lymphatic anaemia in that the glands are not affected and enlarged. Prognosis. — The prognosis of splenic anaemia or enlargement depends entirely upon the etiology. Tubercular and syphilitic cases are unfavorable, as are some cases of rachitic origin ; others, however, improve under good care. Malarial influences, which undoubtedly are the largest factors in producing this condition, usually yield readily to treatment and change of climate. Treatment. — The best results in the treatment of enlargement of the spleen will be obtained by the intelligent employment of drugs directed against the presumed cause of the disease, and sometimes brilliant results follow the use of mercurials in the syphilitic form, and quinine and arsenic in the malarial variety of the affection. In the rachitic and tubercular enlargements we may expect that attention to the diet and the hygiene of the little patient will achieve far more than the mere taking of any special remedy. The catarrhal affections complicating splenic anaemia may be best combated by suitable and warm clothing, and the patient must be kept out of doors as much as possible. Simple, easily-digested, or even predigested foods are indicated, and other complications must be treated as they arise. It is important, moreover, to sustain the patients to the fullest extent, and, after they have started on the road to recovery to guard against relapse, a not uncommon occurrence. Pernicious Anaemia (Anaemic Fever, Idiopathic Anaemia). This affection is characterized by anaemia, fever, and highly-colored urine, from excess of urobilin, together with marked changes in the blood. It is of rare occurrence in children. Morbid Anatomy. — The white blood-cells are diminished in number ; the red corpuscles are very greatly lessened ; they may be reduced to one-fifth or even less of the normal number, while the haemoglobin is relatively in- creased. The red blood-globules are very irregular, and may be much larger or much smaller in size, and may possess amoeboid movements. The blood may contain nucleated red blood-cells, which some observers consider to be pathognomonic ; the blood-plaques are fewer in number. Ecchymoses may occur. Fatty degeneration of the various internal organs — liver, kid- neys, etc. — is of common occurrence. Symptoms. — The skin is generally brown-tinted in color, and the mucous surfaces seem absolutely bloodless and of a pale leaden hue. (Plate IV. Fig. 3.) The pyrexia is not constantly present ; it may come and go. With these special symptoms are always associated those of simple anaemia. Etiology. — The cause of this disease is very obscure. In children it has been known to occur from no apparent predisposing element. It is more apt to result, following grave chronic gastro-intestinal disorders, constant liv- ing in-doors in rooms not often or well ventilated, and from insufficient and improper food. Treatment.— Arsenic seems to be the only drug of service in this affec- tion. Rest in bed, good, nourishing food, and attention to hygiene give the best results ; but in any case the outlook is unfavorable. PRIMARY ANJEMIA. 515 Haemophilia, an hereditary affection characterized by the sudden development of more or less severe hemorrhages, either spontaneously or from slight cause. Etiology. — " Bleeders,'' as the subjects of this affection are called, are generally males, although females, while escaping themselves as a rule, most frequently transmit the inherited taint. For example, if a bleeder marries a healthy woman, the children generally remain free from the affection ; if, on the other hand, a healthy man marries a woman who is free herself, but who comes from a family of bleeders, the male children are generally bleeders. Anatomical Appearances. — No constant changes have been noted in this affection. Importance has been attached by some observers to a certain thinness of the blood-vessels. Probably, however, the chief morbid process will be found in the diminished power of the blood to coagulate. Symptoms. — The first symptom of the affection is sometimes discovered early in life from a fatal hemorrhage following the separation of the umbili- cal cord, but this is of rare occurrence. In other cases trifling cuts, bruises, knocks, or other injuries produce per- sistent hemorrhages, more or less serious in character according to the amount of blood lost. As simple an affair as the extraction of a tooth or an attack of epistaxis may result fatally. The hemorrhage is more often capillary, oozing generally from the bruised surface and presenting no vessel in par- ticular to tie. Diagnosis. — The diagnosis must be made from purpura by the history, and from scurvy by the absence of the given symptoms in addition. Prognosis. — The prognosis is always grave. Constant care must be taken to prevent injuries of all kinds, and no surgical operations must be performed upon these patients. Treatment. — The treatment is chiefly preventive, in not allowing the females to marry, in order to stamp out the disease. During an attack of the hemorrhage rest in bed, ice, and astringents may be employed. Ergot is said to be of service. Free purgation is advised ; iron and arsenic in full doses have been beneficial ; and in desperate cases transfusion is advocated. Purpura, an affection characterized by extravasations of blood, of greater or less extent, into the connective tissue beneath the skin, into the skin itself, and into the submucous tissue. Purpura may be simple and idiopathic or sec- ondary. Etiology. — Although the disease may occur in adult life, it is most fre- quently observed during infancy and childhood. It is probably due to the invasion of micro-organisms, and it may exist as the result of severe eruptive disorders, such as scarlatina, smallpox, measles, and typhoid fever. It is associated with haemophilia and scorbutus. Unsuitable food and unhygienic surroundings predispose to it ; rheumatism and grave gastro-enteritis and jaundice may be associated with it. It is frequently observed, chiefly around the eyes, accompanying the paroxysms of whooping cough. The administra- tion of certain drugs is followed in some instances by purpuric spots ; these are principally the iodide of potash, mercury, chloral, phosphorus, ergot, and belladonna. Anatomical Appearances. — In purpura there are extravasations of blood into the skin, subcutaneous tissue, and mucous and serous membranes. The loss of blood may in some cases be so serious as to result fatally. The cause is uncertain. Any place on the body may be the seat of the 516 DISEASES OF THE BLOOD. purpuric spots, except in the rheumatic variety of the disease, when they are situated in the neighborhood of the joints. In purpura hemorrhagica hematuria may be the chief symptom. Hem- orrhage from the bowels and epistaxis frequently occur. The disease may assume the foudroyant character, terminating fatally within a few hours. Symptoms. — In simple purpura there may or may not be prodromata ; commonly there exists a slight rise in temperature, with pain and aching in the arms and legs, and occasionally nausea and vomiting. Then small pete- chial spots appear on various parts of the body, preferably upon the arms and legs, but also on the chest and abdomen, rarely upon the face. The buccal and conjunctival mucous membranes are favorite sites for these hem- orrhagic spots. They vary in size from a pin-point to an inch or more in diameter ; they may disappear in a few days, and reappear in successive crops. In the rheumatic variety, called poliosis rheumatica, there exist pain and tenderness of the joints — a decided arthritis — and occasionally an endocar- ditis, together with hemorrhagic spots associated with urticaria in the neigh- borhood of the affected joints. In purpura hemorrhagica, called also morbus maculosis Werlhofii, the hem- orrhages may be so severe as to cause death within a few hours or days. The disease commonly lasts, however, from two to four weeks, and relapses are of frequent occurrence. Profound anaemia sometimes results from the loss of blood, and hemor- rhages may occur from the lungs, kidneys, bowels, and stomach. Albumin may be present in the urine. Prognosis. — The prognosis is always favorable, except in the exceptional cases of purpura haeniorrhagica, when the disease suddenly ends with high fever and when the actual loss of blood is considerable. Diagnosis. — The diagnosis must be made from scorbutus, where the characteristic gums in children whose teeth have erupted and the previous history are the chief differential points, and from haemophilia, which is an hereditary constitutional condition. Treatment. — Perfect quiet in bed and symptomatic treatment according to the indications, together with a general effort to sustain the strength by nourishing food and to improve the quality of the blood by arsenic in full doses, rapidly pushed as high as possible, will give the best results ; nothing else seems to be of any avail. Scorbutus (Scurvy), a disease of which the essential points are a swollen and spongy condition of the gums, extravasations of blood into various parts of the body, pain on handling, and intense anaemia. Etiology. — In infants and children the causes of this affection are the same as in adults — dietetic. Scurvy is developed in those who are fed upon artificial foods prepared with milk and water or with water alone. The true cause of the disease is absence of fresh food from the daily regimen, and it is apt, from the nature of things, to be associated more or less with rickets. Scurvy seldom occurs in nursing infants, but in those who are taken from the breast and given patent foods or condensed milk and water, to the exclu- sion of fresh cow's milk and beef-juice ; in such the conditions exist for the occurrence of the disease. Cow's milk itself is an undoubted antiscorbutic, and it is only when it is given in small amount and much diluted that chil- dren receiving it are attacked by scurvy. PRIMARY AXjEMIA. 517 Morbid Anatomy. — Extravasations of blood, varying in size from a pin-point to very large masses, may occur in any part of the body ; the most important of these is the subperiosteal hemorrhage which takes place between the shaft of one or more of the long bones, most commonly the femur, and the periosteum ; it may be so extensive that the membrane is detached from the bone through its entirety, retaining its connection only at the epiphyses ; the joints are never involved. The bone itself may become easily fractured, due to a softening of the osseous structure. Hemorrhages may also take place between the muscles or into the muscular tissue, into the various organs, and into the subcutaneous and submucous tissues. Symptoms — The first symptom of scurvy is generally the manifestation of ecchymoses, occurring quite suddenly in various parts of the body. In one of my own cases an extensive effusion of blood into the cellular tissue of the orbit first called attention to the child's condition. The production of pain upon handling, causing the child to scream whenever touched, calls attention to the lower extremities : one or both thighs or legs may be swollen and exquisitely sensitive to the touch, while the child lies immovable and cries with fear and apprehension whenever approached. This condition may exist also in the upper extremities, but more commonly in the lower. In the course of time the swelling begins to diminish and another extremity becomes affected. The gums are apt to be swollen and spongy, bleeding easily, especially if the teeth have erupted. As the disease progresses complications may be discovered at the extrem- ities of the limbs affected, due to separation of the epiphyses. The patient becomes profoundly cachectic. The rise in temperature, although generally constant, is, as a rule, not very high, rarely more than three degrees. When the case goes on to a favorable termination we find a gradual subsidence of all symptoms. The temperature drops ; the petechise dis- appear ; the pain, swelling, and tenderness over the long bones gradually diminish ; separated extremities unite ; and the color, strength, and appetite improve. Diagnosis. — In syphilis similar changes take place in the bones : if, how- ever, the other signs of syphilis are absent — viz. repeated miscarriage on the part of the mother, snuffles, hoarseness, condylomata, etc. — and if there be present spongy and swollen gums and evidences of localized hemorrhages in various parts of the body, the diagnosis is easily made. The differentiation from rickets is more difficult. In fact, these two dis- eases often coexist ; but the chief point of difference is that of great tender- ness and swelling over the long bones and not at the extremities. From symptoms the history is generally sufficient. Prognosis. — As a rule, patients recover from this condition rapidly after being put upon suitable food. Where the disease results fatally, it is on account of exhausted nutrition. Treatment. — The disease generally manifests itself between the first and second years as a result of the use of improper food after the child has been taken from the breast. We usually find these children being fed with one of the various prepared infants' foods or condensed milk and water. The diet should consist of fresh cow's milk, undiluted, unless it would be more easily digested by the addition of a little barley-water or rice-water or strained oatmeal ; beef-juice expressed from raw beef, freshly prepared, scraped beef; a raw egg beaten up with fresh milk, sweetened, with a little brandy added. Orange-juice should be given freely. It often causes marked improvement of the gums and other parts. In the way of medication the citrate of iron and quinine or the tincture 518 DISEASES OF THE BLOOD. of iron, in conjunction with cod-liver oil or with cream and whiskey or brandy, are all that are necessary. Local applications of hot wet cloths may be made to the tender limbs, and when the epiphyses have separated the affected extremity must be placed in splints. The pain in the affected limbs may be so great that it will be necessary to administer an opiate. PART V. LOCAL DISEASES. SECTION I. INJURIES AND DISEASES OF THE OSSEOUS SYSTEM. CHAPTER I. CAKIES OF THE VERTEBRAE. Vertebral caries (Pott's disease) is of frequent occurrence in childhood. It is an ostitis of the bodies of one or more vertebrae, usually of tuberculous origin. It is more common in the city than in the country, where better hygienic conditions produce a more vigorous constitution. In some cases there is no apparent exciting cause, but generally there is the history of a fall upon or some injury of the spine. Caries may occur in the cervical, dorsal, or lumbar portions of the spinal column, but it is more common in the lower dorsal region than elsewhere. The pathological processes are those of tuberculous infection. The pro- cess is in the cancellous tissue of the vertebral centre, and the inflammation results in a cheesy metamorphosis, beginning in the interior of the mass of granulations and gradually extending in all directions. These deposits, chiefly situated in the anterior half of the bodies of the vertebrae, soften into a pus-like fluid, which escapes by stripping oft' the periosteum and the longi- tudinal ligaments of the column in front of which it accumulates, and then gravitates downward. The intervertebral disks cither escape the inflamma- tory changes altogether or become involved at a relatively late stage of the disease. The result of the disorganization is relaxation of the union be- tween the vertebrae, which favors dangerous displacements, as of the atlas, and angular curvatures in other regions of the spine. The disease begins very insidiously with obscure symptoms referable to the nerves of the affected region. If in the lumbar region, there are pains in the legs and hypogastrium ; if it originate in the dorsal region, the pains will be in the epigastrium, and are frequently treated as indications of stomach and bowel derangements ; if in the upper cervical region, the pains are in the chest or back of the neck and head. As the destructive ulceration progresses there is increasing weakness of the spine, with languor, inability to stand long- erect, avoidance of all jarring movements, and if the upper cervicals are diseased, a disposition to support and protect the head with the hands applied to the chin and occiput ; displacement in the form of a sharp posterior angle next appears, revealing positively the nature of the affection. Finally, pus gravitating from the affected vertebrae accumulates as a congestive abscess beneath Poupart's ligament or in the lumbar region. The diagnosis is often, from the nature of the disease, obscure and uncertain for a time. The long continuance of pain in the chest or abdo- 519 520 LOCAL DISEASES. men. or perhaps in the thighs, without any cause which can be detected located at the seat of the pain, should excite suspicion of spinal disease. Such pain may be produced by spinal irritation, but in this malady pressure on the spine is badly tolerated, and when we touch a certain part the neuralgic pain is intensified. In caries firm pressure upon the spine is tole- rated, and it does not increase the neuralgia. At a later period in caries there are stiffness in the movements of the spine ; pain in the spine on sudden movement or jarring the body ; impaired appetite and general health ; and an instinctive desire to sit or recline in such a way as to relieve the spine partially of the weight of the head and shoulders. In the course of the examination undress the patient so as to completely expose the spine, and note any irregularities of the spinous processes. In infants, sitting, there is a uniform bending of the whole spine, which makes the spines prominent, but no one is markedly projecting ; this has been mis- taken for caries. Direct the patient to pick some article from the floor, which act reveals a stiffness of the spine. The patient inclines to sit down, rather than stoop, to avoid bending the spine (Fig. 145). If the disease is cervical, a slight tap on the head causes pain ; if it is dorsal or lumbar, the patient shrinks from rising on his toes and falling heavily on his heels. There is rarely any local pain or marked tenderness at the seat of the disease, except on percussion. When the disease is more advanced there is a prominent backward curve, a pendulous abdomen, and a slightly stooping attitude (Fig. 146). The most prominent spine always indicates the body of the vertebra originally involved. Fig. 145. Fig. 146. Early dorsal caries : child cannot bend the back in stooping, and supports weight by hand on knee. Attitude of child in angular cur- vature in advanced stage. The course of this malady, even when the caries is slight and the symp- toms mild, is tedious. In the most favorable cases the general health is but slightly impaired, the caries is confined to one vertebra, and is early diagnos- ticated and properly treated. On the other hand, if the general health be decidedly poor, the child anaemic and wasted, the curvature great, and an ab- scess have occurred, the case is very serious. Between these two extremes is every grade. The prognosis is more favorable in the child than in the adult. The few C ABIES OF THE VERTEBBJE. 521 adults whom I have seen with it all died. It is less favorable in the cervical region than in the dorsal or lumbar. A mild case occurring in a good con- dition of health may become grave, and even fatal, by neglect and improper treatment. A majority of the patients, if the disease be not too far advanced when recognized, recover if properly treated, but the deformity which results may prove serious in after-life. The incomplete expansion of the lungs in the humpbacked greatly increases the dyspnoea and the danger in subsequent years if bronchitis or pneumonia occur, and if the caries has been at a low point in the spine and the patient a female, the deformity will probably present an obstacle to childbearing. The treatment niust be constitutional and local, hygienic, medical, and mechanical. It is of the utmost importance to improve the general health, as it is in all chronic inflammation and scrofulous ailments. Pure air, sun- light, personal cleanliness, and plain but the most nutritious diet are required. Tonic and antistrumous remedies are indicated. It is advisable to give, three times daily, cod-liver oil, to which the syrup of the iodide of iron is added ; two or three drops of the latter to a child of one year, and one additional drop for each additional year. The judicious use of alcoholic stimulants will often be found serviceable if the appetite be poor and the general health seriously impaired, as will also the vegetable bitters. The mechanical treatment consists in applying such apparatus as will so support the upper part of the trunk that the pressure will be taken from the bodies of the diseased vertebrae. Of all the means yet employed, the plaster- of-Paris dressing is at once the most available and most efficient. It can be applied by every practitioner, and only requires a careful attention to the following details : Select crinoline or cheese-cloth for bandages, and a good quality of plaster of Paris, such as dentists use. Tear the crinoline into strips 1\ inches wide and 3 yards long ; with a table-knife rub the plaster into the bandage as it is rolled, so that all the interstices are well filled, roll it up loosely 5 apply to the patient a tightly- fitting shirt of elastic, soft woven or knitted material, without arms, extending to the middle of the pelvis and fastened over the shoulder by tabs. Now have the patient's arms raised above the head and held in that position. The bandages, placed on the end in a basin of water until the bubbles cease to rise, are squeezed until the surplus water escapes, and then passed round and round the trunk, begin- ning at the smallest part, and extending downward a little beyond the crest of Fig. 148. Fenestra over curvature. Fenestra over stomach. the ilium, then upward in a spiral direction until the entire body is encased from the pelvis to the axillae ; pads of cotton are to be applied over any very prominent spinous process or other bony projection which maybe inflamed from previous pros- sure or liable to be irritated. The bandage should be placed smoothly, but not 522 LOCAL DISEASES. tightly, round the body, being simply unrolled with one hand and smoothed, so as- to be adapted to all the irregularities, by the other ; after one or two thicknesses have been applied, narrow strips of roughened tin or zinc should be placed on either side and parallel with the spinous processes, and others added at intervals of two or three inches until they surround the body ; over these apply other bandages. The patient must remain quiet in the recumbent position until the dressing is firm, when he may rise ; fenestras are often required at the curvature or where sinuses are discharging. If the diseased vertebras are in the lumbar or lower dorsal region, the bandage need not be applied higher than the axillae, but if the caries exist in the upper dorsal region, there must be additional support of the upper part of the thorax, and this is obtained by continuing the bandage over the shoul- ders, and thus encasing the entire trunk in the common dressing (Fig. 148). When this form is used the arms must not be in the sling, but should hang by the side. By this means the spine can be permanently maintained erect. When the caries attacks the cervicals, means must be used to so support the head that the contiguous vertebrse may not be compressed. This may be accom- Fig. 149. Fig. 150. Fig. 151. Plaster dressing for cervical caries. Jury-mast (Sayre). Apparatus for disease of cervical or upper dorsal spine : plaster jacket with "jury-mast." plished by supporting the chin or by lifting the head entire. The chin may be sustained by extending the plaster-of-Paris jacket upward as a cravat, well lined with cotton batting or other soft material (Fig. 149). Or the head may be raised entirely from the column by an appliance (Fig. 150) so incorpo- rated in the plaster bandage that it has a firm basis of support, and by a sling which accurately fits the chin and occiput and lifts the head directly upward (Fig. 151). To apply the apparatus the patient is suspended or lifted from the axillaa or chin and occiput, and the plaster bands applied, as usual, over a tight-fitting knit or woven shirt. After the bandage has been accurately applied, the patient is removed from the suspending apparatus and carefully laid upon a firm bed until the plaster has hardened or " set." The patient can then stand up, and the apparatus for suspending the head is applied in its proper position, over the back of the plaster Jacket, and the lower portion of it bent and moulded until it accu- rately fits all its various curves. The loose tin strips, being very flexible, can then be smoothly moulded around the jacket which has already been applied to the trunk, and another plaster bandage, having been wetted in water, is to be carefully and tightly applied over the apparatus and jacket first applied in sufficient number of layers to make it perfectly secure. The tin being rough and perforated, a suffi- CARIES OF THE VERTEBRA. 523 Fig. 152. Breast-plate and collar for cer- vical or high dorsal caries (Owen). cient amount of plaster will be incorporated into its holes and meshes to prevent any possibility of displacement. AVe have now a secure point of support from the pelvis and trunk, and the head can be sustained by properly adjusting the movable rod and securing it by screws (Fig. 151). While it is true that the jury-mast, well adjusted and maintained, usually gives good results, it is a somewhat troublesome apparatus to apply, and patients are occasionally intolerant of its use. More con- venient appliances, which equally support the head, may be employed. Owen of London recommends a simple apparatus. He says : 1 " I have given the jury- mast of Dr. Sayre a fair and extensive trial, and have now entirely discarded it. It is heavy and cumber- some, and offers no advantage over the leather cervical collar (Fig. 152), which bears up the chin and occiput. The rotary movement of the neck, which the jury- mast is constructed to permit, is an absolute disadvan- tage : rest, and always rest, is the one indication for treatment in all these cases. The cervical collar gives relief by ensuring this rest, rather than by lifting up the superimposed weight, as may be inferred from the fact that its influence is equally beneficial in high dorsal caries." The gypsum dressing may be worn without change from two weeks to two months, according to the effect which it produces ; when renewed the patient should be thoroughly washed, but without assuming the upright position, ex- cept when the head is well supported. The final cure is rarely completed in the most successful cases in one year. There are several kinds of useful apparatus for spinal caries more or less complicated in their mechanism, and requiring great experience and care in their successful management, but the plaster-of-Paris jacket is to be preferred on account of its efficiency, durability, and economy. A spinal brace may be so applied as to take the weight of the trunk above point of disease from the bodies of the vertebras and throw it on the articular cesses. There are two pieces or levers passing up the back, not over the spine, each side of it, so that it is firmly held from lateral devia- tions : to the upper end of these two curved pieces of steel are fastened diagonally on both sides of the neck ; they pass directly forward and around the shoulder, and thus prevent a great loss of force by diagonal action. The arrangement entirely obviates the painful and injurious ligaturing of the arms, which would occur if the straps passed forward from one point. At the part opposite the point of disease, the point where the fulcrum pads are placed is made of chamois skin or canton flannel, filled with cork filings, which have no felting qualities, or, if desirable, can also be made of hard rubber ; the shoulder- straps and the band around the hips are likewise pro- vided with similar pads to protect the skin from pressure and abrasion ; the instrument, like the spine itself, acts like a double lever, with a common fulcrum at the curva- ture ; this action is directly backward at the hips and shoulders and directly forward at the middle of the back, or wherever the diseased part is located; thus the pos- terior portion, the only healthy portion of the diseased vertebras, is made to support a part of the weight of the body, and the intervertebral cartilage and bodies of the vertebrae, where the disease exists, are relieved of pres- sure. The abdomen is still further sustained in the up- ward direction by an apron in front, which is fastened 1 Surg. Dis. Children, p. 248. the pro- but Spinal brace (Taylor on each corner. If the 524 LOCAL DISEASES. disease is in the upper dorsal or cervical region, an apparatus is constructed for such cases with an attachment for sustaining the head ; the effect and form of this attachment is that of a lever, acting backward to raise the head and neck. Spinal abscesses may find their way to the surface by very circuitous routes, and appear at unusual points quite unexpectedly. In general, how- ever, they appear as lumbar, iliac, or psoas abscesses. They should be opened antiseptically as soon as discovered. By delay in operating, especially on iliac abscesses, they increase in size, involve new areas, impair the general health, and constantly menace the life of the patient. By opening them no danger of suppuration is incurred as formerly, but, on the contrary, the gen- eral health is improved and the carious process may be arrested. Operate as follows : The surfaces having been well cleaned and shaved and the operator's hands being disinfected, under irrigation with bichloride solution, 1 : 1000, make a free incision through the overlying tissues into the abscess. If the abscess is iliac, the dissection must be more cautiously made. The cavity being exposed, cleanse it of all dead tissues and scrape off the granulations ; now explore the cavity, and if the sinus leading to dead bone can be found, gently pass a soft catheter along the track and carry it, if possible, to the abscess-cavity. Along that track it may be possible, especially in the lumbar and lower dorsal regions, to dissect a passage so as to give a full exposure of the carious vertebra and enable the operator to remove the dead bone and cleanse the cavity of all debris. If the carious cavity cannot be exposed, it may still be irrigated through the catheter, and the disease may be arrested. The abscess should be thoroughly washed out with a weak bichloride solution, ] : 5000, a drain-tube inserted, the wound closed, and iodoform dressings applied ; daily irri- gating of the entire cavity should be practised with disinfectants. Absorption of a spinal abscess may occur when the diseased vertebrae are maintained in a condition of perfect rest. Case (Owen *). — Lilian G , six years, came under treatment (in November, 1880) for dorsi-lumbar caries, for which she was kept lying down for nine months, during which time night-shriekings and pains on movement disappeared. She was, as her mother said, " ever so much better." A plaster-of-Paris jacket was applied, which she wore continuously and with the greatest advantage for five months, gain- ing five pounds in weight. The next she wore six months, but on its being taken off the child complained of pains in the area of distribution of many of the cuta- neous branches of the right anterior crural nerve, and especially along the inner side of the ball of the great toe. Abscess was detected in the right iliac fossa. Another jacket was applied, and was worn continuously for fifteen and a half months ; on its removal there was not a trace of abscess, the child was free from pain, quite well, and strong. These abscesses may find their way into the intestines at different points from the duodenum to the anus, into the bladder, and in various localities on the surface in the region of the pelvis and thighs. In some cases, as in paraplegia, the operation of laminectomy has been performed, which consists in the excision of the laminae of two or three ver- tebras for the purpose of opening the canal of the spine and cleansing and curetting it. Macewen disapproves the operation while the tuberculous pro- cess is active in other organs, or when fracture has followed as a result of caries, or when paraplegia has suddenly appeared. The operation is as fol- lows (Power) : Place the child on the left side and make an incision over the projecting part of the spine ; separate the soft parts on each side and the periosteum of two or three vertebras ; divide the lamina of a vertebra with strong cutting forceps and twist it out of place. A second and third is removed in a similar manner, until the canal is sufficiently exposed. All tuberculous matter must be carefully removed. The cord and its sheath, lying along the anterior surface of the canal, must be gently 1 Surg. Bis. Children, p. 247. LATERAL CURVATURES OF THE SPINE. 525 drawn one side -with broad retractors to permit of scraping away granulations. The cavity is to be swabbed with a solution of 1 : 15 zinc chloride, and then flushed with sterilized water of a temperature of 105°. The cord is replaced and pulsation looked for : the soft parts are united without drainage, the purpose being to obtain immediate union. CHAPTER II LATEEAL CUKVATUEES OF THE SPINE. Lateral curvatures occur in children who have suffered from rickets, and these deformities depend upon the period when they occur, whether before or after the child has commenced to walk. It must be re- membered that before the child has walked there is but a single curve of the entire spine — viz. posterior. The normal curves of the adult spine do not form until the child has been walking for some time. It follows that the rachitic curves of the spine which occur in a child, suffering from rickets before the period of walking, differ greatly from the curvatures which take place when the normal curves of the spine have formed. In the former case the curve is usually an exaggeration of the posterior curve of infancy, kyphosis (Fig. 154), or, there may be a simple lateral curve in any region of the spine, or, finally, there may be an anterior curve, lordosis (Fig. 155). The posterior curvature of rickets is nearly uniform throughout the entire length Fig. 156. of the spinal column, and is distinguished from the normal curve by the inability of the child suffering from rickets to straighten its spine fully. The tendency is to sit with Fig. 154. Fig. 155. Kyphosis. Lordosis. Lateral curvature in a rickety child. the head falling forward (Fig. 156). If the child is placed on a flat surface, the curve will disappear. 526 LOCAL DISEASES. When the curvature forms after the normal curves are perfected, the first deviation takes place in the lumbar region, usually to the left ; this is followed by a compensative curvature to the right in the dorsal region, and, finally, in severe cases, there is a cervical curvature to the left and forward. The initial deviation to the left is caused by a lateral inclination of the body to that side as the child sits or stands long in that position. Girls far more frequently than boys assume this attitude, owing to their comparatively sedentary habits. The secondary curve to the right is an effort to preserve the centre of gravity of the upper part of the body, while the cervical curve is designed to place the head in a similar position. In addition to these curves, true lateral curvature at later periods is attended with a partial rotation of the bodies on their axes. In the lumbar region the spinous processes are carried . around to the left ; in the dorsal region they are found far to the right of the centre. Another noticeable feature of this form of curvature, known as rotary lateral curva- ture, is the elevation of the left hip and right shoulder. These are diag- nostic signs of much value, and it not infrequently happens that the dress- maker first detects the curvature by the displacement of the scapula. AVhile the predisposing cause of curvature in these cases is rickets, the exciting cause will be any condition which temporarily deflects the spinal column. The position in which a nurse continually holds the child may give an improper inclination of the spine. In a similar manner a curvature may take place in older children who sit long in a one-sided position, as at school, or who have one leg shorter or weaker than the other, as in infantile paralysis. It is more frequent in girls than boys, owing chiefly to the fact that the former are more restricted in vigorous exercise, and hence have a less sym- metrically developed muscular system. The more quiet and sedentary life forced upon them in the formative period of the osseous system tends to enfeeble the muscles, and, at the same time, to induce postures of the body which cause deviations of the spinal axis. The diagnosis of lateral curvature of the spine in the child is of great importance, for it is at the very commencement of the deviation that the Fig. 157. From Hoffa. progress of the deformity may be arrested, and by very simple measures. In proportion as it progresses the changes of structure tend to become more and more permanent. It is advisable, therefore, always to make frequent examinations of the spine of a child that is passing through a course of treat- LATERAL CURVATURES OF THE SPINE. 527 merit for rickets. In this examination it must be remembered that the spine of the child, up to the time of walking, and oftentimes for a considerable period after, has not the ordinary curves of the adult spine. On the con- trary, the child has a uniform convexity of the spine backward, most marked when it is in a sitting posture, and more prominent in the dorsal region. The peculiarity of this curvature is — 1, that no one spinous process of a vertebra stands out abruptly from the two which articulate with it, as in angular curvature or Pott's disease ; and, 2, that there may be lateral inclinations of portions of the spine without disease when a child is feeble. An important fact in determining the existence of a curvature due to disease is this : if it is caused by disease, it will be unyielding in the movements of the spine. The best test is the following : If the child is laid on its face and its legs are raised, thus lifting the lower part of the body from the surface, the back be- Fig. 158. From Hoffa. be entirely exposed. Then the head to the sacrum by Fig. 159. comes concave if there is no permanent curvature, and all apparent devia- tions of the spine will at once disappear (Fig. 157). If, however, there is a permanent curve, as in angular curvature (Pott's disease), the curvature becomes even more prominent (Fig. 158). For proper examination the back should trace the course of the spinous processes from drawing the end of the finger along their tips. A red line is formed which shows the curva- tures if they exist. The ends of the spinous processes may also be marked with a pencil (Fig. 156) to make the line more distinct. If the patient now bend forward, the deformity becomes more marked. If lateral curvature is established, the chest-walls are also de- formed. There is a flattening on one side and a bulging on the other, which may be very prominent at the junction of the ribs and their cartilage (Fig. 159). The treatment of spinal curvature in a child suffering from rickets is twofold — viz. 1. The general treatment, which should aim to restore the health of the child by measures already given ; and 2. The protec- tion of the spine from permanent curvature. If the child does not walk, care Section of chest, showing deformity consequent on lateral curvature (Shaw). 528 LOCAL DISEASES. should be taken to so change its position from time to time that no continuous curve of the spine can be maintained. If there is a tendency to antero-posterior curvature, the child should frequently be maintained in the prone position. In this position the weight of the upper portion of the body is, for the time, taken from the spine, and the curvature is completely reduced. Gentle rub- bing of the muscles of the spine, with the hands well oiled, increases their nutrition and growth. A light pasteboard splint may be applied to the back for short periods as a support to the spine, but must be employed onl}* tem- porarily. If the child is older and true lateral curvature is impending, the treatment must be modified only to meet the conditions which the ability to walk imposes. The general muscular system should be developed by mas- sage and such kinds of exercise as will tend to relieve the spinal column of the weight of the upper part of the body, as swinging from a bar, climbing a rope, lying prone and exercising the arms by stretching them above the head, and grasping handles to weights raised over pulleys. The question of applying apparatus is very important, and should always be regarded as an accessory and temporary expedient in the aid of the measures already described. In general it is better to avoid all apparatus in the early stages, Fig. 160. Fig. 161. Curvature before suspension (Sayre). and persistently apply those means which will de- velop strong and healthy muscles, and constantly guard the patient against assuming positions tend- ing to deflect the spine. When not engaged in suitable exercise it is better to recline on a sofa or in a chair, which takes the weight of the shoul- ders and head from the spine. The ordinary steamer- chair is well adapted for this purpose. If the child is older, and the deformity is already well advanced toward permanent rotary lateral curvature, the treatment must be governed by the condition of the patient when first brought under notice. If the distortion be Curvature removed by sus- pension (Sayre). LATERAL CURVATURES OF THE SPINE. 529 aggravated by inequality in the length of the lower extremities, or owing to a congenital malformation, or to disease of the joints or fracture, thus caus- ing obliquity of the pelvis, the shortened limb must be artificially lengthened sufficiently to equalize the length of the two limbs before any other treat- ment can be effectual. If the deformity be caused by muscular debility or want of tone in the general system to keep the body erect, we must by proper training, gymnastic exercises, massage, nutritious diet, and tonics restore lost vitality and increase muscular power. Careless habits in sitting, walking, or standing must be guarded against and the vicious tendencies cor- rected. Extension of the spinal column by Sayre's apparatus is useful. This is affected by means of a leather collar passing under the chin and occiput, two straps passing from this up on either side of the head to an iron cross-bar secured by means of a rope and pulley to a hook or beam in the ceiling. The patient is expected to raise the arms over the head to their fullest extent, and, seizing the rope in the hands, commence to climb up hand over hand until the heels are gradually raised from the floor, barring the discomfort before this point may be reached ; the toes, however, should never leave the ground. The effect of this form of suspension upon the cur- vatures is very marked, as seen in the illustrations of the same person before and during suspension (Figs. 160 and 161). The hand on the side to which the concavity of the spine faces should always be the one uppermost when the patient has reached the height where the heels are raised from the floor (Fig. 161). While holding herself in this position the patient should take three full inspirations ; then slowly descend until she once more rests firmly on the floor, allowing the arms to fall by the sides and to rest there a few moments ; the same course is to be repeated, in all, three times ; for the greater convenience of holding on to the rope three or four wooden balls should be strung upon it and secured at a certain point after the patient has found out the limit of extension. It is necessary, in the performance of this partial self-suspension, that the patient should always keep the arm extended in a perfectly straight line, and simply make each hand go over the other, and no more, so that the muscles of the trunk, rather than the neck, may bear the strain. The apparatus for this purpose may be arranged in one's own room, and may be used for exercise night and morn- ing three times, as before described, until after some weeks, when the number of imposed tasks may be increased according to the hints already given. A very useful exercise is to stand in front of the patient while she is sitting upon a chair or stool, compelling her to turn and twist her trunk in the opposite direction in which the deformity exists, while you resist this movement. Another exercise is that of sitting upon a stool with the arm upon the concave side raised in front on a level with the thorax, while the arm upon the convex side of the deformity is placed behind the back ; then, seizing a rubber strap in either hand, the ends of which are secured to staples in the wall or door, the patient endeavors by muscular action to unwind, as it were, the rotation of the spine, and thus over- come the deformity. Suspension also may be made from two horizontal bars, as recommended by Adams, one being from two to four inches above the other — the hand upon the concave side of the curvature of the spine being the one to grasp the upper bar ; exercise upon these bars may be indulged in as often during the day as the patient may desire. Rings attached to ropes of unequal length effect the same object. Yet another exercise is to stand upon a block or box upon the foot of the convex side, and swing the leg upon the concave side, at the same time reaching upward with the arm of the same side as far as possible, the hand grasp- ing a weight of from two to four pounds, and while in this position to take three full inspirations. This also may be repeated several times daily. Sayre attaches great importance to the plaster-of-Paris jacket, applied while the vertebral column is extended (Fig. 161). The principles governing- its application have already been given. 34 530 LOCAL DISEASES. CHAPTER III. INJURIES OF BONES. The examination of a child that has been injured, for the purpose of determining the existence of a fracture, should be made in such manner as to secure its confidence. It is already suffering from the fright which the injury caused, and hence will be intensely excited at the approach of the surgeon. Hamilton's directions are admirable, and should be implicitly fol- lowed. He says : " It is important on first approaching a patient, especially a child, suffering from fracture, to inspire him with a confidence that he is not to be unnecessarily hurt : sit quietly beside hirn and inquire minutely into all the circumstances relat- ing to the accident ; remove the clothes from the injured limb with the utmost care ; notice its position, contour, points of abrasion, discoloration, or swelling ; pass the fingers lightly along the surface of the limb, pressing more firmly at points where there are appearances of injury ; finally, to solve all doubts, grasp the limb so as to make traction of the lower fragment, rotate to obtain crepitus, and make lateral motions to indicate the false point of motion ; in the application of the necessary dressings let gentleness and a manifest regard for the patient's sufferings character- ize every act, and throughout the subsequent treatment of the case proceed slowly, thoughtfully, and systematically, for rude and awkward manipulations, by which pain is needlessly inflicted, are frequent sources of inflammation, suppuration, and gangrene.*' In the treatment of the injuries of bones of children special care must be taken in their treatment. Children will not tolerate the same restrictions as the adult. Bandages around recently injured limbs must be avoided as far as possible ; splints should be protected by soft and yielding padding ; plaster- of-Paris dressings must be carefully watched. In restoring motion to stiffened joints after fracture the force used must be slight as compared with that which is proper in the adult. Injuries of the Skull. Depression of the bones of the skull without apparent fracture is most often seen in the parietal and frontal regions. It is the result of violence applied by a body which has a flat or a round surface. The bending is not unlike that which occurs in the long bones. Though the patient may be insensible from the immediate effects of the concussion, there are no indica- tions of compression, as paralysis. The diagnosis is readily made when the patient is seen immediately after the injury. But after a few days a hard ridge forms around the depressed area, which has often been mistaken for the limits of a fracture. The treatment should be rest and an application of a spirit lotion when there are no evidences of compression of the brain, as paralysis. The depressed bone gradually resumes its natural shape, chiefly owing to the pressure of the expanding brain underneath. Fractures of the skull in children require the same rules of treatment as in adults. Injuries of Long Bones. The long bones of children differ from those of the adult in these import- ant particulars: viz. 1, the epiphyses are united to the shafts by cartilage; 2, the tissue of the bones is yielding ; and 3, the bones are liable to be im- INJURIES OF BONES. 531 paired in their integrity by rickets. Owing to these peculiarities, injuries to the bones of children may result in three conditions rarely found in adult persons — viz. 1, separation of the epiphysis from the diaphysis (diastasis); 2, bending ; 3, partial fracture (green-stick) ; 4, transverse fractures. The separation of the epiphysis is regarded by Holmes l as chiefly a frac- ture, for after the examination of a large number of specimens he states that the fracture occurs not very rarely at or in the immediate neighborhood of the epiphyseal line, and that the line of fracture coincides in these cases partially with that of the epiphyseal cartilage, but seldom completely. Chas- saignac and Marjolin had previously maintained the opinion that separation of the epiphysis strictly in the line of the cartilage rarely occurs. The chief importance of this fracture is the effect which it may have upon the future growth of the bone in length. It would follow that, if the result- ing inflammation should be attended by suppuration, the integrity of the uniting cartilage would be destroyed and the growth of the bone would be impaired ; or. if the cartilage quickly ossified, the growth of the bone would be arrested and deformity would result. Owen gives the following very judicious "general caution" in regard to frac- tures near a joint or through an epiphysis: " In every case of fracture near a joint or through an epiphysis it is desirable that the surgeon, however skilled and com- petent he may be, do not take the undivided responsibility of the case. Some un- toward event is apt to be associated with the injury which no exercise of art can with certainty avert. Thus, suppuration may occur and death follow from pyaemia ; or synostosis or other form of permanent stiffness may result ; or there may be some deformity : the humerus may fail to be properly developed, and the limb may be less useful than was anticipated. Over the result of the treatment of injuries near a joint, skilful as it may have been, great unpleasantness is apt to ensue. See that the parents should be made at once to thoroughly understand the serious nature of the injury, at least as regards the future effect ; they should not be caused needless alarm, but should see the advisability of adopting precautions. A shoulder or elbow left permanently stiff may wellnigh ruin a professional reputation ; its ex- istence is never forgotten. In every country village some brother-practitioner can and should be found to help with anaesthetic and counsel. If, when all swelling has subsided, union be taking place with some deformity, the surgeon should think twice before breaking it down with the idea of resetting the bone. Such inter- ference might result in fracture of the bone in a fresh place, or might be followed by serious local disturbance." The diagnosis of epiphyseal separation is often diflicult, owing to its proximity to a joint and the absence of crepitus. It is often mistaken for a dislocation, and efforts are made at reduction. These mistakes are most fre- quent at the upper and lower extremities of the humerus. An error can be avoided by giving especial attention to the fact that the deformity can be overcome with ease compared with a dislocation, and that when the apparent dislocation is reduced the deformity recurs when traction ceases. Moreover, the head of the bone will be found in the joint. These signs determine the fact that there is a lesion of the bone, while the absence of crepitus and the proximity of the joint prove that the condition is neither a fracture nor a dislocation. The logical conclusion must be that there is a separation of the epiphysis. The treatment of this form of injury does not differ materially from that of a complete fracture. Every possible effort should be made to place the fragments in complete apposition in order to secure perfect union. When the separation is reduced the ordinary dressings for fracture at the same point are indicated. The bending of the long bones of children occurs at an early period. The 1 Surg. Treatment of Children' s Diseases. 532 LOCAL DISEASES. accident is not frequently alluded to by writers, because the bone usually quickly recovers its former position, and Hamilton's experiments prove con- clusively the possibility of the bending, but quick recovery, of the long bones of the young. They also show that if the bent position continues there has been a partial fracture. Partial fracture occurs when on one side, the convex, a fracture takes place involving only the surface, while on the opposite side, the concave, there is an impaction of tissue. It is most frequently seen in the clavicle. In some cases the bone undoubtedly recovers very nearly its normal position when the violence is removed. Case (Hamilton). — An infant boy, three years old, fell from the hands of the nurse. The child cried, but the point of injury was not detected until the third or fourth day, although the mother examined the shoulders and neck carefully at the time. She is quite certain that if any swelling or discoloration had been present she would have seen it then or on the subsequent days while washing and dressing the child. When first seen it was very distinct, but not so large as at present. Seven days later the child was brought to me. A little to the sternal side of the middle of the right clavicle there was an oblong node-like swelling, of the size of the half of a pigeon's egg, hard, smooth, and feeling like bone ; there was no dis- coloration or swelling of the integuments; no crepitus or motion; the line of the clavicle seemed nearly or quite unchanged. The only evidence which remains of a previous fracture is a subsequent nodule which forms at the seat of the lesion of the bone. In the treatment of these forms of injury it must be remembered that there is a constant tendency to a recovery of the proper position. In bend- ing and in partial fracture with slight displacement there is, therefore, no other treatment required than protection from further injury. Moderate efforts may be made, under chloroform, by pressure of the fingers on the convexity of the bone, to restore its position, but care must be taken not to make such strong compression as will produce a complete fracture. A sling for the arm of the side on which the clavicle is fractured ; a splint on the concave side of the arm ; one on the anterior and one on the posterior surface of the bent fore- arm ; a splint on the concave surface of the bent femur, the interior surface of the leg, in which the fibula is bent, — comprises the treatment of the cases which will come under the care of the practitioner. Hamilton remarks : " But we need not be over-anxious to straighten the bone completely, since experience has shown that after the lapse of a few weeks or months the natural form is usually restored spontaneously. I am not now speaking of those cases in which the restoration occurs immediately, in which it is probable that the splintered fibres offer no resistance to the restoration, but only of those in which the bone straightens so gradually as to induce a belief that the broken ends are tha cause of the resistance. In a case mentioned by Gulliver it required about four weeks' time to render the bones of the forearm perfectly straight ; and in one case mentioned by Jurine at the end of six months it was ' difficult to say which arm had been broken, and at the end of one year it was impossible.' " Fractures in the new-born may have occurred in utero or at the time of birth. They represent all of the peculiarities seen in the fractures of tho child in early life. Case. — A woman in the sixth month of pregnancy was injured in the abdomen by striking against a table. Her child had a separation of the lower epiphysis of the tibia. The end of the shaft had perforated the skin and was necrosed. Simple bendings of bones are met with at birth, and simple fractured bones which have united with deformity. Even compound fractures in utero,. which have united before birth, have been reported. INJUEIES OF BONES. 533 Case. — Proudfoot of New York has related a case of compound fracture in utero which was apparently caused by external violence. Mrs. F , during the sixth month of gestation, while attempting to pass through a very narrow passage, was severely pressed upon the abdomen, and immediately experienced a severe pain in that region, accompanied with nausea and faintness. The following day uterine hemor- rhage, with pain, commenced, and these symptoms continued at intervals, in a form more or less severe, up to the period of her delivery, which occurred at full time and was perfectly natural. At birth the right foot of the child, a female, was found to be much distorted and in a condition of valgus with equinus, the outer side of the foot being laid against the side of the leg above the external malleolus. The tibia also of the same limb, near its middle, seemed to have been the seat of a compound frac- ture, the two ends of the bone having united at an angle slightly salient anteriorly, and the skin presenting over the point of fracture an old cicatrix. 1 The treatment of these forms of injury is to be conducted on the same principles as in children. It will often be difficult to adapt suitable splints to the child's limbs and retain restrictive dressings, but very thin and light paste- board splints, well padded, can be employed and retained by bandages or rubber plasters, care being taken that they are not too tightly applied. The clavicle is more frequently bent or fractured in children than any other long bone. This is due to the frequency of their falling upon the shoulder and the several curves of that bone. The indications of treatment are to place the shoulder in a position upward, backward, and outward. In very young children a sling, supporting the elbow and arm, is the best appliance. Recovery occurs in most cases with but little deformity. In older children the adhesive strip of Sayre secures the position of the arm most effectually. Select strong adhesive plaster, and cut it into two strips three or four inches wide, but narrower for children ; one should be of length to encircle the arm and the body, and the other to reach from the sound shoulder around the elbow of the fractured side and back to the place of starting. Pass the first piece around the arm just below the axillary margin, and stitch in the form of a loop sufficiently large to prevent strangulation, leaving a large portion on the back of the arm uncased by the plaster ; draw the arm downward and backward until the clavicular portion of the pectoralis major muscle is put sufficiently on the stretch to overcome Fig. 162. Fig. 163. First adhesive strip. Second adhesive strip. the stern o-cleido-mastoid, and thus pull the inner portion of the clavicle down to its level ; carry the plaster smoothly and completely around the body, and pin to itself on the back to prevent slipping (Fig. 162). This first strip of plaster fulfils a double purpose : first, by putting the clavicular portion of the pectoralis major 1 New York Journal of Medicine, 1846. 534 LOCAL DISEASES. muscle on the stretch, it prevents the clavicle from riding upward ; and. secondly, acting as a fulcrum at the centre of the arm when the elbow is pressed downward, forward, and inward, it necessarily forces the other extremity of the humerus (and with it the shoulder) upward, outward, and backward. And it is kept in this position by a second strip of plaster, which is applied as follows : Commencing on the front of the shoulder of the sound side, draw it smoothly and diagonally across the back to the elbow of the fractured side, where a slit is made in its middle to receive the projecting olecranon. Before applying this plaster to the elbow an assistant should press the elbow well forward and inward and retain it there, while the plaster is continued over the elbow and forearm, pressing the latter close to the chest and securing the hand near the opposite nipple : crossing the shoulder at the place of beginning, it is there secured by two or three pins. The humerus may be fractured at many points, but those most frequent and important in children are separation of the epiphyses and fractures at the elbow-joint. Separation of the upper epiphysis (Fig. 164) is recognized by the location of the false point of motion, absence of crepitus, and the pres- ence of the head in its proper position. It is most frequent on the right side. When separation of the lower epiphysis occurs, the elbow has the ap- pearance of a dislocation backward of the ulna, but its easy reduction and the return of the dislocation without any spreading of the joint, as occurs in separation of the condyle, determines its nature. Fractures at the elbow are as follows : At base of condyles, often difficult of diagnosis, owing to swelling ; most reliable signs are mobility, crepitus ; easy reduction, but immediate return of deformity ; great prominence of olecranon, like a dislocation ; pronation of hand. At the base of the condyles, with longitudinal fracture between them, some- times comminuted ; this fracture has the same symptoms as the last, with widening of joint and crepitus of condyles. Fracture of either condyle is known by separate movement of the condyle. Separation of epicondyles is detected by grasping the fragments. Fractures of the arm at all points are best treated in children by a gutter splint extending from the shoulder to the hand in order to preserve absolute rest. Select a piece of light felt or binder's board long enough to extend from above the acromion process to the hand, and wide enough to enclose about one-half of the circum- ference of the limb; cut it partially down on each side at the elbow, so as to bend it at a right angle : mould it while wet to the outside of the arm and forearm, and allow it to become dry : protect the splint with cotton-wool : re- duce the fracture and apply the splint with a roller bandage. In case of separation of the upper epiphysis a cotton-wool pad should be placed in the axilla. If the fracture is at or near the elbow-joint, place the forearm at a right angle with the humerus, and maintain it Dressing of fractured humerus. in this position by a right-angled splint, well covered with a woollen or cotton sack, and se- cure it to the forearm by a roller. The front or bend of the elbow should always be well covered with cotton batting before enclosing the elbow-joint in the turns Humerus, shaft, epiphyses, and inner condyle detached. Fig. 165. INJURIES OF BONES. 535 of the roller, to prevent strangulation. Passive motion must be commenced in about two weeks by loosening the dressing, supporting the parts thoroughly at the joint, and making slight flexion and extension : repeat this manoeuvre occasionally. The ulna may be fractured in any part of its shaft by direct violence ; the diagnosis is readily made. The treatment is by lateral splints of thin paste- board, the bones being maintained parallel and separated by small pads on the anterior and posterior aspect ; the splints should be wider than the arm, and be retained in position by two adhesive strips, one near the elbow and the other near the wrist, passed completely around the splints. The radius may be fractured through its head, generally in injuries in- volving the joint. Adjust it and apply an angular splint, supporting the elbow in a state of flexion. If the neck is fractured, the biceps will elevate the lower fragment ; the treatment is the same as for the former accident. All fractures above the attachment of the pronator quadratus must be so ad- justed that the proper axis of the bone is maintained to secure the restora- tion of its normal movements. The elbow should be semiflexed, the forearm and hand, excepting the fingers, supported between a dorsal and a palmar splint padded, and secured by adhesive plaster passed completely around the splints ; the limb should be accurately fixed in supination at an angle of 120° by means of angular pads ; the thumb in this position is brought nearly into a line with the outer fleshy border of the supinator radii longus. The epiphysis at the lower extremity of the radius is liable to be sepa- rated, giving the appearance of a Colles fracture. It is usually the result of a fall upon the palm of the hand, in which two forces act in an opposite direction — viz. the weight of the body and the resistance of the ground ; the bone yields near- est the point of impact, where the vibration is greatest and the bone is weakest — viz. the epiphyseal junction. The chief deformity is due to the projection of the lower end of the radial fragment upon the palmar surface, and of the carpal fragments upon the dorsal surface, which give the peculiar silver-fork appearance. The treatment should be the same as for fracture of one of the bones, but the splints should extend down to the middle of the hand. Small pads over the project- ing fragments aid in reducing the displacement. The femur is liable to forcible separation of its upper epiphysis only as the result of extreme violence. The slighter injuries which have heretofore been supposed to cause separation of the epiphysis have, it has been shown by Whitman, caused a partial fracture of the neck. The femur of the infant may be fractured at birth when an operation is performed, either by manipulation or with instruments. At other periods of infancy fracture of the femur is of rare occurrence, and is rarely met with except in severe accidents. These frac- tures are usually so nearly transverse that but little traction is required to retain the fragments in apposition. The treatment of fractures of the femur at birth must be limited to supporting the affected thigh by bandaging it to the other with a compress, as a napkin, placed between them. In infants under one year of age the same method is as useful as any that can be adopted. For children between one and five years of age Schede's method has been preferred by some, notably by Bryant of London. It is called " vertical extension." Position with limbs suspended (Bryant). It is as follows (Fig. 166) : A long, continuous band of plaster is fixed to both 536 LOCAL DISEASES. Fig. 16: sides of the injured limb as high as the seat of fracture, and applied so as to form a free loop below the sole. This long strip is then secured in the ordinary way by circular strips of plaster and by circular turns of a bandage. The leg, having been elevated, is then kept in a vertical position, with the corresponding side of the pelvis suspended by means of a piece of cord fixed to a loop of plaster, and either attached above to some object over the bed or slung over a pulley, with its free extremity sup- porting a weight. This does not necessitate constant and complete rest on the back. The extension is removed at the end of three weeks, and the limbs are allowed to rest on the bed. Hamilton remarks of the treatment of these fractures : ' : Fractures of the thigh in children have generally been found more difficult to manage than fractures of the same bone in the adult, owing chiefly to the shortness and softness of the limb, the delicacy of the skin, its liability to become excoriated or to become soiled, and the restlessness of the patient."' As a result of a large experience in the use of various ap- pliances in the fracture of the femur in older children lie devised the following, which is simple and very effectual : Two long side-splints connected by a cross-piece at the lower ends, and reaching upward to near the axillae, separated a little more widely below than above, so as to render the perineum more accessi- ble, are laid upon each side of the body. The four short thigh-splints, made of binder's board and covered with cotton cloth, are secured in place by four or five strips of bandage tied in front and then stitched to the covers of the splints. These must not embrace the long side-splint. The broken limb below the knee, and the opposite thigh and leg are held in place by bandages passed around the splint. Thus secured and laid upon a bed, such as I have already described as appropriate for children, the least possible annoyance will be given to the surgeon. The dressings are but little liable to be- J ]^^|iJ^j come wet with urine, and when the bed is soiled .g^ ~--f 1513^1 the child can be taken up with the splint and car- , : I ^_J' r 'i e< l t0 another: indeed, this may be done as often as the patient becomes restless or weary, without any risk of disturbing the fracture. In case the surgeon desires to use extension with adhesive plas- ter and weights, the necessary apparatus may be made fast to the bedstead and taken off when the child is moved ; or it may, if thought best, be made fast to the foot-piece of the splint. Occasionally, with children, I employ, as a means of extra safety, a perineal band drawn moderately tight, and fast- ened to the top of the splint on the side correspond- ing to the broken limb. The best perineal band is a piece of soft cotton cloth, one or two yards long by three inches wide, folded lengthwise to a flat band of one inch in breadth, and enclosing, where it passes through the perineum and under the nates, a few thicknesses of paper. The paper prevents its drawing into a round cord. Sometimes I place between the paper and the folded cloth, on the side which is to be laid next to the skin, one or two thicknesses of cotton wadding. To absorb the moisture it is well to lay a piece of sheet lint between the band and the skin. The perineal band may be removed daily and renewed, and the perineum examined and washed. Four or five weeks is generally a sufficient length of time for perfect consolidation in children under five years of age. Dressing for fracture of the femur in children, complete (Hamilton). INJUBIES OF BOXES. 537 Separation of the lower epiphysis of the femur occurs from various applications of violence. It has resulted from traction on the legs at birth, from attempts to break up ankylosis at the knee, and while examining a case of hip-joint disease. The violence may be so great as to cause protrusion of the upper fragment through the skin. In several recorded instances the limb was caught in a wagon-wheel. No prescribed method of treatment can be given in complicated cases, but a double-inclined plane, with side-splints, in ordinary simple cases would best meet the indications. The following severe forms of this injury illustrate their peculiarities and dangers: Case 1. — Little presented to the New York Pathological Society a specimen obtained from his own practice. A boy, set. eleven, while hanging on the back of a wagon, had his right leg caught between the spokes of the wheel, which was in rapid motion. A few hours after the accident he found the upper fragment of the femur projecting through an opening in the upper and outer part of the popliteal space. On examination the wound did not appear to communicate with the knee- joint. Under the influence of an anaesthetic the fragments were reduced, the re- duction occasioning a dull cartilaginous crepitus. There was at the time no pulsa- tion in the posterior tibial artery, and the limb was cold. The limb was laid over a double-inclined plane. The following day the upper fragment was again dis- placed, and it was found that it could only be kept in place by extreme flexion of the leg. This position was therefore adopted and maintained ; considerable trau- matic fever followed, with swelling, and on the thirteenth day a secondary hemor- rhage occurred from the anterior tibial artery near its origin, and it became neces- sary to amputate. The boy made a good recovery. The specimen showed that the line of separation had not followed the cartilage throughout, but had at one point traversed the bony structure. 1 Case 2. — Smallwood, a boy, aged twelve, had his right leg caught in the spokes of a wagon-wheel, breaking the thigh at the junction of the lower epiphysis with the diaphysis, the lower end of the upper fragment protruding five inches through the flesh. The end was nearly square. The lad being under the influence of ether, it was reduced within one hour by violent extension and flexion of the leg over his knee, one finger being in the wound and adjusting the fragments. Lateral splints were employed. The wound closed in about nine months, and in the mean- while two small fragments of bone escaped. He had also a sharp attack of syno- vitis. On recovery the leg was straight, but shortened three-quarters of an inch. There is complete ankylosis of the knee-joint, but the muscles of the leg are well developed and he walks with very little limp. 2 Fracture of condyles in children is rare, and results only from direct vio- lence. The following case of fracture of the internal condyle is instructive : Case (Riggs, Homer, N. Y.).— A lad, eet. fifteen, was kicked by a horse, the blow being received upon the right knee. The internal condyle of the right femur was broken off, carrying away more than half the articulating surface of the joint : the tibia and fibula were at the same time dislocated inward and upward, carrying with thein the broken condyle and the patella. The displacement upward was about two inches, and the sharp point of the inner fragment had nearly penetrated the skin. There was no external wound. The knee presented a very extraordi- nary appearance, and the lad was suffering greatly. The first attempt at reduction was unsuccessful ; but in the second attempt, when the men aiding him were nearly exhausted in their efforts at extension and counter-extension, and while pressing forcibly with both hands upon the two condyles, the bones suddenly came into position, except that the breadth of the knee seemed to be slightly greater than the other — a circumstance which was probably due to the irregularities of the broken surfaces, which prevented perfect coaptation. Neither splints nor bandages were required to maintain the bones in place; the limb was placed upon u a double- inclined plane," which, being supplied with lateral supports, would prevent any deflection in either direction in case the limb was disposed to such displacement. The subsequent treatment consisted in the use of cold-water dressings. Very 1 New York Journ. Med., 1865. 2 Hamilton on Fractures and Dislocations, p. 427, 1891. 538 LOCAL DISEASES. little inflammation followed. A portion of the integument sloughed, but the bone was not exposed, and it healed rapidly. On the twenty-fourth day passive motion was used, and this was repeated at intervals until, at the end of three months, he was able to walk with a cane. At the end of a year the knee was a very little larger than the other, and flexion was not quite as complete. In all other respects it was perfect, and the boy himself declared it was as good as the other. 1 The tibia is less liable to fracture in children than the femur. Separa- tion of the upper epiphysis rarely occurs, and is to be treated by properly adjusted plaster-of-Paris dressings, unless the tissues are too much injured. Fractures in the shaft are rarely displaced, and require only adjustment. In infants employ a thin pasteboard splint moulded while wet to the leg poste- riorly and nearly meeting in front. It should be well protected by cotton batting. Separation of the lower epiphysis and fractures at the ankle are so rare as to require no further notice. The fibula is rarely fractured. Separation of the upper epiphysis has been recognized at autopsies, but has no practical importance. Fracture-sprains (Callender) at the ankle are now more frequently seen among boys engaged in athletic sports. The foot turns in or out, and either fractures a malleolus, generally the outer, or the lateral ligament drags off the end of the bone. These cases should receive applications of very hot water for twenty-four hours, and then the limb should be encased in a plas- ter-of-Paris dressing, well padded, for four weeks. CHAPTER IV. DISEASES OF BONE. Inflammation of the bones of children has some marked peculiarities. Owing to the prolonged process of ossification of the cartilage of the epiph- ysis of long bones, these highly vascular structures are peculiarly susceptible to traumatism, cold, and invasions of the pus-microbe and tubercle bacilli. The short bones, and especially the irregular bones of the carpus, tarsus, and vertebrae, are for the same reasons very susceptible to inflammation. The progress of these affections is also more rapid even in the chronic form, and the effects differ from the same diseases in the adult. In children superficial necrosis is much less frequent, as the supply of blood through the nutrient arteries is more abundant, thus supplying the bone when the periosteum is elevated, as by pus. Acute and chronic inflammations are more exhausting in childhood, and yet operative procedures are highly suc- cessful, both in the recovery of patients and in the reparative results. In the etiology of inflammatory affections of bone in children we have a striking peculiarity as compared with the adult in the frequency of infec- tion by the tubercle bacilli. This affection deserves the most careful study, for on its timely recognition will depend the success of the treatment. The tubercular inflammatory pro- cess is due to the lodgement of the pus-microbe, whether it follows an injury or is the result of a tubercular focus in other tissues. It may commence in the periosteum, the bone-tissue, or in the medulla : in either case all of the structures are liable to be involved in the final issue. Acute inflammation more often attacks the diaphyseal extremities of the long bones, owing to 1 Hamilton : Fractures and Dislocations, 1891, p. 424. DISEASES OF BONE. 539 the great vascularity of the epiphyseal connection, where the process of ossification of cartilage is actively in progress. On the walls of the imper- fectlv formed vessels the pus-microbe becomes implanted, and develops the active process of inflammation. At these points an acute endostitis, ostitis, or periostitis may commence and rapidly spread to the adjacent vascular structures. It is noticeable, however, that the layer of unossified cartilage acts as a barrier against the extension of the products of inflammation into the epiphyses, and hence in the direction of the joints. But the periosteum, by its connection with the cartilage, induces these products to spread rapidly along the loose subperiosteal areolar tissue, thus raising the periosteum from the bone. If the inflammation is less severe, the periosteum may become more firmly attached to the bone, and thus prevent the extension of purulent matters along the bone under the periosteum. Ulceration takes place, and the pus escapes externally at the epiphyseal junction. Acute inflammations of bones may be classified as follows : 1. Periostitis: «, subperiosteal ; b, supraperiosteal. 2. Osteomyelitis : a, epiphysitis ; b, di- aphysitis. Periostitis is a disease of youth, and rarely of infancy. It may be caused by injury, cold, or from the extension of osteomyelitis. When the disease is due to an injury, there is a lowering of the vitality of the tissue, which pre- pares it for the action of the pus-microbes in the circulation. The attack may follow the injury after several days, during which the microbes slowly find access to the blood-clot. When the periosteum alone is involved, as from traumatism, the inflam- mation will be located at the seat of injury, but if it is secondary to other inflammations, it will appear at the diaphyseal extremity of long bones. Acute periostitis often occurs during low forms of fever and during epidemics of the exanthemata. The lowered vitality of such patients renders them more susceptible to the action of germs. In the same manner we must ex- plain the occurrence of several cases in succession among persons living in close association. The symptoms of the two forms of periostitis differ only in intensity. In one the active inflammation is between the bone and deep fibrous layer of the periosteum, the pus forming the true subperiosteal abscess. The other occurs in the superficial areolar tissue of the periosteum. The former is liable to be followed by necrosis, while the latter does not affect the bone, but terminates in superficial abscess. The symptoms are alike, but are less severe in the latter case. In the subperiosteal form rigors, followed by a temperature of 103° to 105° or 106° F., and subsequent delirium, are early indications of the severity of the attack. Drowsiness supervenes, and if the inflammation is subperios- teal the child utters piercing screams, owing to the distention of the perios- teum, though as yet it may give no indications of the source of pain, and there may be no local conditions directing attention to the seat of disease. At this stage the nature of the affection is very liable to be overlooked if the disease is subperiosteal, and the symptoms are often attributed to meningitis or other disease. If the inflammation is superficial, the general symptoms are not as severe, and the local swelling early determines the exact location of the trouble. In the subperiosteal variety, where there may at first be no swelling, there is one characteristic symptom present which must always be sought for in a suspicious case of this kind, and that is local tenderness on pressure. Whatever may be the condition of the patient's mind, he will in- stantly scream when pressure is made over the affected part. If the bone lies deeply, as the femur, prolonged search may be necessary to finally reach the exact locality, but by care it can always be found. 540 LOCAL DISEASES. At a later period the periosteum is perforated, and diffuse cellulitis estab- lished ; the limb becomes swollen, often very largely, tense, and shining, and frequently the neighboring joint is involved. As a rule, the extension of the inflammation toward the joint is prevented by the attachment of the periosteum to the epiphyseal cartilage. At this point, however, it may extend more deeply, and detach the epiphysis from the shaft, and even establish an osteomyelitis. The extent of necrosis of the shaft depends upon the interruption of the circulation in the bone. It may be superficial when the periostitis is limited, or it may involve the entire thickness of the shaft, or the whole shaft may perish by the interruption of the circulation of all of the nutrient arteries, both external and internal. The diseases for which acute periostitis have been mistaken are fever, erysipelas, and rheumatism. Periostitis may be mistaken for fever when there is slight swelling and the most marked symptom is fever. Case (Macewen). — Child admitted to Glasgow Fever Hospital as a case of fever. She was quite insensible and in extremis. Examination of both legs showed scarcely a perceptible difference in size ; pressure on left tibia gave rise to the cha- racteristic scream ; no tenderness elsewhere. Autopsy showed the periosteum stripped from the whole tibial diaphysis by a pus which swarmed with staphylo- cocci. This case impresses the great importance of an examination of the long bones by pressure when the case is doubtful. Periostitis most resembles erysipelas when the inflammation involves only the superficial layer of periosteum. But there is never the defined and rapidly-spreading redness of erysipelas, while the severe and localized pain and dusky skin mark periosteitis. When the swelling involves the parts in the vicinity of a joint, the pain and swelling have a slight resemblance to rheumatism, but a careful examination of the parts readily shows that the joint-structures are not involved. Case. — A girl, aged seven, was seized with rigors, severe pain at the upper part of the leg: temperature 104° F. ; pulse 110; swelling just below the knee. Was treated as rheumatism for one week. Then periostitis was recognized ; an incision evacuated a large quantity of pus, with great relief; a superficial necrosis followed, and patient eventually recovered. The treatment should be prompt relief of the distended tissues by in- cisions down to the bone. These should never be more than two inches in length, and should be made in the long axis of the bone. It may be neces- sary to make such incisions in different parts of the limb, and care should be taken, when there is extensive suppuration, to make a sufficient number to completely evacuate the pus and to admit of thoroughly cleansing the cavity. If no pus appears, one or two incisions only may be necessary to relieve the tension ; but strict antiseptic measures must be taken to prevent the introduc- tion of pus-microbes. If there is suppuration, do not use force in exploring the wound, as by inserting the finger, that the periosteum may not be unnecessarily raised from the bone. The entire cavity and all of its recesses should be irrigated with carbolic solution (1:40), or bichloride (1:1000), or boric acid. Peroxide of hydrogen should be injected during the period of profuse suppuration. The limb should be squeezed as little as possible to force fluids out. It is well to make such incisions as will most effectually drain the wound by gravi- tation. Iodoform gauze next to the wound and antiseptic coverings complete the dressings. The dressing and cleansing of the wound should be repeated every two or three days, and as the discharge diminishes the interval may DISEASES OF BONE. 541 be increased. At the first dressings strips of iodoform gauze may be pushed into the recesses of the abscesses. The subsidence of the severe symptoms on relieving the tension by incis- ion, and on evacuating a large cavity distended with pus, is usually very great, but the patient should be vigorously sustained by tonics, as quinine, iron, strychnine, cod-liver oil, etc. If the symptoms do not markedly improve, examine the limb carefully in order to detect any possible collection that has not been reached. In the upper part of the leg. where the disease seems to be chiefly on the anterior face of the tibia, pus sometimes accumulates on its posterior surface, and until that is reached the fever will continue. In some instances the inflam- mation has penetrated the medulla, and osteomyelitis results. The treatment must now be adapted to that disease, or symptoms of pyaemia may appear, with rigors, sweats, pallor, and rapid exhaustion. The cavity of the abscess should be explored to discover any cul-de-sac or concealed focus which, in spite of the irrigation, still retains decomposing pus. All such places must be rendered aseptic by vigorous cleansing and the tonic treatment pursued. Xecrosis is one of the results of periostitis always to be anticipated. It does not. however, necessarily occur even when the periosteum has been completely separated from the bone over a large surface. The shaft of the bone may continue to receive a sufficient supply of blood from the epiphyseal cartilages and the nutrient arteries to maintain its vitality until the perios- teum again becomes united. Case. — A girl, seven years old, suffered from extensive periostitis of the left thigh ; pus formed and burrowed extensively. On incision down to the bone a large amount of pus was discharged, and the bone was found to be completely exposed the entire length of the shaft. After a long period of suppuration the periosteum again became united and the child recovered without necrosis. When necrosis takes place the treatment of the dead bone must be very judicious. As a rule, no attempt to remove the sequestrum should be made until it has so far separated that it is movable. The period at which this will occur varies from one to many months, chiefly according to the extent of the necrosis. It is impossible to determine at an early period how exten- sive the necrosis will be, and if efforts are made to separate the apparently dead bone from the living, to which it is firmly attached, there is liable to be a destruction of nutrient vessels which will result in the death of bone that might have been saved. If the entire thickness of the shaft of a long bone becomes necrotic, no rude attempts should be made to separate the mass until it is movable, lest the involucrum be injured or broken. Free drainage should be maintained, and such cleansing of the dead structures by irrigation with antiseptic solu- tions as will prevent the retention of putrid pus. When there are evidences that the sequestrum is loose, the cavity should be opened in the direction of a sinus ; the cloacse in the involucrum must be sufficiently enlarged with a chisel or the gnawing forceps, and the mass seized with strong forceps. The first efforts to detach the dead bone from the living should be by gentle movements in its long axis; then more direct traction will dislodge it, but care must be taken not to fracture the bony investment. The after-treatment should be antiseptic. If the entire shaft dies, the case will assume a more serious aspect, but under judicious management a favorable result may generally be secured. The treatment should aim to prevent the collection of pus, to keep the cavity free from putrefactive materials, and support the general health. When the shaft has loosened or has become enclosed in new bone, the entire dead bone should be removed in the manner above described. 542 LOCAL DISEASES. Chronic periostitis is characterized by a mild grade of symptoms as com- pared with those of the acute. It may be due to injury or au exanthematous fever, or to a specific cause, as syphilis or tuberculosis. If it follow an injuiy, there may be a thickening of the membrane simply, and then of the bone, or pus may form, with a more or less extensive abscess. When it appears as a sequela of an eruptive fever, it resembles the periosteitis sometimes seen dur- ing pyaemia, and is probably really due to the lodgement of some septic mat- ters transmitted through the circulation from the local eruption. The sub- jects of this form are feeble and poorly nourished, and the suppuration is often extensive, without any marked symptoms. In the tubercular form the child usually has the signs of a strumous diath- esis. The progress of the case may be very slow, but occasionally it is more acute ; in any case it tends to the formation of purulent collections. It may subside on the evacuation of the pus or inflammation may extend to the medulla. Syphilitic periostitis may be due to the congenital or acquired form of syphilis. When congenital it more often appears after the fourth year, and is generally found in several bones, especially of the upper limbs and the tibia. It is often symmetrical in its attacks, nodes appearing at the same point of the same bones of the opposite limbs. The treatment consists in sustaining the general health, the evacuation of collections of pus, and cleansing cavities by curetting and disinfection, and the removal of dead bone. If the disease is of a syphilitic origin, antisyph- ilitic remedies must be employed. Acute epiphysitis (circumscribed osteomyelitis) is more frequent in chil- dren than the diffuse variety, and is localized at the epiphyseal junction of long bones. It more often occurs at the lower end of the femur. It com- mences in the succulent tissues connected with the ossifying process of the epiphyseal cartilage, and involves the cancellous tissue of the epiphysis. It progresses toward suppuration, and a cavity forms containing pus, giving rise to an abscess of bone. The pus may from this point pass into the neighbor- ing joint or along the shaft or to the medulla, where the inflammation spreads as a diffuse osteomyelitis. The epiphysis may become detached. The causes of epiphysitis are injury, exposure to cold, an exanthem, or infection from an existing suppurative focus. The new-formed vessels in the ossifying cartilage are susceptible of such changes by injury, cold, and other conditions that leucocytes adhere to their walls. If any infective materials are floating in the circulation, it is more liable to find lodgement in these vessels than in any other. The symptoms are usually very pronounced. Fever, pain, and exhaus- tion follow rapidly. The pain, which is the most marked early symptom, is of a gnawing, boring character, while the pus is confined by dense structures, and relief comes only when the pus passes out into yielding tissues, as through the periosteum or into the joint. The position of the limb is semi-flexed, which in some degree relieves tension. Exhaustion necessarily follows as a result of the fever, pain, and disturbance of nutrition. The conditions of greatest importance in diagnosis are as follows : In the early stage, when there may be no swelling of the part nor of the joint, by careful manipulation a marked tenderness will be found at the seat of disease. This point of acute tenderness is very characteristic. When the parts are swollen by the approach of the pus to the surface and the joint is involved, attention must be chiefly given to the early history in order to exclude rheumatism and periostitis. Case. — A boy, age ten years, had continued gnawing pain below knee, moderate fever, loss of sleep except under the influence of opiates ; knee not swollen, but DISEASES OF BONE. 543 flexed. Symptoms had existed more than a month, but had become more severe within a few days. He was suffering acutely on admission from pain in left knee ; temperature 102° F. There was considerable swelling about the inside of the upper end of the tibia, where there was marked tenderness. An incision at this point down to the bone showed evidences of inflammation, but no pus. A small trephine was applied to the bone, which exposed the cancellated tissue infiltrated with pus, and very soft, but no distinct cavity. The wound was treated antiseptically, but subsequently the knee became involved and required to be opened, and carious bone was removed from the head of the tibia. Persistent use of antiseptic meas- ures locally and tonic treatment restored the patient to health with a useful limb. The treatment is the evacuation of the pus by freely opening the soft parts ; if pus is not found, the bone should be penetrated and the abscess fully exposed. The cavity should be freed of any necrotic bone-tissue, cleansed, and completely disinfected. If the joint is involved in the sup- puration, it must be sufficiently exposed to remove all the pus and be disin- fected and drained. In cases which have set up osteomyelitis the shaft of the bone should be trephined at such points as will evacuate the pus, and fre- quent cleansing and disinfection should be practised to preyent septicaemia and pyaemia. In extreme cases amputation may be necessary to save the life of the patient. Such authorities as Fayrer and Macnamara, according to Owen, are strong in urging amputation and reamputation, and the less the delay in resorting to the ope- ration the better. " After rigors (convulsions) and other symptoms, including pyaemia, have commenced, by far the best prospect is to remove the whole bone." Growing fever has been described as occurring in children of from seven to fifteen years. The pain is located at the epiphyseal lines ; there is rapid growth and some fever at times, with general disturbance. The symptoms usually subside without unfavorable results, but osteomyelitis may occur and exostoses may form. 1 Acute osteomyelitis, or diaphysitis, is a suppurative inflammation of the marrow of bone. It is a very common and destructive disease of childhood. It has its origin in the infection of the medullary structure of bone by pus- microbes. Though all bones are liable to be affected, the disease more often appears in the shafts of the long bones, and especially in the vicinity of the epiphyseal extremities. This is due to the fact that at these points the active process of ossification of the epiphyseal cartilage is in progress, and the newly and as yet imperfectly formed vessels readily admit the implantation of the microbes, floating in the blood, on their walls. The inflammation begins within these vessels, and spreads with the leucocytes into the medullary tissue. The large veins become occluded with thrombi which become infected by pus-microbes, followed by liquefaction of the coagulated blood. From this condition may result abscesses, or necrosis from the interruption of the cir- culation, or pyaemia from the entrance of infective matters into the general circulation. The infection gradually extends to the periosteum, and suppura- tive periostitis ensues, with separation of the periosteum from the bone ; or the periosteum may yield and pus enter the cellular tissue, causing wide- spread cellulitis. The origin of the pus-microbes which cause osteomyelitis is often a sup- purating wound, but they may enter the circulation through the lungs or the intestinal canal. A recent injury, as a fracture, may furnish all the con- ditions necessary for the lodgement of microbes entering the circulation from an existing wound. The infectious diseases of childhood, as scarlet fever, measles, diphtheria, and typhoid fever, often furnish the microbes which in- duce inflammation of the medulla. These cases are not generally pyaemic. for the patients usually die of exhaustion. 1 Brit. Med. Journ., April 14, 1888, p. 320. 544 LOCAL DISEASES. Case (Owen). — An infant, aged four weeks, was admitted to hospital on Feb- ruary 7th. An acute abscess involved the lower third of the left thigh, and another was present above the ankle of the same limb. There were also two small subcuta- neous abscesses in the palm and little finger of the left hand. These abscesses de- veloped a few days later, suppuration occurring in cutaneous sores on the arm. The abscesses were opened, flushed, and drained, but the child died two days afterward. The post-mortem examination showed that the abscess above the knee led to bare bone at the diaphyseal surface of the lower epiphyseal cartilage of the femur, and the end of the diaphysis was in a condition of acute osteomyelitis. There was no actual cavity in the bone, and the knee-joint was not involved. The abscess above the ankle led to bare bone at the tibial diaphysis, which was partially necrosed and surrounded by a good deal of new bone. The ankle-joint was not involved. There was a similar condition of the sternal ends of the third right and fourth left ribs and of the spinal ends of the seventh and eighth ribs, in each case the end of the rib being necrosed. There was also in this case purulent meningitis affecting the convexity of the brain, but no other sign of pygemia was present. 1 The frequent occurrence of this disease after exposure to the effects of cold, as prolonged bathing or lying on the ground after vigorous exercise, is explained by Senn as probably due to the congestion which takes place at these nutritive points, where resistance is least, and then the mural implanta- tion of microbes circulating in the blood. The disease may progress with great rapidity, with more or less violent symptoms, or it may proceed slowly and assume a chronic form. Diapliysitis, or osteomyelitis of the shaft of the bone, in its acute form is ushered in by a chill, followed by fever ; severe pain, but not well local- ized ; tenderness at the point of most acute inflammatory action ; swelling is a later sign, attended by a dusky redness of the skin as the pus approaches the surface ; swelling of the neighboring joint and synovitis complicate the case at an early period. As swelling may be a late symptom, the fever may be mistaken for typhoid fever. The swelling of the joint often leads to the diagnosis of rheumatism. In later stages it may be taken for cellulitis, periostitis, or ostitis. There is no one characteristic symptom. Case (Goltdammer). — Patient had been suffering ten days with fever ; pulse 110 to 120 •, tympanites ; dry tongue ; bronchitis ; delirium ; was diagnosed as typhoid fever. On close examination a slight swelling with tenderness was found over lower part of tibia, which proved to be osteomyelitis. The diagnosis must be made on this line of inquiry. The chill and fever are soon followed by pain, which is deep-seated, boring, tearing, and throbbing in the affected limb. In a brief period a careful examination reveals at the epiphyseal junction a tenderness, well localized, which is the focus of the inflammation ; this tenderness becomes more and more marked, until a swelling appears which indicates the approach of pus to the surface. The treatment should be prompt and decisive when the diagnosis is satisfactorily made out. It must be borne in mind that the focus of inflam- mation is in the interior of the bone, and that the active cause is the pus- microbe. Until that is removed the suppurating process will continue its destructive work. It becomes the imperative duty of the surgeon to expose this focus, to thoroughly disinfect the cavity, and, as far as possible, the adjacent structures. When this operation is rightly performed, the change in all of the conditions is very great ; the pain subsides, the swelling dimin- ishes, the fever falls, and the patient secures sleep and much-needed rest. But the great value of this treatment is the arrest of a destructive inflamma- tion which was liable to terminate in pyaemia, necrosis, suppuration in the nearest joint, and possibly in loss of limb and even of life. 1 Lancet, May 5, 1894. DISEASES OF BONE. 545 Case (Pitts). — An infant, aged six weeks, was admitted to hospital on Jan. 5th. In this ease the disease followed a few days after inflammation and suppuration in some cutaneous sores. There was an acute abscess above the left clavicle, and another above the left knee. On opening the former abscess the entire diaphysis of the clavicle came away as a sequestrum, which lay loose in the abscess-cavity. The femoral abscess led to a cavity in the region of the epiphyseal cartilage, which con- tained a small sequestrum. The knee-joint and shoulder-joint were not involved. The child died five days afterward. The necropsy revealed necrosis of the acromial end of the right clavicle, suppuration in the acromio-clavicular joint, and necrosis of the sternal end of the fourth rib on the right side and of the spinal end of the eighth rib on the same side. Subpleural abscesses were found in each case. 1 There may be no guide to the seat of the disease but tenderness on pressure. At that point, or as near it as the vessels and nerves will admit, an incision should be made down to the muscles ; these should be separated and the periosteum exposed. Usually the deeper tissues give marked evi- dence of inflammation, but even that condition may not exist, and on exposing the periosteum there may be no appearance of disease other than congestion. This fact should not deter the operator from proceeding to open the bone. A small trephine may be used, but a semicircular chisel is to be preferred. The opening is to be in the direction of the centre of the bone. When the medulla is reached, if pus has not formed, the tissues will be con- gested and soft, and blood and serum will be discharged. If an abscess exists, there will be a free flow of pus. As the object of exposing the cavity is to remove all of the diseased tissue, it may be necessary to enlarge the opening, which should be in the direction of the axis of the bone. If the inflammation involves a large ex- tent of bone, it is better to make several openings rather than a single one. When the cavity is sufficiently exposed, all of the diseased tissue should be removed with a sharp spoon ; the cavity should be irrigated with a sublimate solution (1 : 5000) ; peroxide of hydrogen or a solution of chloride of zinc (10 per cent.) should be applied to all the surfaces ; the cavity should then be packed with strips of iodoform gauze and the parts covered with anti- septic dressings. The limb should be fixed in a comfortable position, which favors the circulation. The dressings should be repeated, and the cavity cleansed by irrigations with warm boracic- or carbolic-acid solutions or perox- ide of hydrogen. If the temperature indicates an extension of the sup- purating process, the parts involved must be exposed and treated as indi- cated. If the operation is delayed until the suppuration is extensive, incisions should be made at such points as will freely evacuate the pus rather than by one long incision. The treatment should then be conducted on the lines already given. Necrosis is one of the later complications of the severer forms of osteo- myelitis. The most important feature in the treatment is to maintain, as far as possible, an aseptic condition of the entire cavity, and not to attempt removal of the dead bone until it has become so far detached that it can be removed without damage to the living bone. Frequent trials with a probe may be made through the openings to the dead bone to determine whether it is loose. If the involucrum is large, the granulations may so enclose the dead mass as to make it quite difficult to detect actual separations without force. When the sequestrum moves' in its place on pressure with the probe, it will probably be found necessary to enlarge the opening in the bone (cloacae) to make it possible to withdraw it from the involucrum. If this enlarged opening does not give sufficient space, the bridge between two or more cloacae may be removed with rongeur forceps or chisel, always in the direction of the shaft. 1 Lancet, May 5, 1894. 35 546 LOCAL DISEASES. Necrosis of the entire diapliysis sometimes occurs by the extension of the destructive process. The management of these cases is beset with difficulties. The conditions may be such, when the patient is first seen, as to raise the question of immediate removal of the necrosed bone or even of amputation. If the sequestrum is loose and the patient is failing, removal may be at once effected, though the new bone is imperfect. If it is not loose, the effort must first be made to secure complete evacuation of the pus and cleansing and disinfection of the cavity. Usually improvement follows, and an operation may be delayed. Failing to secure a better condition, sequestrotomy or amputation may be necessary as an extreme measure. The former operation is to be selected if there is an even chance of recovery, the latter being a last resort. In general, two features in the treatment are of great importance — viz. : 1. If possible, the dead bone should not be removed until the involucrum is sufficiently formed to sustain the limb ; 2. The epiphysis should be preserved in order to prevent subsequent shortening. The chief danger to be apprehended in these cases is the exhaustion of the patient by septicaemia, owing to the necessary presence of a large amount of septic matter. Case (Masterman). 1 — A girl, aged eleven years, had a rigor with high fever, nausea, headache ; no history of injury ; no complaint of pain in the limbs. Diag- nosis was an ordinary case of rigor. On the second day there was fever, vomiting, and redness along the right leg. Diagnosis was commencing erysipelas. Eight days after the temperature was 103° F. ; joints stiff and painful, especially the wrists and elbows ; right leg was swollen, but redness was gone : there was fluctuation over the inner surface of the tibia, extending four inches up the leg from the malleolus ; the skin was white, but not tense. On incision pus escaped, and the tibia was found bare over a surface of two inches. Symptoms became worse, being marked by rigors and sweats ; the joints became more swollen and painful, and pyaemia terminated the life of the child on the seventeenth day from the attack. To guard against this danger, as free exit of pus must be secured as pos- sible, and thorough antiseptic irrigation of the entire necrosed surfaces and the cavity in which the dead bone is encased. At the same time, the patient must be surrounded with the best hygienic conditions, and be sustained by proper food and tonic remedies. Should chills and perspirations indicate a pyaemic state, the chief reliance must be on large doses of quinine and alco- holic stimulants. The amount and kind of stimulants which are given must be determined by the conditions in each case, as age, severity of the symp- toms, and susceptibility of patient ; but it must be remembered that children suffering from this affection are remarkably tolerant of alcoholic stimulants. Should the case progress favorably, the new bone will form under the raised periosteum, and gradually become so thick and firm as to be capable of sus- taining the limb. At this time the necrosed shaft is usually found to have separated from the epiphyses sufficiently to be removed without damage to the involucrum. The exact time of separation can scarcely be approximately fixed. In general, it may be stated that small bones, as the phalanges, may separate in four or five weeks ; superficial masses of the long bones may separate in seven or eight weeks ; while the entire shaft may require three to six, or even eight, months. The question of operation must depend largely upon the fact that the sequestrum is loose. The date should be fixed according to the condition of the patient. If the health is improving, there is no haste. But, having de- cided to remove the dead mass, all necessary antiseptic precautions should be 1 Lancet, March 30, 1895, p. 804. DISEASES OF BONE. 547 taken. The elastic bandage should be applied at some distance- above the point of incision after the limb has been elevated for a few minutes. The elastic bandage should not be applied from the toes or fingers, as it miaht force pus beyond the diseased area. Senn advises applying the band- age at a point above, where the muscles are large, in order to protect the nerves from undue pressure, as he has known it to cause temporary paralysis. The incision should be in one of the fistulous openings, unless important vessels or nerves are likely to be involved, and should be in the direction of the fibres of the muscles. In following this rule great care should be taken to avoid injury to nerves and arteries which may be in close proximity to sinuses, as the radials in the arm and the popliteal vessels and nerves. When the incision reaches the muscles, it is better to separate parts with the handle of the scalpel down to the bone. When the bone is exposed great care must be exercised in enlarging the opening in the involucrum. The chisel should be carefully employed to en- large the opening in the direction of the long axis of the shaft, the limb meantime being placed on a firm surface, so as to avoid the possibility of breaking the new bone, which is very hard and brittle. When the cavity in which the sequestrum lies is fully exposed, the shaft should be gently de- tached from the healthy bone at each end, and from the granulations which enclose it. and then lifted out of its bed. The cavity should be thoroughly curetted to remove all granulations, washed with a sublimate solution (1 : 5000), and dried with an antiseptic sponge. The healing of these wounds is greatly retarded by their unyielding walls, and hence many efforts have been made to facilitate the process. The most simple is that of Schede, who closed the soft parts with sutures, and allowed the cavity to fill with blood ; the blood-clot organized, and thus the process of healing was greatly promoted. Careful antiseptic methods were employed in dressing the wounds. Senn fills the cavity with decalcified bone-chips and sutures the periosteum and soft parts over the cavity. Senn states that the decalcified bone-chips are preserved in an alcoholic solution of corrosive sublimate (1 : 500) or a solution of iodoform in sulphuric ether. The implantation is made before the removal of the constrictor, in order that after this is done sufficient blood will escape to fill the spaces between the chips, and thus serve the useful purpose of a temporary cement-substance. After the surface has been dusted over lightly with iodoform the chips, which have been washed previ- ously in an antiseptic solution, are dried upon a gauze compress, and are then poured into the cavity until this is packed with them as far as the periosteum. The peri- osteum is then sutured over the surface of the bone-chips. Chronic circumscribed osteomyelitis differs from the acute form in the comparative mildness of the symptoms and its slow progress. It may con- tinue for a long period with no more marked symptom than an aching pain at night, and even this may not be noticed in young children. On this account it is a disease which is very liable to be long overlooked in cases where it is marked by great chronicity. In the progress of the disease there is usually much condensation of the bone surrounding the abscess. In very young children, however, the pus may come to the surface with very little disturbance, or it may extend as in diffuse osteomyelitis. Occasionally neglected cases are seen where feeble children have many sinuses leading to dead bone. Case. — A girl, aged ten years, received a blow on the left knee, from which she seemed to recover ; two or three weeks after the knee and the lower part of the femur began to swell ; the pain was not severe, and the fever was slight. At length fluctuation was detected, and on opening the abscess above the knee and at the inner side of the femur, a large amount of pus was discharged. The bone was enlarged. 548 LOCAL DISEASES. and the probe entered a small sinus leading to the centre of the shaft. This was enlarged, and a cavity was found, involving the epiphysis, and containing a small sequestrum. A similar abscess of the upper extremity of the left humerus formed soon after, and on opening it carious bone was removed. She made a good recovery. The treatment which most immediately effects relief is incision, expos- ure of the bone, and trephining. The true guide to the focus of disease is tenderness. If great care is taken to make out this point, it is very certain to indicate the precise place for the incision. There should be no hesitation in exposing the bone by incision and in opening the bone by trephine or chisel, for the failure to find pus by no means renders the operation useless. Not infrequently the cancellous tissue is simply very red, with, perhaps, a serous infiltration and a few drops of pus. But the relief is uniformly great, as the tension is removed, and the inflammatory process is much relieved and modi- fied. In many instances an early operation prevents the pus from finding its way into a joint. The disease does not always become located in the epiph- ysis, but occasionally appears in the shaft, when the operation must be made in that region, the precise point being where the tip of the finger elicits evidence of the most tenderness. The cavity should always be thoroughly scraped, disinfected, and drained, and antiseptic dressings employed. Chronic diffuse osteomyelitis occurs most often in poorly-nourished and scrofulous children, and is caused by injuries, colds, and infective matters from suppurating foci. The exact point of commencement is not always apparent, but the first evidences of trouble appear usually at the epiphysis. unless the disease results from periostitis. It may. however, be met with in the jaw, ribs, pelvis, and other bones when there is a tubercular condition. The symptoms are frequently very obscure and the actual evidence of disease of the bone is limited to pain in the part at irregular intervals. But at length swelling of the tissues at the seat of pain, and, finally, the escape of pus and the formation of sinuses leading to bone, prove the existence of dif- fuse osteomyelitis. The destruction of bone may be very great, involving- sometimes the separation of an epiphysis or necrosis of the shaft, or even of both. The joints may become involved, with the formation of pus. The progress of the case is very slow, and the sequestra are frequently surrounded with soft and imperfectly-formed new bone. Attempts to remove sequestra by opening the new bone may result in breaking it up. when there is likely to be a tedious effort at repair. Even when the new bone appears to be firm the disease extends in spite of operations for the evacuation of pus, the cleaning out of sinuses and abscesses, and the removal of sequestra. Case. — A boy. aged five years, fell, striking on the left elbow. The bruise, was soon recovered from, but in a month following there were pain and swelling of the injured elbow, extending to the upper part of the arm. It was tense, and fluctua- tion was detected above the joint on the inner side : a puncture evacuated a quantity of pus. The bone was uncovered for a distance of three inches. The child was in feeble condition, but still able to run about and play. The arm seemed to improve for a time, but subsequently the elbow-joint became involved : pus was discharged through an incision, but there was no destruction of cartilage. After a period of apparent recovery the arm again became swollen, with pain and fever. Deep-seated fluctuation was detected, and on incision a large amount of pus escaped. The shaft of the bone was uncovered, the periosteum was greatly thick- ened, and there were evidences of the formation of new bone. After a period of four months the central portion of the shaft separated and was removed. The child recovered, with a much enlarged humerus. This form of osteomyelitis may result in sclerosis of the bone, with ob- literation of much of the medulla and general enlargement of the shaft. At points along the shaft there may be necrosis of small masses, enclosed by DISEASES OF BONE. 549 the new bone. Again, the inflammation may be a rarefying process, the bone becoming enlarged, soft, and filled with granulations. With careful treat- ment the patient may recover and regain a useful limb. In a large number of the>e oases the tubercular condition is recognized. The treatment of this disease should always be very conservative, for recoveries take place under the most unfavorable conditions. It must always be borne in mind that these patients are probably tuberculous, and are cer- tainly feebly constituted. Every necessary means should, therefore, be employed to improve the general health. The local treatment is to be con- ducted on the same principles as that already given. If there are signs of the formation of pus. incisions must be made, and, if necessary, the bone must be opened and all cavities scraped and disinfected. All necrotic tis- sues must be removed, however extensive may be the operation. In tuber- culous cases the exposed cavities must be thoroughly curetted. Tuberculosis of Bone. — Children recognized as scrofulous or strumous are very liable to develop tuberculosis of bone. It has been known in its various forms as abscess, osteomyelitis, spina ventosa, hip disease, spinal caries, etc. The disease results from the escape of the tubercle bacilli from lymphatic glands or the lungs, where they have already formed foci, into the general circulation, and their lodgement in the tissues of the bone. It is not. there- fore, a primary disease in the individual, but is due to the emigration of the microbe, already fixed in other and more favored situations, to the osseous structures. The process of infection is as follows : The bacillus of this affected tissue enters the circulation, and is arrested in a minute artery, where it becomes attached to the wall ; a thrombus now forms around it, which finally completely obstructs the vessel ; a focus of infection is thus created and a pathological process commenced. This results in decalcification or osteoporosis, while the disease continues. It may terminate by progres- sive invasion of healthy tissues, or osteosclerosis of the surrounding bone may occur as the process subsides, and thus the focus will be effectually en- closed. The localization of the tubercle bacilli is at the centre of active growth, and hence they are found in the medullary tissue of the cancellated struc- tures in the vicinity of the epiphyseal cartilages. The newly-formed vessels are imperfect and irregular, and furnish conditions favorable for intercepting any particle floating in the current of blood. Tubercle is therefore most often found in the vertebrae, the carpal and tarsal bones, and the epiphyseal extremities of the long bones. It is rare that there is a single focus ; fre- quently two or more appear in the same part, and occasionally the opposite limb becomes involved. The granulation process set up in the infected part is not unlike that in the glands, and may terminate in caseation and subsequent liquefaction, or suppuration owing to the presence of pathogenic germs. Konig recognizes four principal groups: 1. The granulating focus; 2. The tubercular necro- sis ; 3. The tuberculous infarct ; 4. Diffuse tuberculous osteomyelitis. 1. The granulating focus exists as a small cavity the size of a pea or a hazelnut, and may contain living embryonal tissues, or this may have been destroyed by necrosis and caseation, and the cavity contain cheesy material or tuberculous pus. 2. If the infected area is of considerable size or larger than a hazelnut, the vessels surrounding it become obstructed and necrosis of bone results. In this case a sequestrum will be found in the cavity, the size, color, and porosity of which will depend upon the rapidity of the inflammatory changes. 3. The tuberculous infarct is a wedge-shaped sequestrum, due to the formation of an embolism containing tubercle bacilli in a branch of the 550 LOCAL DISEASES. nutrient artery. The base of this necrosed bone may involve a joint, and may escape detection. 4. The diffuse form of tuberculous osteomyelitis is a rapidly-spreading inflammation of bone characterized by the presence of the tubercle bacilli. It closely resembles acute suppurative osteomyelitis, and is liable to prove fatal by the exhaustion which it produces. The diagnosis of tuberculosis of bone is frequently very difficult, as the general symptoms often do not indicate the extent, or even the presence, of the disease. An apparent condition of health is not incompatible with ex- tensive osteo-tuberculosis. But Senn states that " in 95 out of every 100 cases chronic inflammation in bone means tuberculosis." The earliest symptom which may readily be recognized is a daily rise of evening temperature, even if not more than half a degree, continuing for weeks. Careful search should be made, in a suspicious case having this symptom, for tubercular dis- ease of bone. A second important symptom is progressive angemia. Pain, though a constant symptom, is very variable in intensity, depending chiefly upon the severity of the inflammation. Its value must be estimated in each individual case. Tenderness at the point of infection is always present, and when carefully tested is reliable in localizing the focus of disease. Swelling does not appear until the pressure of the contents of the cavity begins to affect the external wall, as in spina ventosa, or in the progress of the disease the walls have been perforated, when a soft semi-fluctuating swelling is found. A dusky redness of the skin now marks the focus of disease, and at length the skin yields to the pressure, an irregular opening forms, and the contents of the abscess escape. The limb undergoes marked atrophy as the disease progresses. The differential diagnosis depends upon the discovery of the tubercle bacilli. The focus can be explored, for the purpose of extracting its con- tents, with a needle or with a hypodermic syringe, as the bone is quite soft. The needle should be inserted with a rotary motion. It will also determine the density of bone and the size of the abscess-cavity, besides withdrawing its contents. The prognosis depends upon the location of the infected part, the prog- ress of the disease, and the condition of the patient. In general, the prog- nosis is good when the focus of disease is accessible, the progress slow, and the patient is in fair health. It may be possible to remove the infectious material, and by a change of climate restore the general health of the patient. If, however, the diseased focus is inaccessible, the prognosis is more doubtful, and the danger is increased if pus-microbes gain access to the abscess. It must be remembered that a child who has once suffered from tuberculosis of bone is liable to future attacks. The treatment is general and local. It'is of the first importance to im- prove the health of the child by suitable medicines, as iron, quinine, phos- phorus, arsenic, strychnine, and cod-liver oil, and hygienic measures, as pure air, nutritious food, and bathing. Removal of the patient to the mountains or seashore at proper seasons of the year has a most marked influence on the progress of the disease, especially if the child is a resident of the city. The local treatment depends upon the stage of the disease and the accessibility of the part affected. The local treatment should first consist in the removal of all sources of irritation and in securing complete rest of the tissues involved. The immo- bilization of a limb, its elevation and rest, and the removal of pressure, are the immediate measures requiring attention. Destruction of the tuber- cular infection at the focus of disease should be attempted as early as possi- ble. In this procedure every necessary antiseptic precaution should be taken DISEASES OF BONE. 551 to prevent the entrance of pus-microbes into the cavity, for the violent in- flammation which they excite has hitherto proved a most dangerous incident in the progress of the case. Two methods are recommended : Ignipuncture 1 consists in the insertion of the needle-point of a Paquelin cautery heated to a dull-red heat. It should penetrate slowly, being frequently withdrawn and heated again. When it enters the cavity, the resistance suddenly diminishes. The results obtained are — free drainage of the cavity, the destruction of some portion of its contents, and the excitement of a plastic inflammation which tends to limit the infection. Through the track of the needle iodo- form solutions may be applied to the focus of disease. This treatment is adapted to foci in the epiphyses of long bones and in the carpus and tarsus. Pain is usually relieved and a healthy process of cicatrization established. But the removal of the tuberculous collection by incision is the most effective method of relief. This consists in exposing the cavity by dissection, perfora- tion of the bone by chisel or trephine, removing the contents, and curetting the walls. This operation is most successful when performed early and before caseation has occurred. The limb should be rendered bloodless by the elastic bandage, that the cavity may be thoroughly examined. Care should be taken to discover every possible collection of tubercle, explorations being made for any foci adjacent by means of a perforator, and the search should not cease until healthy bone is reached. In some instances it may be well to use the point of the cautery in doubtful places to destroy any infective material and excite healthy reparative action. The dressing consists in thoroughly cleansing the cavity with an anti- septic solution and packing it with iodoform gauze. Senn 2 advises to pack the cavity with decalcified bone-chips and to suture the periosteum over it, draining with a few threads of catgut. This treatment he regards as import- ant in the prevention of a local recurrence and general infection. He states that "if all the infected tissues have been removed, and no infection with pas-microbes has taken place during or after the operation, the wound unites under one dressing in from one to two weeks, and the definitive healing of the cavity is completed in the course of three to six weeks, according to the condition and age of the patient and the size of the cavity." Should suppuration follow, a secondary implantation can be made, when the cavity is made thoroughly aseptic. It sometimes becomes necessary to remove portions of the shaft of long bones, and when the carpus and tarsus are involved entire bones may require extirpation. In extensive osteomyelitis amputation may be the only suc- cessful method of saving the patient. Acute suppurative arthritis 3 is now re-cognized as a not infrequent disease of very early infancy. It has its origin generally in the epiphyses of the long bones and penetrates rapidly into the joint, destroying the cancellated structure of the bone, and perforating the joint surface. It may follow an injury or an exanthem, but the exciting cause is often unknown. Wright has seen a case which gave some evidence that the onset of the disease oc- curred in utero. The age of the child is quite characteristic. Though the disease may appear in older children, by far the larger number affected are under two years of age. The joint swells rapidly, and this swelling may involve the entire limb ; other joints sometimes swell, and for a time it may be impossible to determine the final location of the disease ; one joint, how- ever, soon becomes chiefly involved and the swelling subsides in the other joints. The hip is, perhaps, more frequently affected than the knee, but it is more often distinctly recognized in the latter joint. 1 Richet. 2 Principles of Surgery. 3 T. Smith, Brit. Med. Journ., Jan., 1885. 552 LOCAL DISEASES. The treatment consists in the prompt evacuation of the pus by incision and drainage. The first operation should be searching, and such incisions should be made as will not only drain the abscess at the time, but will enable the remotest recesses to be cleansed and disinfected at every dressing. It may happen that necrotic bone will be found, and in that case all such materials must be removed, but with great care in order to avoid the injury of living bone. CHAPTEE V. DISEASES OF THE JOINTS. The diseases of the joints of children differ from the same diseases in adults only in certain peculiarities depending chiefly upon differences in the maturity of the tissues involved. In the child the immature epiphyses of the long bones, the succulent cartilages and synovial membranes of the joints, afford all the conditions most favorable for the development of inflammatory affections. Injuries give rise to congestions over larger areas, and the vessels of these tissues become thereby enfeebled. These conditions favor the lodgement of infective particles in the circulation, and thus centres of sup- puration are more readily established. The tubercle bacilli from existing foci become implanted on the walls of the large and congested vessels and set up active disease. Even in the absence of traumatism the growing tis- sues of the joint are supplied with new-formed vessels which are extremely liable to intercept the tubercle bacilli. Tuberculosis of the joints, whether as a primary or secondary disease, is therefore far more frequent in children than in adults, and constitutes the prevailing form of joint diseases in the young. The liability of the epiphyses, as well as the joints themselves, to be the original centres of diseased action renders the exact diagnosis of joint affections more difficult in children than in adults. Acute serous synovitis in the child, except when due to injury or rheu- matism, is a comparatively rare affection. The part swells quickly ; effusion follows ; the pain is severe and the fever high. The acute symptoms are not as readily subdued as in the adult, and suppuration is very liable to super- vene, with ulceration of cartilages and destruction of the soft structures. In very mild cases dropsical effusions may distend the joint and require treat- ment. The treatment of the early stages should be absolute rest of the limb in a comfortable position, which will be semiflexed. The limb is best sup- ported on an angular splint, but in its absence it may be flexed over a firm pillow. It is also useful to attach a weight of one to three pounds to the foot in the manner usually employed in fractures, which relieves pain by slightly separating the joint surfaces. Cold applications in the form of an ice-poultice or an ice-bag are very important, but they must be continued without any intermission. The first effect of the cold is often painful, but when the cold penetrates the joint the pain subsides. The effect of the cold should be carefully watched, and if the pain continues, and especially if it is increased by the cold, the application should be removed. Evaporating lotions may be substituted. When the inflammation subsides efforts should be made persistently to restore the functions of the joints if they have been impaired. Passive motion, after the application of cloths wrung out of hot DISEASES OF THE JOINTS. 553 water, is most useful. If fluid accumulates passively in the joint, small and repeated blisters, with compression, is the best treatment. Acute suppurative synovitis is marked by a higher grade of severe symptoms. The pain is greater, the fever higher, and the patient shows marked loss of flesh. When the evidences of the presence of pus are recog- nized, incisions for its evacuation should be promptly made. Before the period of antisepsis such incisions were delayed until the purulent collection so distended the soft tissues as to threaten spontaneous opening. In such cases the infiltration of tissues was very great, and often destructive. With the proper employment of antiseptic preparations not only no harm comes by the exposure of the cavity of the abscess by incision, but, on the contrary, great relief follows, and frequently the process of recovery dates from the operation. To accomplish all the good possible the pus must be thoroughly evacuated, and the joint must be treated as an abscess-cavity — viz. disinfec- tion must be thorough, the removal of necrotic tissues carefully effected, the drainage complete, and antiseptic dressings properly applied. The subse- quent treatment must be governed by the developments as they occur in the progress of the case. Case. — A boy, aged one year, has suffered five weeks from tenderness, pain, and, finally, swelling of left hip : has emaciated rapidly ; all movements of left thigh cause screaming. Child fell from arms of nurse a few days before first symptoms. Fluctuation was apparent, and an exploratory operation was performed, evacuating a large amount of pus. The head of the femur was found separated and was re- moved, with much broken-down bone-structure. The cavity was cleared of all diseased tissues and well drained. Improvement followed, and the child eventually recovered with a fairly good limb, but with some shortening. The tubercular affections of the joints of children are usually of a chronic character. They are recognized under several titles, as chronic or fungous arthritis, strumous arthritis, and tumor albus. The disease may begin in the synovial membrane or in the extremity of the bone entering into the joint. When the infection locates in the synovial membrane the tubercle bacilli are derived from the circulation. Several varieties of tubercular synovitis have been described, but clinically two are noticeable. The tubercle-nodule first appears in the synovial membrane and spreads over that structure ; as granulation progresses one of two pecu- liarities will be noticeable in this fungous synovitis: 1, the membrane may become pulpy throughout without effusion, giving the true tumor albus, or white swelling, with its characteristic deformity of the joint, and later back- ward and outward dislocation of the tibia ; 2, or there may be an effusion into the joint without deformity, and suppuration may follow, terminating in destruction of the granulations and perforations of the capsules. In the primary osteal form the joint becomes involved by the extension of the dis- ease through the epiphysis. The disease may therefore progress for a considerable period without any unusual symptoms at the joint. The cause of the disease in the vast majority of cases is some form of injury, often very slight, for severe injuries protect the joint by the severe inflammation which follows. The diagnosis between a primary osteal and a primary synovial tuber- culosis of the joint is often difficult. The former is four times as frequent as the latter at the knee, hip, and elbow. The most reliable symptom of osteal tuberculosis is the presence of tender points beyond the joint. If the disease is synovial, the symptoms depend upon the form of inflammation. If it is plastic and without effusion (cartes sicca), the progress is slow, and is detected by the pain, gradual stiffening of the joint, and slight roughness of the joint-surfaces. Or there may be effusion into the joint, which then be- 554 LOCAL DISEASES. comes gradually distended, with distinct fluctuation. Finally, the granula- tions may become of large size, so as to distend the joint like an effusion, and may involve the tissues around the joint until it assumes a spindle shape, while the skin becomes dense and white, forming the true white swelling. The seeming fluctuation is deceptive, as will appear on using a hypodermic needle. Pain is variable and not reliable. Deformity occurs only when the tissues of the joint are weakened or destroyed. The prognosis of joint tuberculosis is favorable. Its curability depends upon the intensity of the infection and the resistance of the patient. It may terminate in recovery where the infection is limited and the patient is in good condition, but the joint is liable to be impaired in motion. The other forms are amenable to. and largely curable by, surgical treatment. The treatment of tuberculosis of the joints, when undertaken at an early period, should consist in immobilizing the part and improvement of the general health. Plaster of Paris is for most joints a useful appliance, and the limb should be fixed in such position as will render it most serviceable should ankylosis occur. If the joint is distended with fluid, antiseptic aspiration should be performed, followed by pressure, to prevent a return of the effusion. Injections of iodoform have been successfully used in the form of an ethereal solution, 1 part to 20 ; or in glycerin and alcohol ; or in glycerin, water, and mucilage of gum arabic. making a 10 per cent, solution. If the disease affects only the synovial membrane, and not the bone, excision of the diseased structures (arthrectorny) is the proper method of radical treatment. The opening of the joint must be by an incision which com- pletely exposes every part and recess. If the bone is involved, the operation must extend to the curetting of all the foci in the joint-surfaces of the bones, and, if necessary, to a removal with the saw of the articular ends of the bones. In all these operations every particle of tuberculous material must be scrupulously removed. The Shoulder-joint. The shoulder-joint is liable to inflammation from injury, or the extension of the disease from neighboring parts, or tuberculosis. It may become sec- ondarily affected when other joints are involved or after exantheins. The simple acute form of inflammation is extremely rare. The shoulder rapidly enlarges, forming on the anterior part a globular tumor, painful on pressure or when the arm is moved. The temperature is not high if the shoulder only is involved. The treatment must consist in supporting the arm in a sling so adjusted as to sec are quiet to the joint, without pressure of the joint-surfaces together or dragging. Evaporating lotions are the most useful as well as convenient applications. The inflammation usually subsides within a few days, and leaves no other complications than a stiffness which is soon overcome. The tubercular form of inflammation of the shoulder-joint in children is also rarely met with. It may first appear as a synovitis, but often the bone is primarily affected. It progresses as a chronic disease usually, but tends to ultimate suppuration and the formation of sinuses, through which dead bone can be detected. The early treatment consists in placing the joint at perfect rest. If pus forms, evacuation, by free incision and the removal of dead bone, must be promptly effected. The cavity should be curetted and all diseased structures cut away. If the head of the humerus is seriously involved, excision may be necessary. The general health must be sustained by improving the sur- roundings of the patient and the judicious employment of tonics. DISEASES OF THE JOINTS. 555 Case. — A girl, aged three years, began to show symptoms of disease of the left shoulder-joint. At first there were only stiffness and pain on moving the arm, espe- cially forward over the chest ; her general health was impaired ; at times there was some fever. The arm was fixed by a pasteboard splint applied to the flexed elbow and held in position by a sling. Oleate of mercury was applied. At the end of four months fluctuation was discovered at the inner edge of the insertion of the deltoid, and on opening the swelling curdy material was discharged. On explora- tion the probe passed upward to the joint, but no bare bone was detected. After several weeks of treatment the joint was laid open and the head of the humerus was found partially destroyed. The bone was excised at the anatomical neck, after which recovery progressed favorably. The subsequent history of the child showed a resto- ration of most of the functions of the arm. The Elbow-joint. The elboic-joint is liable to the same forms of inflammation as the shoulder, but. being of more complicated structure, the results are liable to be crippling to the functions of the forearm. Synovitis may result from the ordinary causes which produce it in other joints, and should be treated by rest in the semiflexed position, the part being supported by a well-padded pasteboard angular splint. If the affection of the joint assumes the chronic form, the original focus of inflammation was probably located in one of the condyles of the humerus. The limb becomes fixed in a flexed position, and the tissues infiltrated. The enlargement of the joint assumes a spindle shape, finally fluctuates, and on opening the abscess pus, mixed with curdy, cheesy masses, is discharged. The cartilage is often found removed and the bones carious. If the case comes under treatment in the early stage of the disease, the joint must be fixed in a flexed position by an angular splint. Local appli- cations are of little service. Tonics, nourishing food, and good air are of im- portance with reference to the final results. When the presence of pus is determined operative interference is imperative. Incision should be made at the point of fluctuation, and then the joint should be thoroughly explored. It is often possible, by careful exploration through longitudinal incisions on the external and internal aspects of the joint, so to remove diseased tissues and to curette carious bone-surfaces as to leave the joint free from diseased structures, and in a condition for recovery with a comparatively useful joint. If, however, the disease of the bones of the joint involves the epiphyses, ex- cision must be practised. The lateral incisions are the best adapted to pre- serve the soft structures of the joint from impairment. In the enucleation of the diseased bone the periosteum should be preserved. Frequently this membrane will be found very dense and easily separated from the bone. While it is important to remove all of the necrotic bone, care should be taken not to sacrifice any more of the joint extremities than is absolutely necessary. At as early a period as possible passive motion should be commenced in order to recover as much flexion as possible. Case. — A boy, aged four years, injured the right elbow-joint by a fall six months previously. There was moderate swelling, which soon subsided. On being lifted by the right hand he complained of pain ; the joint became tender : swelling slowly increased. When first seen the elbow was largely swollen, very sensitive on slight movement, and crepitus was discovered. An incision was made along the external margin of the elbow, giving escape to pus and some curd-like masses. The external condyle of the humerus was uncovered, and the olecranon was also involved on its joint-surface. A second longitudinal incision over the internal condyle exposed the carious condition of that bone. The periosteum was raised and the joint-ends of the humerus exposed. A small portion of the bone was removed from each condyle with a fine narrow saw, the wound cleared of some fragments of tissue, and anti- septically dressed. Recovery followed slowly, and by persistent efforts flexion was secured to the extent of enabling the patient to feed himself with that hand. 556 LOCAL DISEASES. The Wrist-joint. The wrist-joint is rarely the seat of simple synovitis. When affected, a well-padded splint should be applied to the dorsum of the forearm and hand, and the forearm must be supported in a sling which includes the hand. Evap- orating lotions seem often to relieve the inflammation in some degree, but they are troublesome dressings to maintain. By maintaining complete rest the inflammation usually subsides slowly, but is likely to leave some stiffening of the joint, which may be overcome by gentle passive motion. The tubercular form of disease is liable to be serious, as the inflammation often involves the carpal joints. The swelling occurs slowly, and is not as strictly limited to the wrist-joint as synovitis ; it finally assumes a baggy or cedematous condition, often involving the entire carpal region. Finally, rough- ness of the wrist-joint, and perhaps of some of the neighboring carpal joints, is detected, showing a disorganization of the joint-structures. Complete rest to the wrist and carpus must be secured and maintained by well-padded ante- rior and posterior splints, and the general health improved by tonics and nutri- tion. Pus must be evacuated by incision when detected, and the wound well drained. If the disease involves the bones of the wrist or of the carpus, excision must be performed. This operation should be performed with great care, in order to preserve the parts in such relations as to secure a useful limb, and still all of the tuberculous tissues must be removed. If the dis- ease is intelligently treated from its first inception, no other excision may become necessary than the removal of the joint-end of the radius. In this case the movements of the joint may be very well preserved. But usually the carpus is also involved, and then the operation becomes much more com- plicated. The approved methods of operation are as follows : (a) Listers excision of the entire wrist consists of a series of operations, each of which must be executed with scrupulous care, as follows : Break down adhesions of tendons by freely moving all the articulations of the hand ; commence the first incision at the middle of the dorsal Fig. 168. aspect of the radius, A (Fig. 168), on a level with the styloid process ; carry it toward the inner side of the metacarpo- phalangeal articulation of the thumb, running parallel in this course to the extensor secundi internodii ; on reach- ing the line of the radial border of the second metacarpal bone carry it down- ward longitudinally half the length of the bone, the radial artery lying farther to the outer side of the limb ; detach the soft parts from the bone at the radial side of the incision, the knife being guided by the thumb-nail ; divide the tendon of the extensor carpi radialis longior at its insertion into the base of the second metacarpal bone, and raise it along with that of the extensor carpi radialis brevior previously cut across, and the extensor secundi internodii, while the radial is thrust somewhat out- ward : separate the trapezium from the rest of the carpus by cutting forceps ap- plied in the line with the longitudinal part of the incision : leaving the trape- zium in position until the rest of the carpus is taken away, dissect the soft parts on the ulnar side of the incision from the carpus as far as convenient, the hand Excision of wrist : .4, Lister's radial incision ; B. Lister's ulnar incision ; C, Oilier ; D, Boeckel. DISEASES OF THE JOINTS. 557 being bent back to relax the extensor tendons of the fingers; commence the second incision, B (Fig. 16S), on the palmar surface, at least two inches above the end of the ulna, immediately anterior to the bone, and carry it downward between the bone and flexor carpi ulnaris, and on in a straight line as far as the middle of the fifth metacarpal bone on its palmar aspect ; raise the dorsal lip, cut the extensor carpi ulnaris at its insertion into the fifth metacarpal bone, and dissect it from its groove in the ulna without isolating it from the integuments ; separate the extensors of the fingers from the carpus, and divide the dorsal and internal lateral ligaments of the wrist-joint; leave the connections of the tendons with the radius undisturbed : now clear the anterior surface of the ulna by cutting toward the bone, avoiding the artery and nerve ; open the articulation of the pisiform bone, and sepa- rate the flexor tendons from the carpus, the hand being depressed to relax them ; clip through the base of the process of the unciform bone with pliers, but avoid carrying the knife farther down the hand than the bases of the metacarpal bones ; divide the anterior ligament of the wrist-joint, separate the carpus from the meta- carpus with cutting pliers, and extract the carpus with sequestrum forceps through the ulnar incision, dividing any ligamentous attachments ; the articular ends of the radius and ulna may be protruded at the ulnar incision and excised ; divide the ulna obliquely with a small saw so as to take away the cartilage-covered rounded part over which the radius sweeps while the base of the styloid process is retained ; clear the radius sufficiently to remove the articular surface ; if the caries is slight, remove a thin slice without disturbing the tendons in their grooves on the back of the bone ; clip away the articular facet of the ulna with bone forceps applied longi- tudinally ; if the caries is extensive, remove freely all the diseased bone with pliers and gouge ; examine the metacarpal bones and excise the articular surfaces only if they are sound, and more extensively if diseased ; next seize the trapezium with strong forceps, and dissect it out without cutting the tendon of the flexor carpi radialis, and excise the end of the metacarpal bone ; clip off the articular facet of the pisiform bone, and, if sound, leave the remainder in position ; close the radial incision firmly throughout with sutures, and also the end of the ulnar incision, but the middle must be kept open by pieces of lint introduced lightly to give support to the extensor tendons and afford free escape of discharges. (b) In BoeckeVs operation the incision may be made from the middle of the ulnar border of the metacarpal bone of the index finger upward to the middle of the dorsal surface of the epiphyses of the radius, D (Fig. 168), crossing to the ulnar side of the extensor carpi ulnaris at its insertion into the base of the third metacar- pal bone, and dividing the dorsal ligament of the carpus between the tendons of the long extensor of the thumb and the extensor indicis ; the soft parts being raised through the incision by careful manipulation of the hand, the carpal bones may be removed, one by one, by dividing the ligaments which bind them together and to other bones. (c) Oilier makes an incision, C (Fig. 168), from an inch below the styloid pro- cess of the radius upward along the external border of that bone, to a sufficient ex- tent ; a branch of the radial nerve being preserved, the extensor tendons of the thumb are exposed and drawn aside and the insertion of the superior longus ex- posed. With the periosteum denude the end of the radius and bend the carpus forcibly inward, dislocating the head of the radius outward. After separating the fibrous attachments excise the requisite amount. The end of the ulna may be reached through the same wound, or an incision along the inner border will expose it. The after-treatment must be pursued with due recognition of the fact that the new joint at the wrist is produced by an approximation of the bones of the forearm and of the metacarpus, partly by shortening of the limb and partly by the growth of new bone from the divided ends ; with proper care perfect symmetry of the hand can always be ensured ; for as the radius and ulna above and the metacarpus below are divided in parallel lines, the shrink- ing of the new material between them draws the hand equally upward toward the forearm ; the surgeon should aim to maintain flexibility of the fingers by frequently moving them, and at the same time to procure firmness of the wrist by keeping it securely fixed during the process of consolidation. These 558 LOCAL DISEASES. indications are met by placing the limb on Lister's splint (Fig. 169), which consists of an obtuse-angled piece of thick cork attached to a splint, with a cross-bar of cork attached to the under surface about the level of the knuckle ; Fig. 169. Hand after excision of wrist, laid in splint. on the splint the hand lies semi-flexed, its natural position, the fingers mid- way between the extremes of flexion and extension into which it is necessary to bring them in the daily passive movements ; the thumb is to be kept from the index finger by a pad of cotton maintained between them ; flexion and extension of the fingers should be commenced on the second day whether inflammation has subsided or not, and continued daily, each finger being flexed and extended to the fullest degree possible in health, care being taken that the metacarpal bone concerned is held steady ; pronation and supination must not be neglected, and as the wrist acquires firmness flexion and exten- sion, adduction and abduction, should be occasionally encouraged ; passive motion must be continued until there is no longer a tendency to contract ad- hesions. The Hip -joint. The hip-joint is liable to all the forms of disease peculiar to other joints, but in a very different ratio. Simple synovitis, uncomplicated by other affections, is rare and difiicult of correct diagnosis. It is most apparent when it immediately follows an injury. It soon subsides with rest and extension of the limb, the only treat- ment applicable. The acute suppurative forms of inflammation of the hip-joint are epi- physeal in origin and run the course of osteomyelitis. The joint becomes secondarily affected. The swelling is considerable, the pain severe, especially on moving the limb, and the temperature high. The treatment consists in extension of the limb by a weight at the foot, perfect rest, and, when pus is detected, free incision. It often happens that necrotic bone is discovered, which must be removed, even to the extent of excision of the entire head and neck of the femur, if necessary, in order to leave the cavity free from dead structures. Recovery usually follows, and a useful limb is often secured. Convalescence is always prolonged according to the extent of damage done to the bone and the general health of the patient. The joint must be protected from motion by the hip-splint, or by extension while the patient is confined to the recumbent position, until the consolidation of the cavity is well advanced, and then movements must be restricted for a considerable period. Usually the patient should be confined in bed, with extension at the foot, until the wound is granulating, when he can resume the hip-splint. The tubercular form of hip disease is by far the most common, and demands the most intelligent care on the part of the practitioner. It was DISEASES OF THE JOINTS. 559 formerly one of the most painful and destructive surgical diseases of child- hood, but at the present time it has become amenable to treatment, so that it may not only be rendered comparatively free from pain, but recovery may be secured with a useful limb. In a total of 277 cases, 142 were males and 135 were females ; 9 were over fourteen years of age, and 261 were under that age. Sex is therefore unimportant as a factor in the liability to the disease, but it is peculiarly a disease of childhood. Tubercular hip disease, therefore, should be thoroughly understood by the practitioner. The disease may commence in the synovial membrane, or in the acetabu- lum, or in the head of the femur. It is more frequently of osteal origin, and extends to the joint secondarily through the epiphysis. Four forms of tubercular synovitis have been recognized, the difference depending upon the formation of the granulation tissue. It is, however, difficult to distinguish the special form of the disease at an early period, nor is it of practical im- portance, as the treatment of the several forms does not differ. In all cases the progress of the affection, when of synovial origin, is more liable to be acute than when of osteal origin. The symptoms of both synovial and osteal tuberculosis of the hip depend upon the progress of the disease. It usually follows an injury to the hip. If the inflammation is acute, it is attended with great intolerance of movements of the limbs, fever, swelling of the hip, emaciation, and dis- turbed sleep owing to the spasms of the muscles at night. Pus forms at an early period, with great tumefaction of the region of the hip. In the sub- acute form all of the preceding symptoms are less marked. The pain does not prevent the child from playing, and is often referred to the inside of the knee ; the starting of the limb at night is less constant ; the flexion is less restrained, but cannot be carried to an extreme degree ; the swelling comes on slowly, and many months may elapse before the child finally ceases to use the limb. But the diseases may be more chronic still, especially when of osteal origin. It frequently happens that there is a long period of slowly progressing trouble at the hip which escapes the attention of even the physi- cian. The pain is so slight and occasional that it is never complained of; very often it is at the knee, and may follow a fall on that part, thus the more readily deceiving the attendant ; the patient does not give up active exer- cise, and there is nothing to indicate any affection at the hip. It is only after a long period that the symptoms become so pronounced as to attract notice to the actual spot. The practitioner cannot be too careful in these cases, for on a correct diagnosis will depend the recovery of the patient with a useful limb. The diagnosis of hip disease is liable to great errors. If seen at an early stage, when the disease is of a chronic form and the symptoms slight, it has been mistaken for an affection of the knee, of the sacro-iliac joint, for chronic rheumatism, rickets, and hysteria. In advanced stages, when the swelling is great, it has been treated as acute rheumatism, periostitis of tro- chanter, abscess of glandular, psoas, gluteal, or iliac origin, and other dis- eases. Pain is a most uncertain and often misleading symptom. The patient may vaguely admit that he has pain, but he often refers it to other places than the hip. These pains are often called " growing pains." The} T may be in the region of the pelvis, down the thigh, at the knee or the ankle. They sometimes remain so persistently at the knee that the disease has been located in that joint, and applications have been made to the knee for its relief. Efforts to elicit symptoms of pain in the joint by pressure over the trochan- ter or on the foot generally fails ; it is only by extreme abduction or adduc- tion that the patient gives evidence of being injured. Disturbed sleep, from 560 LOCAL DISEASES. starting of the limb, is sometimes a symptom which attracts little atten- tion. Lameness is also present, but often it is so slight that neither the patient nor immediate relatives recognize its existence for a considerable time. It is, however, significant of impairment of the movements at the hip-joint. At length it becomes apparent, owing to permanent flexion of the thigh and the effort of the patient to avoid the jar caused by stepping on the heel. The swelling occurs later and is a most important factor in the diagnosis. It may appear very early in front, and then indicates distention of the capsule with fluid. This, with accompanying symptoms, points unmis- takably to the hip-joint as the seat of trouble. Later the tissues around the joint become involved, and finally the capsule ruptures, when the swell- ing becomes most marked behind the trochanter. The attitude of the patient should be carefully studied. Place him on the back, and, grasping the leg below the knee, slowly flex each thigh on the body. The unaffected joint will permit the thigh to be pressed down firmly upon the abdomen (Fig. 170), but when an effort is made to flex in a Fig. 170. Sound thigh flexed on abdomen for ascertaining exact amount of deformity. similar manner the opposite thigh, the joint of which is affected, the flexion, even in the earliest stages of disease, is suddenly arrested, and the child resists all further attempts at flexion. A very simple method of making this test is to request the child to touch his nose to his knee ; he accomplishes the feat readily with the healthy limb, but fails with the diseased limb or succeeds with difficulty, though he makes great efforts to effect the object. This is one of the most reliable evidences of hip disease, and can readily be made. A second test of a similar kind should be made at the same time. If the patient lies on a smooth, hard surface, and his spine rests on it, the flexion Fig. 171. Limb brought down, but loin arched (Owen). of the thigh, caused by the fixation of the joint, will at once elevate the knee of the affected limb. If, now, the knee is pressed down so as to touch the surface, the spine becomes arched (Fig. 171), owing to the fixation of the hip-joint. The same test can also be applied by placing the patient in DISEASES OF THE JOINTS. 561 Th< Fig. 172. a prone position and slowly elevating the leg, seizing it at the ankle, healthy limb will move readily to the fullest extent backward, while the affected limb admits of but limited backward motion. Atrophy of the limb is a very early sign of hip disease. The points of measurement are the middle of the upper thirds of both the thigh and leg. At these points we measure the muscles at their largest development. If there is atrophy of the limb which is suspected, the fact is of value only in connection with the other signs and symptoms. Of more im- portance in diagnosis is the wasting of the muscles of the affected part. The hip assumes a flattened appearance, and the usually well-marked trans- verse (Fig. 172) gluteal fold disappears or takes an oblique direction downward and outward. As the disease advances the symptoms and appearances be- come more marked and significant. In the first stage the limb emaciates, and the thigh becomes flexed ; in the second stage the limb is abducted and rotated outward : and in the third stage it is adducted and rests on the other thigh. Sayre explains the pathological conditions as fol- lows : The cavity of the joint becomes distended with fluid, and the affected limb is slowly abducted and apparently lengthened ; subsequently suppura- tion occurs in the joint, the capsule ruptures, and the limb becomes adducted, and it appears to have undergone a process of shortening. These differences in length are, ever, only apparent, owing to an inclination of the pelvis. Owen remarks: "As soon as the pelvis is brought square with the spine and the lumbar vertebrae are all flat upon the table, the amount of deformity may be accurately determined. Apparent shortening is then explained, and a limb which hitherto might have been considered to be in good position maybe found of normal Fig. 173. length, but flexed and greatly adducted. The schemes represent (a) pelvis and lower extremities in every respect normal ; (b) disease of the left hip-joint, tilting of the pelvis, the left limb being apparently shortened, but in the normal line ; (c) shows how, by the squaring of the pelvis, the limb has been brought down and found greatly adducted, yet of normal length : (d) represents disease of the left joint, the pelvis having been tilted (possibly dropping from want of the accustomed support), so that the left extremity seems increased in length, though still in normal 36 562 LOCAL DISEASES. parallelism. But on bringing the transverse line of the iliac crests at right angles with the spinal column, as in (e), the left limb is found of normal length, but greatly abducted. " The position of the limb, therefore, marks three stages in the progress of the disease, and becomes a valuable diagnostic sign: viz. 1, there is simple flexion, with perhaps slight abduction and outward rotation ; 2, flexion with marked rota- tion outward, and abduction with apparent lengthening ; 3, flexion, rotation inward, adduction and apparent shortening. : " As the case progresses the hip becomes flattened and the gluteal fold is lost or becomes very oblique. The patient suffers at night from starting pains, and during the day maintains the limb in a fixed position, partly by muscular force and partly by the thickening of tissues. The pain varies much ; it may be absent in severe cases or intermittent, and is liable to change from one locality to another as to the thigh, knee, leg, and feet. Its diagnostic value is very slight. Finally, the child assumes a perfectly quiet position, and resists every effort to move the limb. This peculiarity marks the last stages of the disease. The swelling, which was at first most marked in front of the thigh, now becomes prominent over the trochanter, and indi- cates suppuration in the joint. The abscess at length opens, usually behind and below the trochanter, and afterward at other points, following the course of the muscles. On moving the limb, grating may now be felt if the joint is destroyed, owing to the escape of the pus. which by distention prevented the head of the femur from free contact with the acetabulum. From this time the limb remains permanently flexed and adducted. In cases which have progressed uninterruptedly the head of the femur may be destroyed or may escape from the acetabulum. During this period of suppuration the health of the patient deteriorates ; there is septicaemia, and often pyaemia ; emaciation increases, and the larger number die of ex- haustion if the disease is allowed to pursue its course to its termination. Those who survive the natural processes are doomed to have a crippled limb for life. The prognosis of hip disease under intelligent treatment is extremely favorable. It can be arrested in the early stages by modern methods of treat- ment, and the general health preserved. In the later stages it can be ren- dered painless and the patient can be protected from loss of health. Finally, in the most advanced and unfavorable cases when first brought under treat- ment life may be preserved and a comparatively useful limb secured. The treatment of hip disease is now based on rational principles, and can be successfully carried out by every practitioner. At every stage of the case the result aimed at in this treatment is the protection of the diseased structures from injury and the promotion of the health of the patient. These conditions are not secured by rest in bed. It is true that rest will prevent the shock and impact of walking, but it will not save the joint from the injury caused by the spasm of the muscles and the movements of the limb. Proper protection can only be secured by such traction of the limb as will relieve all pressure of the head of the femur on the joint-surfaces. This can be effected by the weight and pulley when the patient is confined to his bed, and by the hip-splint when he is allowed to move about. The employment of these appliances should not be delayed after the diag- nosis of hip-joint disease is made, nor should they be intermitted until the cure has been perfected. In the early periods of a very chronic case it will be difficult to persuade the patient and friends to submit to this plan of treat- ment. But the practitioner will be culpable who does not firmly insist upon the application of well-adjusted and efficient apparatus. The period during which the hip-splint will be required, even in the most favorable cases, will exceed a year, and more often eighteen months or two years. DISEASES OF THE JOINTS. 563 The importance of the hip-splint in tubercular disease of the joint cannot be over-estimated. It enables the patient to take the necessary amount of exercise in the open air to preserve his general health, while the affected joint is placed in a condition of rest from its ordinary functions. Frequently the child is enabled to resume many of those sports in the open air which give zest to exercise and are essential to health. There is no single device in practical surgery which more exactly meets all its indications than the ordinary hip- splint. It is doubtful if in the whole realm of inventions a greater service has been rendered to an individual class of patients than this splint has ren- dered to those afflicted with hip disease. It has not only rescued vast num- bers of children from a prolonged and painful sickness and a lingering death, but it has saved them from pain and suffering. When, therefore, the disease is recognized as involving the structures entering into the hip-joint, whether as a synovitis or an osteomyelitis, this treatment should be commenced. It is generally better to employ, for a time, extension of the limb while the patient is in bed before permanent apparatus is applied. The patient should accordingly be placed in the recumbent position, with a weight at the foot to make such extension as will counteract muscular contraction. The rubber plaster should be selected, and cut in strips about an inch and a half wide and of sufficient length to extend to the middle of the thigh and form a loop below Fig. 174. Bed for extension. the foot. The bed should be firm, the foot being elevated slightly (Fig. 174) and the surface smooth. The weight need not exceed four to six pounds. At first the extension should be in the direction of the flexed thigh, but grad- ually it should assume the straight position. Usually great relief to all of the symptoms follows the use of the weight. This is due to the traction of the muscles of the thigh, which prevents the undue pressure of the head of the femur on the joint attending their spasmodic contraction. But confinement to the bed soon impairs the patient's health, and hence the necessity of supplying an apparatus at an early period which enables him to take proper exercise, while it protects the joint from injury. The hip-splint meets every indication now present. The following is a description of the splint : The splint (Fig. 175) extends from the sole to the crest of the ilium, where it is connected to a pelvic band by a joint allowing flexion and extension, abduction and adduction, but properly regulated. Extension is made by means of adhesive plaster applied to the leg and attached by buckles to the two ends of a leather strap fastened to the foot-piece ; counter-extension is made by means of two perineal pads fastened to the pelvic band with straps and buckles ; at the knee-joint is a movable cross-piece for attaching a leather cap to steady and support the knee ; at the bottom of the instru- ment is a foot-piece with a leather sole attached, to prevent jar in walking : a leather strap, passing under the foot through apertures in the foot-piece, turns up an end on each side of the ankle, and fastens to buckles in adhesive strips, which prepare as follows : Cut two pieces of strong plaster, to reach from the middle of the thigh nearly to the ankle and two inches wide ; attach a strong saddler's buckle to the 564 LOCAL DISEASES. lower end of each ; apply the plasters against the lateral aspects of the leg, begin- ning about two inches above the internal and external malleoli with the ends hav- ing the buckles attached ; a few turns of roller bandage are then made around the ankle, just under the lower ends of the straps, to protect the flesh under the buckles, and then continued over the strips on the whole limb. The patient should be laid on his back, and great care ought to be taken that the pelvis is not inclined forward by contractions of the flexor muscles ; should this be the case, elevate the leg until the lumbar vertebrae come near the couch and the spinal column assumes its normal shape ; the instrument is then applied. The pelvic band ought to be loose enough to allow the pelvis to move freely in it ; the anterior superior spine of the ilium ought to be above the pelvic band (Fig. 176) ; in applying the ankle-straps leave a little Fig. 175. Fig. 176. Hip-splint. Hip-splint applied. space between the foot and the foot-piece, so that in standing or walking the weight of the patient does not rest on the leg, but on the instrument ; the perineal straps must be so adjusted that the patient sits firmly and comfortably upon them : when the apparatus is adjusted tighten the perineal straps until the patient gives evidence that the strain is sufficient. The attendant should be instructed to keep all the straps as tense as the patient will bear without complaint. The hip-splint, properly adjusted, should be entirely comfortable, and should enable the patient to walk with comparative ease. In ordinary cases of hip dis- ease of osteal origin the splint must be worn for eighteen months to two years. Case. — J. C , a boy, aged nine years, strumous, developed tubercular epiph- ysitis of the neck of the femur. "When first seen the left leg was flexed and slightly abducted; the pain constant; sleep was disturbed ; there was marked emaciation. The hip-splint was applied, and he soon began to walk freely ; the pain disappeared, and he began to take on flesh. He wore the splint twenty months, and during the time took active exercise. Latterly he played games of ball. All signs and symp- toms of hip disease meantime disappeared. The removal of the splint must be undertaken with great care, and only after all of the symptoms have disappeared for a considerable period. To determine the condition of the joint, the limb should be flexed, abducted, adducted, percussed, and rotated. The motions, especially flexion, will not be as free as are those of the healthy limb, but they will not be painful as DISEASES OF THE JOINTS. 565 formerly. The splint should for a time be removed only at night, to be resumed in the morning before rising. Then it may be omitted while the patient remains in the house, and applied if he walks out, to prevent acci- dent. Finally, if the case progresses well, the intervals of use of the splint may be lengthened. If at any time there is a recurrence of symptoms, the splint must be resumed for a time. Abscess is likely to appear in the progress of the disease, and there has been much discussion as to the propriety of evacuating the pus. It is held that if the abscess is not disturbed it will be harmless, and may be absorbed, while if the cavity is opened, profuse suppuration is liable to be established, greatly to the detriment of the patient. Such reasoning is fallacious, in that, first, there is danger that the retained pus will infect the system as it invades new areas of cellular tissue ; and, second, the pus can be evacuated without endangering increased suppuration. The rule of practice should be to freely open abscesses which arise in the course of hip-joint disease, taking all need- ful antiseptic precautions. The result of such treatment is always beneficial, and in some instances is followed by immediate improvement. Case. — A. B , a lady, twenty years old, had been under treatment for hip disease one year, during which she wore the usual hip-splint. An abscess appeared four months before admission to the hospital, but it was not opened. It was now of large size, being most prominent behind the trochanter. She was greatly ema- ciated, had fever with irregular chills and sweats, and a rapid, feeble pulse. An anaesthetic was given on two occasions for an operation, but in both instances the heart failed, her face became purple and the respiration greatly embarrassed. A third attempt was preceded by securing partial intoxication with whiskey. The patient took an ounce of whiskey in half a pint of hot milk every hour, commencing at eight o'clock in the morning. At twelve o'clock she was talking foolishly ; her eyes were suffused, her pulse quiet at 96 beats per minute, her skin warm and natural, and her respirations full. She required but little of the anaesthetic, and during the operation her pulse continued at 96, without showing any signs of weakness, and the respirations remained unchanged. A large amount of pus was evacuated. The head of the femur had separated, and was removed, with much disintegrated bone. The general condition of the patient improved rapidly, and she made a good recovery. The abscess may not communicate with the joint, and in that case the cavity should be thoroughly curetted and packed with antiseptic gauze. The healing of the abscess-cavity generally progresses favorably. If how- ever, the abscess is connected with the joint or with diseased bone, the operation should extend to the removal of all dead structures, even to the extent of excision of the head of the femur. Aspiration of the distended capsule may be practised in the early stage of effusion. This condition is marked by a swelling over the joint and that feeling of elasticity which is due to the tense capsule. It is safer to make the puncture behind the trochanter than in front. Aspiration to remove a purulent collection during the progress of hip-joint disease is a waste of time. If the indications are that the head of the bone is seriously involved, excision will be required. An exploratory operation to determine the extent of the destruction of tissues should be deliberately undertaken, provision having been made to excise the necrotic bone. The extent of the resection should depend upon the amount of disease ; if limited to the head, that part alone should be removed ; if the neck is carious, the trochanter may still be preserved ; but if the latter is involved, the bone must be divided at the trochanter minor. The methods of operating are numerous, but the single incision, with sub- periosteal removal of the bone, most nearly meets the anatomical indication of the part. 566 LOCAL DISEASES. Fig. 177. Several arteries are distributed to this region — viz. the gluteal, sciatic, obturator, and circumflex, the only one which approaches the line of the incision near enough to be incised before dividing into branches of distribu- tion too small to give rise to noticeable hemorrhage is a twig of the internal circumflex, which at one-eighth to one-fourth of an inch from the insertion of the obturator externus breaks up into its terminal divisions ; this branch may be avoided by keeping the point of the knife well against the bone, and divid- ing the tendon of the obturator externus muscle in the digital fossa. Excision is as follows : The patient lying on the sound side, with a strong knife com- mence an incision, A (Fig. 177), at a point midway between the anterior inferior spinous process of the ilium and the top of the great trochanter •, carry it in a curved line over the ilium in contact with the bone, across to the top of the great trochanter ; extend it not di- rectly over the centre of the trochanter, but midway between the centre and its posterior border ; complete it by carrying the knife for- ward and inward, making the whole length of the incision four to six or eight inches, accord- ing to the size of the thigh ; if the periosteum has not been divided by the first incision, carry the point of the knife along the same line a second or third time ; an assistant sepa- rating the wound with the fingers or retractors, the great trochanter, b (Fig. 178), is exposed ; with a narrow, thick knife make an incision through the periosteum only at right angles with the first at a point an inch or an inch and a half below the top of the great trochanter, opposite or a little above the lesser trochanter, and extend it as far as possible around the bone, making sure that the periosteum is freely divided ; at the junction of the two incisions of the periosteum introduce the blade of the periosteal elevator, and grad- ually peel up the periosteum from either side with its fibrous attachments until the digital fossa has been reached ; with the point of the knife applied to the bone divide the attach- ments of the rotator muscle, and continue to elevate the periosteum, carefully avoiding rupturing it at any point : when the perios- teum is removed as far as necessary, adduct the limb slightly, depress the lower end of the femur sufficiently to allow the head of the bone to be lifted out only so far as is requi- site to permit its removal with the saw, g ; divide the bone just above the trochanter minor and remove the fragment ; if the head of the bone cannot be raised before division on account of the involucrum, saw the bone first and then remove the head ; if the shaft at the point of section is necrosed, expose and exsect more ; examine the acetabulum, and if found diseased remove all dead bone ; if perforated, the internal periosteum will be found peeled off, making a kind of cavity be- hind the acetabulum, and all diseased bone Passing chain-saw. must be very carefully chipped off down to Excision of the hip : A, Sayre ; B, Oilier. DISEASES OF THE JOINTS. 567 the point where the periosteum is reflected from sound bone. Every part of the wound and all sinuses must be thoroughly cleaned of particles of bone and false membrane. For some time after the operation the patient must remain in bed. and extension of the leg by a weight should be continued, and not omitted until the hip-splint is resumed. As soon, however, as the wound has healed suffi- ciently to allow him to move about and without discomfort, the patient should resume his splint and continue to wear it until the tissues of the joint are consolidated. The amount of shortening which follows is very variable. Primarily, it depends upon the extent of the bone removed, but this does not affect it so greatly as does the treatment. If a suitable degree of extension of the limb is maintained, two important changes occur — viz. first, the femur continues to lengthen by the natural growth of the bone at the lower epiphysis ; and, second, the new structures which form at the seat of excision are extensive, and, becoming firmly attached to the bone, main- tain it in good position. It is very important, therefore, to maintain exten- sion, first, by a weight during the confinement of the patient to the recum- bent position, and when he is able to resume the splint, that should be faith- fully employed until the wound is firmly closed and perfected. The wound sometimes reopens and small fragments of bone are discharged '; this reopen- ing is occasionally due to an injury of the new tissues of the abscess- cavity. As recovery progresses the question of mobility of the limb becomes important. The tendency of the cicatrization of the new-formed tissues is to immobilize the upper end of the femur. If no effort is made to prevent this contraction and consolidation, immobility will become complete, and ankylosis at the hip will result. It is desirable, therefore, to commence slight passive motion at an early period, and gradually increase the mobility. If the limb has been shortened by excision of the head of the femur, a proper shoe should be applied. The Knee-joint. The large extent of the surfaces of the knee-joint, its complicated mechan- ism, and its exposed position render it peculiarly liable to inflammatory affec- tions. Acute synovitis is caused by injury. Its diagnosis is readily made, as the significance of the swelling, heat, and pain is at once appreciated. The treatment should be absolute rest, the limb being somewhat flexed over a pillow, and applications made of the ice-bag or of an ice-poultice. The disease is of short duration, but the patient must resume active use of the joint very gradually. Chronic synovitis, with the large collections of fluid which occur in the adult, is very rarely seen in the child. When it exists the child will be found to be in impaired health. The treatment must be directed to improvement of the health, and the application of such measures as will promote absorption. One of the most simple and effective methods is strapping. The straps should be applied in such manner as to compress the contents of its cavity firmly against the hard tissues, and not into recesses of the capsule. This is effected by placing the straps alternately above and below, and completing the process by apply- ing the last over the centre of the joint. They should not meet posteriorly, in order not to interrupt the circulation in that region. Painting the knee with strong iodine frequently is sometimes useful, as are small blisters, often repeated. 568 LOCAL DISEASES. Tubercular disease of the knee may begin in the synovial or bony tissues, the latter being to the former in the proportion of 3 to 1. In the early stages the former is recognized as a degeneration of the synovial membrane, cartilage, and the bone-surfaces through a process of granulation. It usually proceeds slowly, with no severe symptoms. The destruction of tissue is extensive. In the early stages of the affection two conditions may be found. In one there is little or no effusion and the knee is pulpy, owing to the amount of granulation tissue. The joint-ends of the bone seem to be en- larged, but this condition is due to the dense thickening of tissues by gran- ulations. This is the " white swelling " of early writers, and is followed by such deformities as flexion, backward dislocation, outward rotation. In the other form effusion takes place without deformity, and fluctuation is notice- able. If the disease is of osteal origin, the primary swelling is not so directly in the line of the joint, but in the vicinity of the epiphysis involved, and tenderness may be detected on this line. The progress of the acute disease is that of an osteomyelitis, the joint becoming involved secondarily by the penetration of the pus from the focus of suppuration. The symptoms at first are pain, swelling, and tenderness, well localized. But the progress may be slow and the general health may not be seriously disturbed for a long period. When, however, pus has formed in considerable quantity, and is penetrating the structures of the joint, there will usually be an accession of the severe symptoms, as fever, loss of flesh, and rigors, fol- lowed by perspirations. The prognosis will depend upon the stage and progress of the disease. In the early period with complete rest of the joint, with a well-applied plas- ter-of-Paris dressing extending from the toes to the hip, and with tonic treatment, the disease may sometimes be arrested. But there is frequently a certain danger of deformity remaining, and a liability to a renewal of the disease. If the disease is advanced, perfect results are more likely to be secured when the tuberculous tissues are completely removed. In these conditions operative procedures, by which the infective material is destroyed or removed, offer the best chance of permanent recovery. When the knee-joint is filled with fluid, aspiration will relieve the dis- tention, and to that extent prove useful. A more radical treatment is the injection into the cavity, after its evacuation, of an ethereal solution of iodo- form. For this purpose a trocar may be used both to withdraw the fluid and to inject the iodoform. Before the iodoform is injected, it is well to wash out the cavity with a boric-acid solution. It may be necessary to inject the iodoform several times at intervals of a week or more. Arthrectomy is a much more useful operation where the synovial mem- brane is extensively diseased. It consists in completely exposing the inte- rior of the joint, and with the forceps and scissors cutting away all diseased tissues. The joint may be exposed by making a flap convex downward or convex upward, or by a transverse incision over the centre of the patella, and sawing through that bone, but uniting it, after the joint is cleared, by wire or even by silk ligatures. Too much care cannot be taken to excise every particle of tuberculous structure, and hence the operation, if well per- formed, will be tedious. If small cavities in the cartilage and bone are filled with tubercle, they should be thoroughly scraped with a sharp spoon. If the tuberculous cavities are found to involve the articular ends of the bones, excision becomes necessary, and may be successfully performed by one familiar with operative procedures. The most useful operation is as follows : DISEASES OF THE JOINTS. 569 Fig. 179. The leg being slightly flexed on the thigh, make a curved incision, commencing at the insertion of the internal lateral ligament into the inner condyle of the femur, and passing just below the lower extremity of the patella, terminate it at the same point on the external aspect of the joint : the lateral incisions should not be made lower than the insertion of the lateral ligaments, to avoid division of the articular arteries ; remove all diseased and degenerated tissues ; reflect flap up- ward (Fig. 179) : remove the patella if diseased ; if not, leave it undisturbed and divide the lateral and interarticular ligaments ; pass a fold of cloth through the joint, and draw it firmly under the extremity of the bone to be sawn, thus completely isolating the soft parts behind : apply the saw first to the extremity of the femur, and then to the articular head of the tibia. The bones must be maintained in apposition by two or three silver wires, which should now be introduced into the anterior part of the tibia and femur, and, when sufficiently twisted, cut off and the ends turned down between the bones. The dressings should be antiseptic — viz. layers of iodoform gauze next to the wound, then gauze bandages treated with bichloride solution, next Excision of knee. borated cotton firmly bound by gauze bandages, and last gypsum bandages sufficient to immobilize the knee. The more superficial dressings should extend from the hip to the ankle. The limb should now be placed in a sling. The dressings should not be changed, except to remove the drain-tube, for several weeks. The wires are allowed to remain. The Ankle-joint. Synovitis of the ankle-joint results from that form of injury known as a " sprain." This is due to the sudden turning of the foot when planted on a rounded body, as a stone or stick. A strain of the ankle may occur when the foot is caught and the child falls, as at play. The pain on attempting to walk is more or less severe, and the joint at once swells from the effusion which results from the rupture of tissues. Owen states that " in this stretching the synovial membrane also participates, and a considerable amount, if not of blood, at least of altered synovia, is quickly poured into the interior of the joint." The important features of the treatment are complete rest and the early application of hot water. To carry out this treatment satisfactorily the child should first be confined to the bed, with the foot elevated. The leg, nearly to the knee, should at once be placed in hot water of a tempera- ture as high as can be borne. After a submersion of half an hour the ankle should be wrapped with three or four layers of flannel wrung out of water as hot as the child will tolerate, and covered with oiled silk to retain heat and moisture. These dressings should be renewed every three or four hours, or the heat may be maintained by a hot-water bag or hot-water bot- tles, especially at night. After this treatment has been continued for one day, the dressings should be changed for hot camphorated oil. The swell- ing usually rapidly subsides, and then adhesive strips should be applied to the entire ankle, and retained two or three weeks or until the cure is complete. 570 LOCAL DISEASES. Fig. 189. Gentle but very firm rubbing of the foot, ankle, and leg, with the hand softened with vaseline or oil, will be very useful in restoring the functions of the joint. The child may begin to move about on crutches when action gives no pain, but actual attempts to walk must be delayed until the joint has so far recovered that the weight can be readily borne. Tubercular disease of the ankle is chronic in its character, and, like this affection in other joints, is often obscure at its origin. The pain is slight, the swelling limited, and the lame- ness unnoticed. At length the puffmess about the posterior and inner part of the ankle be- comes noticeable (Fig. 180), lameness increases, and the pain prevents the free use of the foot. The disease usually commences in the synovial membrane, but it is frequently complicated with tuberculous affections of the tarsal bones. As the disease progresses the swelling increases, until the joint has a peculiar tuberose or spindle-shaped appearance. The foot assumes a position of extension, unless the tarsus is involved, when the whole foot and ankle be- come a swollen mass, with the foot at right angles to the leg. The disease often extends, also, along the sheaths of tendons, giving rise to swelling in the lower part of the leg, the dorsum of the foot, and even the plantar region, though the plantar fascia maintains the arch of the foot. The treatment, in the early stages, is proper fixation of the joint. This is readily and effectually accomplished by the plaster-of-Paris bandage. In its first application care must be taken to protect the limb by covering it with so much cotton batting that the plaster will not produce irritation of the skin. It is especially important to envelop the swollen ankle with a large amount of the cotton, in order that the bandages may be applied very tightly for the purpose of securing as much pressure as possible. Compression is an important feature in the treatment, and the cotton, while protecting the skin, has an elasticity which is highly beneficial. When the plaster dressing is well applied, the child can move about on crutches, keeping his diseased foot from the ground. Sayre very properly attaches great importance to extension in the treatment of Fig. 181. Tubercular disease of the ankle. Sayre's steel brace. Apparatus applied. DISEASES OF THE JOINTS. 571 ankle-joint disease, and has devised an ingenious apparatus for that purpose : The steel brace is applied (Fig. 1S1) as follows : Cut adhesive plaster in strips about one inch in width, and long enough to reach from the ankle to near the tubercle of the tibia, and placed all around the limb : secure the plaster in its position, to within an inch of its upper extremity, by a well-adjusted roller, as seen in Fig. 181 ; fix the instrument and secure the foot firmly by a number of strips of adhesive plaster. In applying the gypsum brace the foot, held at a right angle, is wound with plaster from the base of the nail of the great toe as far as the disease extends, and from above the ankle almost to the knee. The bracket is placed in position and bound down by repeated turns of the plastered bandage, taking care that the foot is still at right angles ; the whole is neatly covered with fresh bandage. If the case progress unfavorably, pus forms and makes its appearance at the inner or outer side of the joint. The treatment should now be changed. The pus should be evacuated by incision and the joint thoroughly examined. If the abscess does not communicate with the joint, the plaster bandage should be renewed, and a window should be cut in it over the opening, so as to allow the escape of pus and the use of proper dressings. If, however, the synovial membrane is pulpy and the cartilage disintegrated, the joints should be exposed and all injured tissues removed. Although arthrectomy does not usually succeed at the ankle as well as at the knee-joint, it is worthy of trial. The method of operating is not unlike that of excision. If the disease has also seriously damaged the bone, as well as the soft structures of the joint, excision must be performed. The operation is diffi- cult, and the results are not always favorable. The chief difficulty encoun- tered is the proper exposure of the parts to be removed without injuring im- portant structures. It is necessary to avoid dividing the tendons of the mus- cles of the legs, as well as the arteries and nerves. Methods of operating, therefore, which involve the incision of such structures should not be adopted. The operation which best preserves vessels, nerves, and tendons, as well as the periosteum, is by two longitudinal incisions, one over the external and the other over the internal malleolus, and extended above and below suf- ficiently to give free access to all of the diseased bone. All transverse in- cisions involving the vessels, nerves, and tendons should be avoided. The limb being turned on the inner side upon a firm pillow, make an incision two or three inches long (B, Fig. 182) on the middle of the fibula down to the Fig. 182. Excision of ankle ; outer surface (Treves). point of the malleolus, and sufficiently deep to divide the periosteum ; from the extremity of the malleolus continue the incision backward around the 572 LOCAL DISEASES. malleolus, an inch, merely through the skin, so as not to injure the tendons, and jet permit of their being raised from behind the malleolus ; at the point where the bone is to be divided separate the periosteum with the raspa- Fig. 183. Excision of ankle ; inner surface (Treves). torium, and turn down as much as circumstances will permit ; introduce the point of the index finger or a spatula into the interosseous space to protect the soft parts during the act of sawing ; incline the saw slightly toward the joint, so that the part to be removed will be external at the point of division ; seizing the upper extremity of the fragment with very strong forceps, separate its connections with the raspatorium and knife when necessary. Now turn the foot upon the external surface, and make the same straight incision as upon the fibula, and a transverse one at its lower end (B, Fig. 183) ; the periosteum is more easily separated than from the fibula ; saw the tibia in place with a fine-bladed saw. It may be possible, after the periosteum has been separated and the ligaments incised, to gradually dislo- Fig. 185. Fig. 184. Suspension-splint. J Leg suspended. cate the foot outward with the aid of the knife, and remove the tibia with the saw. To gain more complete access in many cases the incisions made along the centre of the malleoli may be extended laterally along the margins of the extremities of these bones. Or the same result may be attained by DISEASES OF THE JOINTS. 573 extending the incisions made along the posterior margins of the tibia and fibula around the lower and anterior margins of the malleoli (Figs. 182, 183). The after-treatment requires the protection of the ankle from movements, with free drainage. This is best effected by apparatus which allows suspen- sion of the limb. A convenient method of suspending the limb is as follows : Make a splint of wood or metal fitted to the anterior surface of the leg and ankle (Fig. 184), with rings inserted at three points for suspension ; in its application the splint is well padded and laid on the front part of the leg and the limb fixed in the ordinary bandage, the ankle being free (Fig. 185) ; or the gypsum bandage may be applied over the splint and around the leg, a layer of old flannel being first adapted to the leg and the ankle left exposed. The Tarsus. Synovitis of the tarsal joints occurs when the anterior part of the foot is caught and the leg is twisted by the movements of the body. This is a i: sprain of the foot."' The injury consists in the tearing of the ligaments of these joints and injuries to the synovial membranes. The tarsus swells quickly in the line of the injured joints, and is very painful on pressure and on moving the anterior portion of the foot. The treatment should be the same as that given for similar injuries of the ankle-joint — viz. absolute rest, hot water at first, followed by strap- ping or the plaster-of-Paris bandage. Tubercular disease of the tarsal joints and bones of children is always serious as regards the usefulness of the limb. When the tubercular infec- tion has once entered these structures, it spreads insidiously, and its progress is arrested with difficulty. Not infrequently it extends to the joints of most of the tarsal bones, and both bones and joints become involved in the destructive inflammation. The ankle-joint is also often invaded by a pri- mary tubercular disease of the tarsus. The symptoms develop after an injury, and at first consist of pain through the central part of the foot in walking, with swelling in the form of a puffiness over the tarsus. At this early stage the precise location may sometimes be defined with considerable accuracy by holding the heel firmly with one hand, while with the other the anterior part of the foot is moved in such manner as to compress the tarsal joints, with friction of their surfaces. The early treatment should be that of a sprain. But if suppuration occurs, a carefully-planned operation should be performed, having for its object the evacuation of pus and the removal of dead structures. Great care must be taken to avoid injuring tissues not affected, for the joints of the tarsus are so related that one may be curetted without injuring another. No special method of operation can be given, but, as a rule, it is important not to make a deep transverse incision which will divide the tendons of the muscles causing dorsal flexion of the foot. If any one of the dorsal bones is carious, it should be carefully dissected from its fellows, the cavity thoroughly cleansed and drained, and the foot supported in a plaster-of-Paris bandage, with openings that will allow the change of dressings. If the disease invade the tarsus so generally that partial excision would be satisfactory, the tarsal bones, excepting the calcaneum and astragalus, may be removed, and a fairly useful extremity may result. In this case the incision may be across the foot, dividing all the tissues down to the bone, for dorsal flexion of the foot will not be an important function. When tendons are thus divided, they should be reunited by sutures. The support of the foot can best be secured by a pasteboard splint applied to the posterior part of the leg and to the plantar surface. 574 LOCAL DISEASES. If the disease still progress, a Syme's amputation at the ankle-joint must be the operation of final resort. Excisions of the ankle for tubercular disease do not always progress favorably. The infection will sometimes escape the most thorough search, or there may be a renewed infection from foci pre- existing in the system. There is also in these cases a constant liability to infection with pyogenic microbes, owing to the susceptible tissues of stru- mous children. If suppuration continue freely, renewed efforts should be made to remove sources of septic matters. If, however, the disease continues to progress, it may finally be necessary to resort to amputation at the joint. The method of amputation which gives the most favorable results, both in the prompt recovery of the patient and in the adaptation of a stump for an artificial limb, is Syme's. PirogofTs method, which some recommend, has two disadvantages — viz., first, the fragment of bone taken from the os calcis is liable to necrose, owing to the failure of nutrition ; and, second, the stump is not as well adapted to an artificial foot, owing to the length of the limb, which brings the ankle-joint too near the surface for easy progression. Syme's amputation is as follows : Place the foot at a right angle to the leg ; enter the knife at the point of the external malleolus (B, Fig. 182), and carry it directly across the sole of the foot to a point opposite, or six lines below the internal malleolus (B, Fig. 183) ; the posterior tibial artery divides beneath the internal annular ligament into the internal and external plantar arteries, and if the incision extends to the point of the internal malleolus, the Fig. 186. Fig. 187. Syme's amputation of the foot : anterior incision and disarticulation. Syme's amputation of the foot : cleaning the os calcis. vessel may be divided ; join the two extremities of this incision by an anterior incision in a direct line over the instep, so that the cicatrix may come well in front (Fig. 186). In dissecting the posterior flap, place the fingers of the DISEASES OF THE JOINTS. 575 left hand upon the heel, and with the thumb press the edge of the flap firmly backward, cutting between the nail of the thumb and the tuberosity of the os calcis (Fig. 1ST), so as to avoid lacerating the soft parts ; the tendo Achillis is exposed and divided. Disarticulate the foot and saw off the malleoli, leave the articular extremity of the tibia uninjured, for it is better not to interfere with the bone if it is healthy. The Foot. In cases of disease or injuries which so involve the anterior part of the foot as to render amputation necessary, it is important to save the phalanges as far as possible. Of these it must be remembered that the great toe is the most useful in the act of walking. The spring and elasticity of the step of the patient depends more on this toe than on all the others taken together. This toe should not, therefore, be sacrificed if it is possible to preserve even a portion of the phalanx. While the other toes are comparatively less use- ful in the preservation of a good step, they are important in maintaining the proper breadth of foot. In amputating one or more phalanges the flap should be so constructed as to bring the plantar surface over the stump, so that this dense tissue will receive the pressure of the shoe, and the impact of the step when the foot strikes the ground. This operation requires a short dorsal and a long plantar flap, so formed that the cicatrix is on the dorsal surface rather than on the end of the stump. SECTION II. DISEASES OF THE CEREBROSPINAL SYSTEM. Diseases of the brain and spinal cord are less frequent than those of the respiratory and digestive systems, and, being less amenable to treatment, they largely increase the aggregate of deaths. They contrast with the diseases of the other systems in their greater relative frequency in infancy and childhood than in adult life. This is explained, as regards the brain, by the rapid devel- opment and active molecular change in this organ in early life, its great im- pressibility by the emotions, and the thinness of the covering which protects it from external agencies. Some of the most important of the diseases of the cerebro-spinal system are peculiar to early life, as tetanus infantum and spina bifida. The diseases of this system also contrast with other local affections in their greater obscur- ity, especially in their commencement ; for, while maladies of the thorax can be readily ascertained by auscultation and percussion, or those of the abdo- men by the nature of the evacuations or the degree of tenderness or disten- tion, our means of conducting examination through the bony encasement of the cerebro-spinal axis are meagre and unsatisfactory. The condition of the brain and spinal cord must be determined chiefly by the study of symptoms, and not by direct examination. The state of the anterior fontanelle in young in- fants, however, enables us to determine the presence or absence of active con- gestion of the brain. If there be an excess of arterial blood, it is convex. Prominence of the fontanelle is common in inflammatory and febrile diseases, and is a sign of considerable diagnostic and prognostic value. Within a few years the ophthalmoscope has been employed as a means of diagnosis in cerebral diseases, and, although the use of this instrument for such purposes is but recent, enough has been elicited to prove its value as an aid in determining the state of the brain. Prof. H. D. Noyes remarks on this subject: ". . . . The argument for making ophthalmoscopic examination in all cases of brain disease becomes irresistible. Indeed, a moment's reflec- tion would lead to this conclusion without any considerations drawn from pathology. The optic nerve is only an outlying portion of the brain ; its extremity is fully exposed to view. Situated within about two inches of the brain, it is the only nerve in the body which we can inspect ; it contains blood- vessels which communicate directly with the intracranial circulation. We thus come into relation with the cerebrum by continuity of nerve-structure and also of blood-vessels." Structural changes in the optic nerve and retina have been discovered by means of the ophthalmoscope in meningitis, hydrocephalus, phlebitis of the sinuses, apoplexy, etc. Among the lesions which have been observed by this instrument are hyperemia, more or less opacity and tumefaction of the optic nerve, engorgement of the vessels of the retina, with serous or sero-fibrinous exudation and ecchymotic points. In certain protracted diseases, as chronic hydrocephalus, in which dimness or loss of sight occurs, the ophthalmoscope discloses a state of atrophy of the optic nerve. Heretofore this instrument has been chiefly employed by oculists, but as it comes into more general use DISEASES OF THE CEREBROSPINAL SYSTEM. 577 there can be little doubt that it will be recognized as an important aid in the diagnosis of obscure cerebral diseases. Still, with all possible aid to diagnosis, the obscurity which attends the invasion of many of the cerebro-spinal diseases must be acknowledged. To the hasty and careless physician their symptoms are often deceptive. Careful weighing of the phenomena and thorough and protracted examination are requisite in order to ensure correct diagnosis and proper treatment. Some of the cerebro-spinal affections are, in reality, sequelae of other diseases — as, for example, spurious hydrocephalus — and some are, strictly speaking, only symptoms, as convulsions ; but on account of their importance, and because they require special treatment, it is proper to consider them as diseases per se. The brain presents certain peculiarities in infancy and childhood. In the foetus, while the other organs are well formed, the brain, especially its cerebral portion, is still diffluent, and at birth it has so little consistence that it must be handled carefully to prevent laceration. This softness is due to the large proportion of water which it contains. The following analyses show the com- position of the brain in three periods of life : Infant. Youth. Adult. Albumen 7.00 10.20 9.40 Cerebral fats 3.45 5.30 6.10 Phosphorus 0.80 1.65 1.80 Osmazome, salts 5.96 8.59 10.19 Water 82.79 74.26 72.51 At birth the brain has a nearly uniform white color. The gray substance, in which the nervous power originates, is undeveloped. The date of its ap- pearance corresponds with the first exhibition of emotion or intelligence, and the decided gray color which we observe in the brain of the adult does not appear until the age of full mental activity. In the new-born the brain is large in proportion to the rest of the body, and its growth during infancy and childhood is rapid. Until the fifth year, as appears from the observations of Dr. Peacock, its weight is about one- seventh or one-eighth that of the entire system, the proportion varying some- what in different cases. The brain does not attain its full size, as stated by Dr. West, at the age of seven years, but, according to Dr. Peacock's statistics, it continues to increase till the age of twenty-five or thirty, although its growth is less rapid after the age of seven years than previously. The membranous covering of the cerebro-spinal axis is scarcely less inter- esting to the pathologist than the axis itself. I shall speak in the follow- ing pages of the arachnoid and cavity of the arachnoid for convenience of description, although aware of the fact that some eminent authorities, as Virchow and Kolliker, whose opinions in reference to the minute anatomy of the system always command attention, if not assent, believe that there is no arachnoid, but what has heretofore been called by this name is on the one side the smooth surface of the dura mater and on the other of the pia mater. The dura mater is seldom involved in the diseases of early life, except as it is affected by pressure, while the pia mater and arachnoid are the seat and source of some of the most important diseases, as meningitis, meningeal apoplexy, etc. The more complicated and delicate the structure of an organ, the more liable it is to errors of nutrition and growth. There is, therefore, no organ which is so liable to irregular development as the brain. It may be entirely wanting or it may be partially developed, certain portions being absent, or, lastly, its growth may be excessive, constituting hypertrophy. 37 578 LOCAL DISEASES. CHAPTER I. CONGESTION OF THE BRAIN. Congestion of the brain is not peculiar to infancy and childhood, but it is much more common in these periods of life than subsequently. This is due, in a great measure, to the fact that in the young the circulation is more readily disturbed by moral as well as physical causes than in the adult. Congestion of the brain is occasionally primary ; more frequently it occurs as a concomitant or sequel of some other affection. Diseases, whether con- stitutional or local, which in the adult have no appreciable effect on the vas- cularity of the brain often cause in the child a decided increase of blood in this organ. Causes. — Cerebral congestion is of two kinds, active and passive. The former results from a cause which directly affects the brain and increases the flow of blood toward it, or from a cause operating primarily on the heart and increasing the frequency and force of its systolic movement ; the latter is due to some obstruction in the course of the circulation or to feeble propel- ling power on the part of the heart. Among the causes which most frequently produce active congestion of the brain in the child may be mentioned blows or falls on the head, excessive fatigue or excitement, heat, dentition, and also various inflammatory and febrile affections, especially in their first stages. Cerebral symptoms occurring in the course of an essential fever are no doubt often due, in a great measure, to the irritating effect on the brain of the specific principle, whatever it may be, circulating in the blood. Occur- ring in inflammatory diseases which are located elsewhere than within the cranium, they are often attributed to functional disturbance of the brain. But observations show that symptoms referable to the brain, arising in the commencement of the essential fevers and of the phlegmasia, are in many instances preceded by, and are therefore doubtless in greater or less degree dependent on, hypersemia of this organ. Difficult as it is to ascertain the state of the brain in many diseases in which it is involved, we may determine whether or not there be congestion in the young child by observing the anterior fontanelle. If it be elevated and tense in an acute disease, hyperemia is indicated. Now, it is often unusu- ally prominent in fevers and inflammations, especially in their first stages. when cerebral symptoms are present. Its elevation, under such circum- stances, is obviously coincident with cerebral congestion. The acute inflammations which are most likely to be attended by cerebral congestion are those of the mucous surfaces and pneumonia. Severe coryza, tracheo-bronchitis, entero-colitis, and colitis, commencing suddenly with great febrile excitement, are frequently accompanied in their initial stage by active congestion of the cerebral vessels. Cases like the following, which I find in my note-book, are not infrequent : An infant, four months old, had been sick about two days with coryza and bronchitis when I was called to see it; the pulse numbered 156, respiration 64; it took the breast, but was restless : cough frequent and dry : bowels moderately relaxed. The mucous membrane of the fauces was injected, and coarse mucous rales were present in the chest. The anterior fontanelle rose above the level of the cranium and pulsated forcibly. Soon after convulsions occurred, which were relieved by appropriate measures, and on the following day the fontanelle had subsided. The patient gradually recovered without any untoward symptom. CONGESTION OF THE BRAIN. 579 Cerebral congestion and convulsions often mark the initial stage of active intestinal phlegmasia. This is especially true of dysentery. The little patient, perhaps from the very inception of the colitis, is drowsy ; its surface is hot ; pulse full and rapid. There is sudden and momentary starting or twitching of the limbs. The anterior fontanelle, if still open, is elevated, and it is not till the lapse of several hours that the cause of these symptoms is apparent from the occurrence of bloody stools. The causes of passive congestion of the brain are very different from those of the active form. A common cause is obstruction in a sinus or vein by a fibrinous concretion or by a tumor or abscess external to it. I have occasionally met cases in which this form of cerebral congestion appeared to be plainly referable to obstruction to the return of blood from the brain by the pressure of bronchial glands, enlarged by hyperplasia in tubercular disease, these bodies diminishing by external pressure the calibre of the venge innominatae or the descending vena cava. Rilliet and Barthez have called attention to such cases in the clinical history of tuberculosis. The following case may be cited as an example ; it occurred in the infants' service of the New York Charity Hospital : An infant, about one year old, affected with tuberculosis, both bronchial and pulmonary, was observed during the ten days preceding its death to bore the pillow with its head almost constantly, so as to wear the hair from the occiput. The movement of the head was the only prominent cerebral symp- tom. Nothing abnormal was noticed in the appearance of the eyes, nor was the stomach irritable. A spasmodic cough and progressive emaciation attracted attention, but these were referable to the tubercular disease. At the autopsy we found the cerebral sinuses, veins, and capillaries greatly con- gested. On tracing the veins which return blood from the brain, an inflamed and enlarged bronchial gland was discovered in the angle formed by the con- vergence of the right and left venas innominatae. This gland, which con- tained but a single point of cheesy degeneration, had attained such a volume by proliferation of its cells that it pressed upon both vessels, so that it had obviously retarded the circulation in each and given rise to cerebral conges- tion of the passive form. Passive congestion often occurs in the infant at birth, either from tedious- ness of the labor or delay in the expulsion of the body after the birth of the head. If it be simple congestion, and not congestion with hemorrhage, it soon passes off. Passive congestion of the brain also occurs in severe parox- ysms of whooping cough, in which return of blood from this organ is tem- porarily retarded. All are familiar with the congestion which occurs in parts external to the cranium from the severity of the cough, producing epistaxis, extravasations under the conjunctiva, etc. The extracranial con- gestion obviously indicates the presence and degree of congestion within the cranium. Those who practise in malarious regions sometimes meet cases of danger- ous passive congestion of the brain, the result of malaria, occurring especially in the cold state of intermittent fever. In these cases the surface is pallid, its temperature reduced, and the pulse feeble. The blood, leaving the pe- ripheral vessels, collects in undue quantity in the internal organs, producing congestion of the brain as well as of the thoracic and abdominal viscera. In the child with malarial disease, in whom there is less vigor of constitution than in the adult, death sometimes results from this passive congestion. Two such cases have occurred in my practice, although in this latitude the malarial maladies are mild in comparison with the type which they present in many parts of the United States. Symptoms. — The symptoms of active congestion of the brain are stupor, 580 LOCAL DISEASES. heat of head and headache, throbbing of carotids, restlessness when aroused, twitching of the limbs, and perhaps convulsions. There is also sometimes intolerance of light, and the anterior fontanelle. if open, pulsates strongly. In passive congestion many of the symptoms are the same as in the active form. Stupor, twitching of the limbs, and fretfulness or irritability when the patient is disturbed are common, ordinarily without increase of temperature : the surface may indeed be cool, and the face is not flushed nor the eyes injected. The strong pulsation and elevation of the anterior fontanelle, so conspicuous in active congestion, are — the former always, the latter often — lacking. In both acute and passive cerebral congestion, constipation is a common symptom. In many cases the symptoms of congestion of the brain are associated with others which proceed directly from the cause of the congestion, but it is not difficult, unless in exceptional instances, to determine which are due to the congestion and which to the antecedent and coexisting pathological state. Anatomical Characters. — In active congestion there is an excess of arterial blood in the brain and its membranes. The arteries, to their minutest branches, are seen to be full, presenting the bright hue of oxygenated blood. In passive congestion the sinuses and veins are distended. The pia mater. choroid plexus, and the vessels of the brain have a darker appearance than in active congestion. In both forms of congestion, unless they quickly abate, other anatomical changes soon occur. If there be great distention of the capillaries, these vessels are liable to give way. and we find here and there little patches of extravasated blood. In other cases the over-distention is relieved by the transudation of the serous portion of the blood through the coats of the vessels. The cephalo-raehiclian fluid is then found in excess external to the brain and in the ventricles. Prognosis. — The duration and the result of congestion of the brain depend, in great measure, on the nature of the cause. If the cause be trivial, as mental excitement, fatigue, exposure to heat, there is usually prompt relief if the condition of the patient be understood and properly treated. If the cause be general or constitutional, as one of the essential fevers or whooping cough, or if it be local, but its seat external to the cranium, the prognosis, so far as the congestion is concerned, is not unfavor- able if there be a timely and judicious use of remedies. The most unfavor- able cases are those in which the cause is seated in the encephalon and those in which there is some obstructive disease in the course of the circulation. Congestion occurring from a structural change within the cranium is. from the nature of the cause, without remedy and ordinarily fatal. Obstructive diseases of the circulatory system, wherever located, being for the most part permanent, give rise, as a rule, to incurable congestion. Congestion of the brain, if it be not relieved in a few hours, becomes less and less amenable to treatment. It soon passes beyond the resources of our art and ends in coma : it is seldom protracted beyond a few days. Extrav- asations of blood, common in active congestion, and serous effusion, common in the passive form, diminish the chances of a favorable result. Treatment. — The indication for treatment in active congestion is plain. Measures should be employed which produce derivation from the brain. Unless there be an asthenic primary affection, in the course of which the congestion is developed, active purgation is required. A saline purgative is ordinarily preferable. If the stomach be irritable, there is no better purga- tive than calomel. In all cases of active congestion, whatever the cause, the bowels should be kept open. It is often better not to wait for the tardy action of a cathartic, but to give at once an enema of soap and water or salt and water. External derivative agents are also indicated. A warm mustard INTRACRANIAL HEMORRHAGE. 581 foot-bath, sinapisms to the back of the neck or chest and to the feet, and cold applications to the head, are measures which should never be neglected. In many cases those medicines are useful which reduce the contractile power of the heart, as phenacetin. This treatment, if employed early, will relieve the congestion in a large proportion of cases ; but if there be no improvement and if the child be robust, an ice-cap should be constantly applied to the head. If after the lapse of some hours cerebral symptoms continue, sanguineous or serous effu- sion has probably occurred. The treatment appropriate for passive congestion is somewhat different : cold applications to the head and those of a derivative nature to the extremi- ties are useful. As this form of the disease is not primary, but is dependent on some antecedent pathological state, it is evident that it can only be treated successfully by removing or obviating the cause as far as possible. But the nature of the various obstructions to the intracranial circulation is such that our ability to accomplish this end is very limited. If the cause be constitutional, or if it be some disease in the neck or chest, it may sometimes be partially or even wholly removed, but if seated within the cranium it is beyond our control. In general, it may be said that depletion is not required or tolerated in passive congestion, and stimulants are often needed. CHAPTER II. INTEACEANIAL HEMORRHAGE (MENINGEAL HEMOEEHAGE, CEEEBEAL HEMOEEHAGE). Hemorrhage within the cranium is not very infrequent in infancy and childhood, and there is no part of the encephalon, whether the meninges or brain, in which it does not sometimes occur. If the blood be extravasated upon the surface of the brain or between the meninges, the disease is des- ignated by writers meningeal apoplexy ; if in the substance of the brain, cerebral apoplexy. Extravasation may also occur in one of the lateral ventricles. Causes. — Apoplexy is usually (there is an exception) preceded by con- gestion. If the congestion increase to a certain degree, the distended capil- laries give way and extravasation of blood results. Therefore the causes of congestion which have been enumerated in the preceding chapter are, in great measure, those of apoplexy. Microscopic examinations have demonstrated that the corpuscular elements of the blood may escape from capillaries with- out rupture. While, therefore, it is probable that intracranial hemorrhage in early life commonly occurs from rupture, its occasional occurrence by diapedesis, or escape of blood through the walls of the capillaries, must be admitted. Intracranial hemorrhage is not infrequent in the new-born. It results in them from tediousness of the birth and severity of the labor-pains. At first there is extreme congestion of the meningeal and cerebral vessels, correspond- ing with that of the scalp and face. This congestion, continuing, soon ends in extravasation of blood. In some of these cases forceps have been used to effect the delivery, but it is doubtful whether the use of instruments mate- rially increases the congestion or the amount of extravasation. Certainly, in a large proportion of intracranial as well as supracranial hemorrhages of the 582 LOCAL DISEASES. new-born, instruments have not been used. An additional cause of the hem- orrhage is, in some instances, the use of ergot, which, by producing strong and continuous labor-pains, interrupts the placental circulation and increases the congestion of the foetal veins and capillaries. In infants a few days old intracranial hemorrhage may result from that rapid and fatal disease, tetanus infantum. The hemorrhage is preceded by intense passive congestion, which the tetanic rigidity and spasms produce by obstructing respiration and circulation. Few cases of tetanus infantum occur without more or less extravasation of blood, either meningeal or cerebral. Another cause of this disease is obstruction in the vessels which return the blood from the brain. The various structural changes which produce this obstruction in different cases have been sufficiently described in our remarks on cerebral congestion. The congestion which precedes hemorrhage, when occurring under the conditions described above, is passive. Among the causes which produce hemorrhage through the intermediate state of active congestion may be mentioned great mental excitement, of which M. Legendre relates a case, and lengthened exposure to the sun's rays, an example of which Eilliet and Barthez have seen. It is also said that compression of the aorta by an enlarged liver or an abdominal tumor has sometimes produced meningeal or cerebral hemorrhage by causing an increased afflux of blood to the head. A very important cause of cerebral or menin- geal hemorrhage to which I have not alluded is that general state of the circulatory system which is designated by the term purpura hemorrhagica. This sometimes results from the antihygienic conditions in which the child is placed. In other instances it results from some antecedent disease, pro- tracted and debilitating, which has produced a profound alteration in the state of the blood and the vessels. The capillaries become less firm and elastic and easily give way, so that in such patients ecchymotic points are ordinarily found in different parts of the system. The diseases which occa- sionally end in this hemorrhagic diathesis are numerous. I have known it to occur after measles, scarlet fever, and smallpox. It is also an occasional sequel of chronic diarrhoea or intermittent and typhoid fevers, and of rachitis. Anatomical Characters. — Hemorrhage in or upon the brain in infancy and childhood differs in important particulars from that occurring in adult life. In the adult, and more so as life advances, the arteries become less distensible and more brittle, so that when hemorrhage occurs it is usually from one of these vessels. In early life, on the other hand, the blood does not ordinarily escape from an artery, but, as has been stated, from the capil- laries. The extravasation is not, therefore, so rapid and violent, and is not attended by such laceration and injury of surrounding parts in infancy and childhood as at a subsequent age. In the adult the hemorrhage commonly occurs in the substance of the brain. The flow of blood from the ruptured artery separates the brain-substance, producing a cavity in which a clot forms. This constitutes the usual form of apoplexy in the adult. In the first years of life, on the contrary, the extravasation is commonly from the meninges, and the symptoms to which the effused fluid gives rise are for the most part due to its mechanical effect. Cases of hemorrhage in the sub- stance of the brain constitute a small minority, unless during the days imme- diately succeeding birth. In early life, therefore, on account of its greater frequency, meningeal hemorrhage is a disease of more importance than cere- bral, and its anatomical character should be carefully studied. In meningeal hemorrhage the extravasation may be between the cra- nium and dura mater, upon the visceral layer of the arachnoid, in the meshes INTRACRANIAL HEMORRHAGE. 583 of the pia mater, or in a lateral ventricle from rupture of the capillaries in the choroid plexus. Much the most common seat is external to the pia mater in the so-called cavity of the arachnoid ; the blood escaping in this situation spreads uniformly in all directions. It soon separates into two por- tions, the solid and liquid. The solid portion, or the clot, is free or but slightly attached to the adjacent membrane. The meninges in the vicinity of the extravasated blood preserve their normal appearance or are but slightly injected; the clot gradually becomes extended on all sides, so as to form a lamina at the seat of the extravasation, thinner at its circumference than centre, and at first of a dark -red color. The color gradually fades, and the lamina, becoming smooth and polished and at the same time more and more attenuated, finally resembles the arachnoid in appearance. Its diameter varies in different cases from a few lines to two or three or more inches. M. Tonnele relates two observations in which the adventitious membrane extended over the superior surface of both hemispheres, and in one of them also over the falx cerebri. The extravasation may occur at any part of the surface of the brain, but its usual seat is the vertex. The next most frequent locality is the base of the brain. The subsequent history of the delicate membrane into which the clot is gradually transformed is interesting. It often extends so as to cover more space than was occupied by the extravasated blood, and its edges are then scarcely distinguishable, in consequence of their extreme tenuity and their close resemblance to the arachnoid. The attachments of this mem- brane, so far as it forms any, are usually to the parietal surface of the arach- noid. Sometimes a portion of the membrane is attached, while the rest lies free, bathed on either side by the liquid portion of the blood which still remains from the extravasation. According to M. Legendre, in the most favorable cases the serum is absorbed, and the membrane which has resulted from the clot, and which I have described, becomes intimately adherent to the internal surface of the dura mater. It forms an integral part of this membrane, and there only remain a little thickening and increased opacity, indicating the seat of the extravasation. The health is fully re-established. But the result in other cases is as follows : The serum is not absorbed, and the newly-formed membrane, uniting at points with the inner surface of the dura mater or its arachnoidal covering, encloses the fluid so as to produce a circumscribed hydrocephalus. Sometimes there is only one cyst ; in other instances the membrane, especially if large, unites in such a way as to give rise to more cysts than one. The size of the cyst varies according to the quantity of fluid, which may be only a few drachms or several ounces. Rilliet and Barthez report a case in which there was a pint of fluid lying over each hemisphere, there being two cysts. If the cranial bones are not united, so that they yield to the pressure, the size of the cranium is increased, and if the extravasation be confined to one side, an inequality results and the symmetry of the head is destroyed. The fluid which causes the enlargement of the head in such cases is in part the serum of the extravasated blood and in part a subsequent secretion. Various writers relate cases of ventricular hemorrhage. Valleix met it in an infant that died at the age of two days. In the Edinburgh Journal of Medicine and Surgery, October, 1831, an interesting case is related. A boy, nine years old, died of hemorrhage in both ventricles, and also at the base of the brain and in the spinal canal. In the Nursery and Child's Hos- pital of this city the post-mortem examination was made of an infant who died at the age of one month. In the posterior cornu of the left lateral ventricle were two clots, elongated and black, one larger than the other. In 584 LOCAL DISEASES. the corresponding cornu on the opposite side was a smaller clot. A similar post-mortem appearance was observed at the autopsy of a young infant that died in Charity Hospital. A dark crescentic clot lay in each posterior cornu. The clot, if remaining a long time, undergoes degeneration. In the case of an adult in which a year had elapsed after the extravasation I found it to contain crystals of cholesterin and carbonate of lime. Cerebral hemorrhage, or hemorrhage in the substance of the brain, may occur at any time in infancy and childhood. The blood is sometimes extrav- asated in points here and there over the entire organ or a part of the organ ; in other cases it is extravasated in one or perhaps two cavities, as in the ordi- nary form of apoplexy in the adult. In the first form of cerebral hemorrhage, or that in which the blood escapes from numerous points through the brain, there is evidently little laceration or injury of the organ. The brain-sub- stance surrounding the hemorrhagic points sometimes preserves the usual appearance. It is white and firm. In other cases it presents a reddish or yellowish appearance, and is softened to the depth of a line or two. If the hemorrhage occur in a cavity, as in apoplexy of adults, the nerve-fibres are evidently torn and separated and there is more or less compression of the surrounding brain-substance. Unless the disease be of long standing, the cavity contains a dark and soft clot bathed with serum which has a reddish or a yellowish-red appearance. The brain in the immediate vicinity of the cavity is sometimes softened. Rilliet and Barthez state that they have seen 8 cases of cerebral hemorrhage of the capillary form ; 10 cases in which the hemorrhage was in cavities ; and in 2 of the 18 both forms were present. In 5 of those in which the form was capillary the disease was limited to portions of the brain, while in the remaining 3 the hemorrhagic points were found in nearly every part of the brain. Apoplectic cavities are seldom seen in the cerebellum, and, whether the hemorrhage be capillary or in a cavity, there is in most cases, as previously stated, more or less congestion of the vessels of the brain. The proportion of cases of cerebral to other forms of hemorrhage is be- lieved by some to be greater in the new-born than at any other period of life. Valleix relates 4 cases of intracranial hemorrhage occurring at this age, 2 of which were cerebral, 1 ventricular, and in the other the extravasation was in the cavity of the arachnoid. Mignot has published 8 cases occurring in the new-born, in 2 of which the hemorrhage was in cavities in the cerebrum ; in 3, in the lateral ventricles ; and in 3, external to the brain. If the same proportion be observed in other statistics, 1 in 3 of the cases of intracranial hemorrhage occurring in the new-born is cerebral. Symptoms. — The symptoms in intracranial hemorrhage are not uniform ; they vary according to the seat as well as the quantity of the effused blood. In some cases the extravasation occurs without such symptoms as would direct attention to the brain. When the hemorrhage occurs at the time of birth in consequence of strong and long-continued labor-pains, the infant is often born apparently dead. This is due partly to the hemorrhage, partly to the great congestion of the brain which precedes and accompanies the hemor- rhage. Resuscitation is gradual and difficult. The infant's features are livid and perhaps swollen ; its respiration is gasping, and both pulse and respira- tion are slow. Its cry is feeble, with but slight movement of the facial mus- cles, and the lungs are but partially inflated ; the eyelids are closed and the limbs almost motionless. By artificial respiration and by friction the pulse and breathing may be rendered more frequent, but the latter remains irreg- ular and gasping. Finally, the limbs grow cold, the surface, from a state of lividity, becomes pallid, and death occurs in profound coma. M. Cruveilhier made many observations at the Maternite in reference to the death of new- IXTBACBAXIAL HEMORRHAGE. 585 born infants, and he believes that one-third of those who die in birth at the full period die of apoplexy. I have made post-mortem examinations in a few cases when death had occurred from this cause, and in all the hemorrhage was meningeal. One of these was born on the 30th of December, 1864. The birth was delayed by unusual projection of the promontory of the sacrum, so that finally the application of forceps was necessary. The infant was ap- parently stillborn, but by persistent efforts on the part of the physician who assisted it was resuscitated so as to live several hours, though with constant embarrassment of respiration and with lividity. At the autopsy a large ex- travasation of blood was found in the cavity of the arachnoid over a consid- erable part of the convexity of the brain, and the substance of the brain was deeply congested. Apoplexy in the new-born does not always terminate fatally, or, when fatal, in the sudden manner which I have described. Valleix relates the case of an infant who died of pneumonia at the age of three and a half months. Its birth had been protracted and difficult, but was completed with- out the use of instruments. It had had during its entire life paralysis of the right side. At the autopsy a clot was found near the base of the right thal- amus opticus, evidently existing from birth. Around the clot the brain was softened to the depth of some lines and was of a bluish-red color. A very similar case is related by M. Vernois. An infant lived forty-nine days with paralysis of the left side, and died of pneumonia. At the autopsy a hemor- rhagic excavation in process of cicatrization was found behind the right corpus striatum and the thalamus opticus. Intracranial hemorrhage occurring from accidents of birth is generally attended by marked symptoms, such as have been described. But when it occurs subsequently to birth, whether in infancy or childhood, the symptoms vary greatly in different cases and are generally obscure. I will briefly state the symptoms which have been observed in both the cerebral and meningeal forms of this disease. First, the cerebral. Sedillot relates the case of a child seven and a half years old whose bare head had been exposed several hours to the sun's rays. Suddenly, after a paroxysm of anger, it was seized with great pain, corresponding with the posterior and inferior fossae of the cranium. It uttered piercing cries and died in a quarter of an hour. A clot was found in the right lobe of the cerebellum. Richard Quinn (Rilliet and Barthez) gives the history of a boy, nine years old, who in playing with a hoop sud- denly stopped, carried his hands to his head, and fell backward unconscious. Three or four hours afterward, when examined, he was found pallid, surface cool, respiration slow and at times stertorous, pulse 50 to 60 per minute ; the left arm was flexed, the left leg paralyzed ; the right leg and arm con- vulsed ; right pupil strongly dilated, the left contracted. He died seven hours after the commencement of the attack, and a large clot was found in the centrum ovale on the right side. Rilliet and Barthez relate the following case from Campbell : A boy with good previous health was suddenly seized about 7 A. M. with repeated vomiting, followed in an hour and a half by violent convulsions ; he rolled his eyes and uttered inarticulate cries ; pulse frequent and hard ; pupils contracted ; trunk and lower extremities cool. In the afternoon he presented symptoms of com- pression of the brain, such as dilatation of the pupils, frequent and feeble pulse. Death occurred in the evening, and a hemorrhagic cavity was found occupying the right middle lobe of the cerebrum. Guibert relates a case of extravasation in the superior part of the right hemisphere of the brain in a boy fourteen years old. The principal symptoms were feebleness of the limbs, inability to walk, cephalalgia, involuntary evacuations, fever, grinding the teeth, rigors severe and prolonged, lividity, loss of intellectual faculties, dila- 586 LOCAL DISEASES. tation of the pupils, insensibility to light, stertorous respiration. Death oc- curred in about an hour. Rilliet and Barthez narrate the history of a girl two years old who, after an attack of measles, was taken with convulsions accompanied with fever and prostration. The convulsive movements affected especially the eyes and upper extremities ; the right leg was immovable ; the left pupil dilated. These symptoms resulted from hemorrhage in the corpus striatum and opticus thal- amus. The same authors relate also the case of a girl seven years old who died with a large apoplectic cavity in the left thalamus opticus. The symp- toms were headache, convulsive movements, loss of consciousness, delirium, vomiting, constipation, and convergent strabismus. The symptoms nearly dis- appeared, but in a few days the headache returned, with strabismus and a slight drawing of the face toward the left ; on the twenty-seventh day con- vulsive movements of the right eye were observed, with paralysis of the arm. Finally, contraction of the arms occurred, with acceleration of pulse, irregular breathing, dilated pupils, paralysis, and retraction of the head, followed by death on the forty-eighth day. These cases, and those from Valleix and Vernois which have been related in our remarks on hemorrhage of the new-born, are sufficient to show the character of the symptoms in that form of cerebral hemorrhage m which the extravasated blood forms a cavity in the interior of the brain. If the amount of extravasation be large and the substance of the brain be much lacerated and compressed, death may occur almost immediately, and therefore without symptoms, or before it is possible to determine whether or not symptoms are present. If the disease be not so speedily fatal, the symp- toms, as appears from the above cases, are headache, confusion of thought, or even insensibility ; cries, sometimes piercing ; cold extremities, pallor, slow and perhaps stertorous respiration ; convulsive movements followed by paral- ysis, or convulsions affecting one or more limbs, with paralysis of others ; pupils contracted or dilated, sometimes one contracted and the other dilated ; stra- bismus, rolling of eyes, vomiting. These symptoms have all been observed in different cases, but they are not all present in any one case. Those which are generally present, and on which we mainly rely for diagnosis, are headache, convulsive movements, paralysis,, confusion of thought, irregularity in the pupils, and strabismus. In the capillary form of cerebral hemorrhage there is usually some com- plication, so that it is not easy to determine how far symptoms are due to the hemorrhage and how far to the coexisting pathological state. There are, indeed, but few published observations of hemorrhage in the substance of the brain unaccompanied with meningeal hemorrhage, hemor- rhage into a ventricle, or some other distinct disease ; but, so far as I have been able to ascertain the symptoms referable to this form of extravasation, they are as follows : The child is drowsy ; fretful when disturbed ; it perhaps moans. There are sometimes slight convulsive movements and partial paralysis. If there be considerable extravasation, the respiration is irregular and sighing. Death occurs in coma, occasionally preceded by convulsions. Taupin relates the case of a child, nine years old, who died with this form of hemorrhage, accompanied by softening of the brain. The disease began at night with delir- ium, agitation, and piercing cries. In the morning the patient lay in bed, drowsy, not complaining of pain and not replying to questions ; pupils dilated and insensible to light ; left eye half open during sleep and its axis changed ; eyebrows contracted ; face pale ; mouth open ; had no convulsions, but tran- sient stiffening of the limbs, during which the thumbs were firmly compressed by the fingers; senses unimpaired, but the face drawn to the right : deglu- tition difficult ; pulse small, irregular, and feeble ; respiration 32, sighing. In INTRACRANIAL HEMORRHAGE. 587 the evening he had rigidity of the limbs and back, and finally was taken with general convulsions, in which he died at eleven o'clock. The hemorrhagic points in this case were numerous. A boy five years old, whose case is de- scribed by Rilliet and Barthez, died of this disease, pneumonia, and white softening of the intestine. During the last five days there were cerebral symp- toms, the chief of which were drowsiness, fretfulness when disturbed, and moaning without apparent cause. Another child, whose case is described by Rilliet and Barthez. died at the age of four years with cerebral capillary hem- orrhage, accompanied hy yellow softening. Six months before death he had general convulsions, followed by spasmodic movements of the left side. These subsided, but the left side remained feeble. In meningeal hemorrhage there are often convulsions, general or par- tial—in some patients tonic, in others clonic. When partial, the convulsive movements may only occur in the muscles of the face and eyes. With the spasmodic muscular action is a degree of drowsiness with irritability. Paral- ysis, so common in the apoplexy of the adult, and not infrequent, as we have seen, in the cerebral form in early life, is sometimes, but not ordinarily, pres- ent in meningeal hemorrhage. Instead of paralysis, there are vomiting, some febrile action, thirst, and loss of appetite. The symptoms are different, how- ever, according to the exact seat of the hemorrhagic extravasation and the duration of the disease. If the extravasation end in the formation of a cyst, the symptoms are those of hydrocephalus. The following condensed history of cases which I have selected as typical will give us a clearer idea of the his- tory and course of the various forms of meningeal hemorrhage than can be imparted by a narration of symptoms : 31. Tonnele relates the case of a child which was taken with faintness and convulsive movements. On the following day the trunk and inferior extrem- ities became rigid ; deglutition was painful ; the pupils were largely dilated, immovable ; face pale ; pulse feeble and intermittent. Death occurred the same day. The dura mater was distended. A layer of coagulated blood of great thickness extended over the convexity of each hemisphere. The veins ramifying into the superior portion of the cerebrum were distended with coag- ulated blood. The hemorrhage was in the meshes of the pia mater. Drs. Lombard and Pane-hard of Geneva relate a somewhat similar case. A child thirteen months old was convalescing from inflammation of the bronchial and intestinal mucous surfaces when it was seized with general convulsions ; the mouth and eyes were open and the eyes directed upward ; pupils contracted ; pulse frequent and irregular. The convulsions abated somewhat, but soon reappeared with violence. The patient became insensible, and died nineteen hours after the commencement of cerebral symptoms. The extravasated blood covered the upper surface of both hemispheres. From the above cases we see the symptoms and the course of meningeal hemorrhage when the extrava- sation is so large that death speedily results. In protracted cases of menin- geal hemorrhage there is either a gradual disappearance of symptoms and return to health, or, circumscribed hydrocephalus occurring, the symptoms of that disease arise. Diagnosis. — It is evident, from what has been stated, that the diagnosis of intracranial hemorrhage is attended with unusual difficulty, since the symptoms of this disease occur also in other and distinct pathological states. The history of the case, and especially the character of the cause, if ascer- tained, will aid in diagnosis. If there have been an obvious determination of blood to the brain or some known obstruction to the return of blood from that organ, the persistence of cerebral symptoms would justify us in con- cluding that either serous or sanguineous effusion had supervened on a state of congestion. The points of differential diagnosis between apoplexy and 588 LOCAL DISEASES. meningitis are the sudden and full development of symptoms in one case, the gradual commencement and gradual increase of symptoms in the other; differences also of symptoms in certain respects ; for example, as regards fever, constipation, etc. There is one symptom in cerebral hemorrhage which is of great diagnostic value — namely, paralysis. Its presence affords strong evidence that there is extravasation of blood, and probably in a cavity of the substance of the brain. If the extravasation end in the formation of a cyst, the symptoms and appear- ance of hydrocephalus, which after a time arise, throw light on the nature of the disease. Prognosis. — There can be no doubt that many cases of intracranial hemorrhage occur and terminate favorably without the nature of the disease being suspected. In such cases the amount of extravasated blood is small or moderate. In several published cases in which the accuracy of the diag- nosis was shown by post-mortem examinations, the patients were convalescing from the hemorrhage when they succumbed to intercurrent disease. If, however, the amount of extravasated blood be such as to give rise to those symptoms which have been described, the prognosis is unfavorable. Recur- ring convulsions and persistent stupor from which it is difficult to arouse the patient are unfavorable symptoms. If the convulsions cease and conscious- ness return, even if there be paralysis, the result may be favorable, Treat3IENT. — The proper treatment in intracranial hemorrhage depends on the state of the patient, the time which has elapsed since the extravasa- tion, and the degree of it as shown by the nature and severity of the symp- toms. If, as is often the case, the patient be robust and be visited soon after the commencement of the attack, cold applications should be made to the head, mustard to the back of the neck and perhaps chest, and derivation should be produced by mustard pediluvia. In active congestion prompt pur- gation by salines or other cathartics is sometimes of great importance. The object of such treatment is to relieve congestion of the cerebral and meningeal vessels, and thereby prevent further extravasation of blood. If the conges- tion be active, the pulse continue full and frequent, and the face be flushed, it is proper in many cases to control the action of the heart by a sedative. For this purpose the tincture of aconite-root may be given in doses of one drop to a child five years old, repeated in three hours, or a more prompt sedative, as phenacetin, may be given. If the stupor or convulsions continue after sufficient time have elapsed for the patient to receive the full benefit of the above remedies, more counter-irritation is required. Cantharidal col- lodion should be applied behind each ear. If the hemorrhage occur from passive congestion or in a cachectic state of system, active depressing reme- dies should not be employed. External derivatives are of service, as well as cool applications to the head, and we should attempt, as far as possible, to remove the cause of the congestion and hemorrhage. If it depend on a cachectic state, tonic or other remedies calculated to relieve this state are indicated. The hemorrhage from such a cause is usually in points in the substance of the brain or in moderate quantity over the surface of this organ, and by a timely use of constitutional remedies possibly we may prevent further extravasation of blood and increase the chance of the patient's recovery. If a cyst result from the hemorrhagic effusion, the treatment which is proper is that described in the chapter on Acquired Hydrocephalus. CONGENITAL HYDROCEPHALUS. 589 CHAPTER III. CONGENITAL HYDKOCEPHALUS. Congenital hydrocephalus consists in an excess of the cerebro-spinal fluid, lying either external to the brain or more frequently in its interior. It is due to some vice in the development of the brain or its membranes or to a pathological state occurring in them during intra-uterine life. This disease is in some patients apparent from the symptoms and appearances at birth, but not always. Occasionally nothing unusual is observed in the shape of the head or aspect of the infant till after the lapse of some weeks, when the characteristic physiognomy begins to appear. In these cases the disease is still congenital, since there is every reason to believe that the abnormal state to which the excessive production of fluid is due existed from birth. In cases of arrested or partial development of the brain — as, for example, when a considerable portion of the hemispheres is absent — there is often an unusually large quantity of fluid which serves as a compensation for the lack of brain. I do not regard such cases as examples of hydro- cephalic disease, since the effect of the fluid is not injurious, but rather useful. I restrict the term congenital hydrocephalus to those cases in which the brain is complete, or, if incomplete, the quantity of fluid is more than sufficient to supply the deficiency. Anatomical Characters. — According to M. Breschet, the fluid in con- genital hydrocephalus may be — 1st, between the dura mater and the cranium ; 2d, between the dura mater and the parietal arachnoid ; 3d, in the cavity of the arachnoid ; 4th, in the ventricles ; 5th, between the arachnoid and the brain. In a large majority of hydrocephalic patients the effusion occurs in the ventricles. As the quantity of fluid increases, the pressure from within grad- ually unfolds the convolutions of the brain, at the same time producing expan- sion of the cranial arch. When the amount of fluid is considerable — and it becomes so in the course of a few weeks or months — the hemispheres are spread out in a thin lamina on either side, gradually decreasing in thickness from the base of the cranium to the vertex, where the brain-substance is sometimes so thin as to be scarcely perceptible. Complete absence of brain in this situation — namely, at the vertex, even in extreme cases of expansion and flattening of the hemispheres from the pressure of the liquid — is rare, though the brain-substance at this point is sometimes almost as thin as either of the membranes, so that the wall of the sac is translucent. The membranes which surround the brain do not usually undergo any alteration, except such as arises from the distention. The falx cerebri sometimes disappears, and sometimes the meninges present a whiter hue from maceration than in health. The distention also causes such an expansion of the pia mater that it becomes very thin, and in places scarcely visible, but its presence in every point can be demonstrated. The accompanying woodcut represents congenital hydrocephalus as it ordi- narily occurs. I saw this infant when it was a few days old, and examined it from time to time till its death. The parents are healthy and have other healthy children. This infant when nine days old began to have clonic convul- sions of a mild form in the muscles of the face, neck, and limbs, which occurred almost daily till the age of six weeks, and sometimes every five or ten minutes. When the convulsions ceased in the sixth week the head was observed to enlarge, and its excessive growth continued till death, which occurred at the 590 LOCAL DISEASES. age of seven months and one week. "While the volume of the head progres- sively increased, the trunk and limbs emaciated. At death the occipitofrontal circumference of the head was nineteen and a half inches ; the vertical from auditory meatus to meatus, thirteen and a half inches. The changes which the cranial bones undergo, both in their chemical character and in their shape, in hydrocephalic patients, if the amount of fluid Fig. 188. be considerable, are interesting and remarkable. The base of the cranium undergoes little change, but those portions of the frontal, parietal, and occip- ital bones which constitute the arch are expanded in all directions, while they become much thinner. There is deficiency of lime in their constitution, so that the organic elements are greatly in excess. This renders them flexible and semi-transparent. Notwithstanding the expansion of the bones, there are usually interspaces between them, of greater or less size according to the amount of fluid. The scalp, being stretched by the pressure underneath, becomes tense and thin, and is scantily covered with hair. The veins which ramify in it are unusually prominent and large, and the head is elastic on pressure from the amount of liquid beneath. In the common form of congenital hydrocephalus — namely, that in which the liquid is in the interior of the brain — the shape of the orbital plates of the frontal bone is often changed, so that the eyeballs have a downward direction. This change in the axis of the eyes occurs at an early period, and it continues through the entire disease, becoming more and more marked as the quantity of liquid increases. If the amount be large, the lower part of the cornea is buried under the under eyelid, while the conjunctiva is visible between the cornea and the upper eyelid. The per- sistent downward direction of the eyes is characteristic of this disease, and in connection with enlargement of the head is an important diagnostic sign. Nevertheless, hydrocephalus, even of the ventricular variety, sometimes occurs without change in the direction of the eyes. If we examine the interior of the cavity after the fluid is evacuated, we will find at its base the parts which lie in the floor of the lateral ventricles, but changed in appearance in consequence of pressure. The cornua are enlarged and the thalami optici and corpora striata are flattened. In the COXGEXITAL HYDROCEPHALUS 591 early stages of the disease, when the amount of fluid is small, there is prob- ably no absorption or destruction of parts in the interior of the brain. The various portions of this organ retain nearly their normal relation to each other. As the quantity of fluid increases the foramen of Monro, which unites the lateral ventricles, becomes enlarged, the septum lucidum which separates them disappears, and the two ventricles form a common cavity. In most fatal cases we find this single large cavity. The surface which surrounds the cavity occasionally presents a whitish or semi-opaque appearance, which has led to the belief that at a period antecedent to birth there was subacute inflammation of this surface, and hence the effusion. The bones of the face are ordinarily less developed than in healthy chil- dren of the same age, so that the disproportion between the head and face becomes a marked peculiarity. The shape of the forehead and face is nearly triangular. The foregoing remarks in reference to the anatomical characters of con- genital hydrocephalus refer in the main to cases which have continued for a considerable time, so that their characteristic features are well marked. In very young infants, in whom the disease is still recent, similar anatomical characters are present, but in less degree. Congenital hydrocephalus is often associated with other vices of confor- mation, especially with spina bifida. The two, when coexisting, are only parts of the same disease, the large quantity of cerebro-spinal fluid preventing the spinal canal from closing during foetal development. The fluid in congenital hydrocephalus consists largely of water, in the proportion even of 99 parts in 100. In addition to this element there are traces of albumen, chloride of sodium, phosphate and carbonate of sodium, and osmazome. I have had an opportunity to witness only one post-mortem examination in a case of congenital hydrocephalus in which the liquid was exterior to the brain. This case was under observation in the children's service of Charity Hospital in 1866. Full notes and measurements of the head were taken, which, unfortunately, were mislaid or lost. The infant had congenital syph- ilis and had a pallid, strumous appearance. The shape and relative size of the head are seen in the woodcut (Fig. 189), from a photograph. While the whole head was enlarged, there was a relative excess of development in the part between and above the ears. The axis of the eyes was not changed, and the vision was good. The appearance corresponded so closely with descrip- tions of hypertrophy of the brain that this was supposed to be the anatomical state. Antisyphilitic treatment was employed, and the syphilitic eruptions had disappeared when diarrhoea supervened, followed by death. At the autopsy a quantity of transparent or light straw- colored liquid, estimated at six or seven ounces, was found exterior to the brain in the great cavity of the arachnoid, lying mostly over the superior surface of the organ. There was no excess of liquid in the ventricles, and the brain, though of good size, was not abnormally large, nor did it possess the firmness which is present in true hypertrophy. All cases of congenital hydrocephalus may be embraced in two groups — namely, that in which the liquid is in the interior of the brain, and that in which it lies exterior to the organ. Liquid pri- marily in the arachnoidean cavity permeates the meshes of the pia mater, and lies in part underneath it, or this delicate mem- Fig. 189. 592 LOCAL DISEASES. brane may be ruptured. Four of the groups, therefore, described by Breschet, may properly be reduced to one — namely, those groups in which the liquid lies under, between, or external to the meninges. It is probable that some of the cases which led to Breschets classification were examples of acquired circumscribed hydrocephalus, the result of extravasation of blood. Etiology. — The constitutional vice which gives rise to this disease is probably different in different cases. I have been able, I think, to attribute correctly a considerable proportion of cases which I have observed to con- genital syphilis, but in other instances from the character of the parents I could not assign this cause. Symptoms. — If there be a considerable amount of hydrocephalic fluid prior to the birth of the child, so that the head is abnormally large, partu- rition is seriously interfered with. The scalp and meninges may become ruptured by the severity of the pains, so that the fluid escapes. If this do not occur, the labor is often necessarily instrumental. Whether the liquid be present before birth or accumulate subsequently to it, the tendency is to an increase of the quantity and a corresponding enlargement of the head. The digestive function in this disease is at first well performed. The infant nurses readily and has its evacuations with the regularity of other children. Not many weeks, however, elapse, in the majority of cases, before defective nutrition is apparent. While the volume of the head increases, other parts are imperfectly nour- ished and stunted in their growth. Emaciation of the neck, trunk, and limbs is common, associated with progressive feebleness. In the last stages of this disease there is more or less vomiting, with constipation. If there were previously the ability to support the head, it is now lost, and the erect position is no longer possible. In marked cases, when there is great dispro- portion between the head and the rest of the system, there is frequently not even the ability to rotate the head on the pillow. So long as the cranial bones yield readily to the pressure from within and there is no compression of the brain, the function of this organ is not seriously impaired. The child recognizes its mother or nurse, and it can be amused like other children, though easily fatigued. The state of the senses is different in different cases, and sometimes at different stages of the same case. The sight and hearing in some are perfect, in others impaired, while in others still they are good at first, but gradually become obscured and lost. It is said that the sense of smell may be perverted, so that agreeable odors are unpleasant, and vice versa. Many, reaching the age at which children begin to walk, cannot walk, or, if they do, it is with a tottering, unsteady gait. When the liquid increases to that extent — and it usually does sooner or later — that the brain begins to be compressed, dangerous cerebral symptoms arise. The child becomes drowsy and takes less notice of objects. Spas- modic muscular contractions, and finally convulsions, occur. The pupils act feebly or irregularly by light, or one is more dilated than the other. Strabis- mus also occurs. As death approaches, eclampsia, partial or general, be- comes more frequent, and is succeeded by stupor from which the patient cannot be aroused. The following; case, which I copy from my note-book, is an example of the common form of congenital hydrocephalus ; it will aiye an idea of the ordinary course of this disease, and show the difficulty which we meet with in its treatment : Female, born November 9, 1859, with the aid of forceps. At birth the fontanelles were unusually large, the cranial bones separated, and the aspect in a marked de- gree hydrocephalic. She nursed at first, but, the mother's milk failing, she was afterward bottle-fed. At the age of four months her head, which had increased faster than her general growth, measured from one auditory meatus to the other, CONGENITAL HYDROCEPHALUS. 593 over the vertex, seventeen inches ; the occipitofrontal circumference, twenty-three inches. At this time she manifested considerable intelligence, being able to distin- guish her mother from other persons, though the head was so large that it was necessary to support it constantly on a pillow. From the age of four to six months the operation of tapping was performed six times with a small hydrocele trocar by Dr. Stephen Smith, at a point near the coronal suture and from one inch to one inch and a half from the sagittal. At each operation an amount of fluid varying from twelve ounces to one pint was removed, and the head then covered with strips of adhesive plaster, so as to form a complete cap. It was necessary, however, within the twelve hours succeeding each operation to loosen the dressing on account of either the occurrence of convulsions or symptoms premonitory of them. The head within a week subsequently to each operation regained its former size, and, as there was no permanent benefit, this treatment was discontinued. She finally died of entero-colitis at the age of ten months and five days. At the autopsy the distance from one auditory meatus to the other was twenty and a quarter inches : the occipitofrontal circumference, twenty-six and a quarter inches. The anterior fontanelle measured antero-posteriorly four and three-fourths inches : transversely, seven and three-fourths inches. The parietal bones were separated from each other to the distance of two or three inches, and they measured in length nine and a half inches. On opening the cranial cavity, seven pints, by measurement, of transparent fluid escaped, exposing a vast open space at the bottom of which were the parts which constitute the floor of the ventricles, somewhat changed in shape, and from them on either side the hemisphere was spread in a lamina, so as to cover the internal surface of the cranial bones. The laminae near the base of the brain measured in thickness from half an inch to one inch, and they gradually became thinner on approaching the vertex, at which point the brain-substance was ex- ceedingly thin, so as to be scarcely demonstrable. The brain had its normal vascularity and consistence, and the cerebellum, medulla oblongata, the base of the brain, and cranial nerves presented their usual appearance. On folding the brain together, it had the size, shape, and aspect of this organ in its ordinary development. Nothing unusual was observed in the membranes except their great expansion. The above case corresponds in its gen- eral features with most cases met in practice. Diagnosis. — The ordinary form of congenital hydrocephalus, that in which the liquid occupies the interior of the brain, can in most cases be readily diagnosticated. If there be only a moderate amount of liquid, it may be confounded with hypertrophy of the brain. In hydrocephalus there are commonly more rapid growth and greater expansion of the head ; more- over, the enlargement occurs equally on all sides, while in hypertrophy, though all parts of the cranial vault are expanded, the enlargement is more at the vertex than elsewhere. The hydrocephalic head yields more readily to pressure than the hypertrophied, and often communicates a fluctuating sensation. Moreover, in the ordinary form of hydrocephalus the change in the axis of the eyes described above is an important diagnostic sign. In rachitis the volume of the head is often considerably enlarged, due some- times, in part at least, to a deposit of calcareous matter on the exterior of the cranial bones. The differential diagnosis is based on the shape of the head, round in one, square or with prominences in the other, on palpation, direction of the eyes, etc. The smaller the amount of liquid, the greater the liability to error of diagnosis ; but if the amount be inconsiderable and not increasing, little treatment is required except hygienic and tonic, which is also proper in both hypertrophy and rachitis. If the liquid be exterior to the brain, as in the case represented in Fig. 189, diagnosis may be difficult. but such cases are infrequent. Prognosis. — In the majority of the cases this is unfavorable, since the secretion of liquid usually continues. The most favorable result is no in- crease, or but slight, in the quantity, while the natural growth of the infant 38 594 LOCAL DISEASES. increases, and thus the disproportion between the head and the rest of the system gradually disappears. Such patients may live to maturity and have tolerable health, and may engage in occupation. But ordinarily in cases left to themselves, and even in a large proportion of those having the best treat- ment, the body and limbs gradually waste from defective nutrition, and the patient, if not cut off by an intercurrent disease, finally succumbs with cere- bral symptoms produced by pressure of the liquid. Probably more than half of the hydrocephalic patients die before the close of the second year. Treatment. — We may attempt to diminish the quantity of fluid by the use of diuretics. Digitalis, squills, nitrate and acetate of potassium have been used. The most efficient diuretic in these cases, however, is the iodide of potassium. This may be given in doses of one to two grains every two hours to an infant of three months. Constipation, if present, should be relieved by an occasional purgative. If it be tolerated, we may partially prevent the expansion of the head by a close-fitting cap. For this purpose strips of adhesive plaster, about one-third of an inch in width, should be applied so as to cover the entire head. The proper way of applying these is as follows : First, one strip from each mastoid process to the outer part of the orbit on the opposite side ; secondly, from the back of the neck, along the longitudinal sinus, to the root of the nose ; thirdly, over the whole head, so that the different strips will cross each other at the vertex ; and, lastly, a strip long enough to pass three times around the head should be applied, passing above the eyebrows, the ears, and below the occipital protuberance. Too tight an application should be avoided, as it may give rise to convul- sions or other cerebral symptoms. If the cap can be tolerated and the gen- eral health be good, the prospect is more favorable ; but usually, from the increase in the quantity of fluid, it is necessary in a few days to remove or loosen the strips in order to prevent convulsions, or, which is preferable, to diminish the size of the head and relieve the pressure by tapping. In 56 cases collected by Dr. West in which tapping was employed, 4 recovered. The operation is simple, easily performed, devoid of danger, and it frequently gives temporary relief. It should therefore be recommended to the parents, even if it do not effect a cure. It should be performed by a very small trocar, which should be introduced in the coronal suture, about an inch ex- ternal to the anterior fontanelle. A few ounces should be removed, and strips of adhesive plaster or an elastic skull-cap applied. In a few days the opera- tion should be repeated as the liquid increases. It is important to maintain compression of the skull before and after the operation (Treves). Some- times a dozen or more tappings are required at intervals of a few days or weeks, when the secretion may come to a standstill. In the Med.-Chir. Trans. (1864) a case is related in which two tappings effected a cure, but so good a result is exceptional. Iodine injections in connection with tapping have so far not produced any satisfactory result. Sir James Paget 1 relates a case in which he injected ten grains of iodine and twenty grains of iodide of potassium in one ounce of water, but the child died of convulsions after the second injection. No appreciable good result has followed the use of irritating or sorbefacient applications to the head. Nutritious diet and atten- tion to the general health are requisite. 1 Medical Times and Gazette, 1860. ACQUIRED HYDROCEPHALUS. 595 CHAPTER IY. ACQUIRED HYDROCEPHALUS. Hydrocephalus, or dropsy of the brain, may also occur in those who at birth are well formed and free from disease. Pathologists call this acquired hydrocephalus. It is in nearly all cases the result of disease, which is located sometimes within the cranium, but often in other parts of the system. Causes. — The diseases within the cranium which most frequently produce serous effusion are the meningeal inflammations, both simple and tubercular, tumors or other causes which obstruct the venous circulation, and hemor- rhagic effusion ending in the formation of cysts. Prolonged passive conges- tion often ends in transudation of serum through the coats of the capillaries. Therefore, all causes of congestion, except such as have a transient or momentary effect, may be regarded as causes of serous effusion. In rare instances chronic hydrocephalus results from cerebro-spinal fever (menin- gitis), as has been stated in my remarks on the latter disease. Among the diseases external to the cranium which produce serous effu- sion within or upon the brain may be mentioned retropharyngeal abscess, tuberculization or inflammation of the bronchial glands, scarlet fever, and certain affections of an exhausting nature, especially protracted diarrhceal maladies. In at least five cases which have fallen under my notice, and in which post-mortem examinations were made, the cause was enlarged tuber- cular bronchial glands, which, by pressure on the venae innominatae, so retarded the flow of blood from the brain as to cause congestion and effu- sion. The causal relation of these glands to cerebral congestion is described in our remarks in reference to this disease. Dropsy of the brain is common in protracted infantile diarrhoea ; as, for example, in advanced cases of intestinal catarrh of the summer months in the cities. It is preceded and accompanied by passive congestion of the cere- bral veins and sinuses, due in part to feebleness of circulation in consequence of the exhausted state of the patient, and in part to wasting of the brain, which always give rise to more or less passive congestion, unless in young infants, in whom the cranial bones become depressed and override each other. Dropsy of the brain, resulting from scarlet fever, and that peculiar circum- scribed dropsy which results from hemorrhagic effusions, are described else- where. But the most severe and injurious form of acquired hydrocephalus is that which results from cerebro-spinal fever, since it causes great and in- creasing cranial expansion and loss of sight, and sometimes of hearing. A few cases have been related by different observers, Abercrombie among others, in which the dropsy of the brain seemed to be essential. Nothing abnormal was observed except the serous effusion. But the reports of such cases are, for the most part, meagre, and, as Barrier has well said, we are not to accept such cases as examples of essential dropsy of the brain unless the post-mortem inspection be so complete as to render it certain that there was no pathological state which might cause the dropsy. Anatomical Characters. — Acquired hydrocephalus usually occurs after the cranial bones are firmly united, and therefore the shape of the head is not materially altered. If it occur at an early age, before there is firm union, there may be expansion of the cranial arch, as we sometimes observe in the circumscribed hydrocephalus resulting from hemorrhage. The effu- sion in acquired hydrocephalus occurs over the surface of the brain, in the subarachnoid space, or in the lateral ventricles. In the dropsy of protracted 596 LOCAL DISEASES. diarrhoeal maladies I have rarely failed to find the liquid over the whole superior surface of the brain as well as at its base. The quantity of fluid in this disease is not large. In the majority of cases it does not exceed four ounces and is often much less. It is trans- parent or it has a slightly yellowish tinge. The membranes of the brain sometimes present their normal appearance, but in other cases they are injected. The brain itself in some instances has an injected appearance from passive congestion of the veins and capillaries ; but in others, when there has been more or less compression of the brain, there is no more than the ordi- nary, or even less than the ordinary, vascularity, and the convolutions are somewhat flattened. Symptoms. — The symptoms of the pathological state which gives rise to the dropsy precede and accompany those which are referable to the dropsy itself. The dropsy declares itself by symptoms which are alarming from the first. In children old enough to speak or manifest intelligence there may be at first complaint of headache. The child is irritable, its mind confused or wan- dering at times, or there is actual delirium. After a time drowsiness occurs. The head seems too heavy for the body and is buried in the pillow. In fatal cases the features become pallid, the pupils sluggish, and perception and consciousness are gradually lost. The child lies in profound sleep, which increases. There are now often convulsive movements, partial or general, and these soon end in coma, in which the patient dies. In January, 1890, 1 exhibited to the New York Pediatric Society a child with acquired hydrocephalus which dated back to an attack of cerebro-spinal fever of mild type that occurred a few months previously. Prognosis. — Acquired hydrocephalus commonly ends unfavorably. The prognosis depends not only on the quantity of liquid, but on the nature of the cause. If the cause be venous obstruction within the cranium or thorax, death is inevitable, since we have no means of removing it. If it be an ex- hausting disease, as entero-colitis or scarlet fever, although the case is not absolutely hopeless, the prospect is still unfavorable. It is only favorable when the quantity of effused fluid is small, the system not much reduced, and the primary disease mild. When acquired hydrocephalus arises from meningeal apoplexy, the case is usually chronic. The symptoms and termination of this form of the disease are very similar to those in congenital hydrocephalus. Treatment. — The treatment in acquired hydrocephalus must vary in different cases according to the nature of the disease on which it depends. I shall indicate the treatment, in part, at least, in the description of these diseases. Occasionally the condition of the patient is such that no material improvement can result from any mode of treatment. CHAPTER V. MENINGITIS (TUBERCULAR AND NON-TUBERCULAR). The most interesting and important disease of the cerebro-spinal system in early life is that which is now designated meningitis. It is not infrequent. The mortuary statistics of this city show that it is the cause of death in from 1 in 25 to 1 in 50 of the entire number of deaths, the proportion varying somewhat in different years. MENINGITIS. 597 In 1768 the attention of the profession was particularly called to this malady by Dr. Whytt of Edinburgh. This observer and the pathologists succeeding him. forming their opinion of meningitis from its most prominent anatomical character — namely, serous effusion — believed it a dropsy. They accordingly designated it acute hydrocephalus. The disease is now properly regarded as inflammatory, and hence the name by which its true pathological character is expressed. Inflammation limited to the dura mater has been designated pachymeningitis, in consequence of the thickness of this mem- brane ; and that affecting the thin and soft membranes, the pia mater, and arachnoid has for a similar reason been designated leptomeningitis. Sometimes meningeal inflammation in children occurs without tubercles. In other instances it results from the presence of tubercles, and in most, if not in all, such patients there are tubercles in or under the meninges, which excite the inflammation in the same manner as in the lungs they cause pneumonitis or pleuritis. Therefore two forms of meningitis are recognized — to wit, tuber- cular and non-tubercular. Meningitis is also, as we have seen, the characteristic anatomical character of cerebro-spinal fever, but as this is a general disease, with the meningitis as a local manifestation, we have treated of it among the constitutional maladies. In patients over the age of eighteen months, although the proportion of tuber- cular to non-tubercular cases is larger than under this age, the excess is not so great, according to my statistics, as the remarks of some observers lead us to sup- pose. There can be no accurate statistics of tubercular meningitis without careful post-mortem examination of the state of the brain and other organs in each supposed case, and this examination sometimes shows the meningitis to be non-tubercular when the symptoms and signs had indicated its tubercular character. As an example may be mentioned a case which occurred in the children's service of Charity Hos- pital in March. 1868. The infant died at the age of twenty months, having had a cough of moderate severity at least three weeks before death, and symptoms of meningitis about four days. It was considerably wasted, and was supposed to have tuberculosis. At the autopsy no tubercles were found in any part of the body, but portions of both lungs were hepatized. A fibrinous deposit, varying in thickness, was found over the pons Varolii, the optic commissure, along the fissures of Sylvius, over the superior surface of the anterior half, and also upon the superior lobe of each cerebral hemisphere. As the examination failed to disclose any tubercles, the menin- gitis was considered non-tubercular. Those who make these examinations, failing to find tubercles in the lungs and other organs in which they usually occur, should examine the lymphatic glands, since cheesy glands may be the cause of the forma- tion of tubercles in the meninges, while the organs of the trunk remain unaffected. The presence of cheesy glands in the absence of visceral tubercles and with granu- lations upon the meninges, small, covered with fibrin, and of a doubtful character, goes far toward establishing the tubercular nature of the meningitis. Since the cases embraced in the following statistics were observed, now more than twenty years ago, I have been led by a more extended experience, and especially by the ob- servation of cases in the New York Foundling Asylum, where there is ample mate- rial, to regard not only the presence or absence of tubercles, but also of caseous substance, as the proper test of the form of meningitis. Not a few that seem at first to have non-tubercular meningitis will be found, on more thorough examination, to have caseous substance in some part, the result of a pre-existing inflammation ; and if we regard the inflammation of the meninges occurring under such circumstances as tubercular, the relative proportion of tubercular cases will be considerably aug- mented. The following is an example: When on duty in the asylum in August. 1881, an infant one year old died of meningitis. No tubercles were observed in the fibrin at the base of the brain and along the fissures of Sylvius, but one inflam- matory nodule (cerebritis) as large as a chestnut, with suppuration inside. Avas found at the summit of one hemisphere. No tubercles could be detected in any of the organs of the trunk, unless a few whitish spots in the spleen were of this nature, but the bronchial glands were cheesy and softened, and the middle lobe of the right lung also contained cheesy substance. It seemed to me probable that some of this 598 LOCAL DISEASES. degenerated product taken up by the vessels had lodged in the meninges and pro- duced the tubercular neoplasm "there which was hidden under the fibrin. (See chapter on Tuberculosis.) Age. — The following table gives the age in meningitis, tubercular and non-tubercular, in forty-two cases in my collection, which is a small propor- tion of those which I have observed ; but these are the only cases of which I have preserved notes : Cases. Age. 1 2J weeks (autopsy). '2 3 months. 20 From 3 to 12 months. 10 From 1 year to 2 years. 5 From 2 years to 5 years. 4 Over 5 years. 42 Rilliet and Barthez have also published statistics of the age in meningitis. Their cases were observed chiefly in hospital practice, and the result is somewhat different. In 32 cases of non-tubercular meningitis observed by these authors, 8 were under the age of one year, 6 from two years to five, and 18 over the age of five years. In 98 cases of tubercular meningitis, 2 were under the age of one year, 51 between the ages of one year and five, 38 between the ages of five years and ten, and 7 between ten and fifteen years. Growers states that the age at which menin- gitis is most frequent is between the first and tenth years. Pathological Anatomy. — This differs considerably in different cases. The dura mater is usually unaffected or is affected secondarily. In many cases it retains its normal appearance, its internal surface remaining smooth and polished, while in others it is more or less injected and its internal sur- face dim or lustreless. The free surface of the pia mater, formerly designated the visceral arachnoid, is in a great part of its extent unchanged, but is often hyperasmic or dry and cloudy or opaque over the seat of inflammation. Exu- dation does not occur upon the free surface of the pia mater, however intense the inflammation. In meningitis, tubercular and non-tubercular, the inflammatory action occurs in the pia mater. In its meshes or underneath them those lesions result which characterize the disease, and to which other lesions are secondary. Tubercular meningitis is most frequently basilar, or is basilar chiefly and pri- marily, although the inflammation may extend along the sides of the hemi- spheres. The meningitis is ordinarily most intense around the pons Varolii, in the subarachnoid space, and along the fissures of Sylvius, for the tubercular neoplasm occurs chiefly at the base of the brain and along the vessels. In non-tubercular meningitis the inflammation may also occur at the base. It may in young infants be quite diffuse, and of little intensity in any one place, producing, in addition to hyperaemia of the pia mater, slight cloudiness and a moderate or slight escape of leucocytes from the blood, these (pus-cells) being perhaps visible only under the microscope. In meningitis due to extension of inflammation from an otitis media the inflammatory action is intense, con- fined to the portion of the meninges nearest the ear, and is often attended by inflammation of the adjoining brain-substance, with perhaps the formation of an abscess. If the cause be exposure to the sun's rays or traumatism, the meningitis is usually at the summit of the brain. The exudation of fibrin is greatest along the course of the vessels and in the depressions between the convolutions, and the opacity is most marked in these situations. Pus, when present, is often semi-solid, from the small pro- portion of liquor puris which it contains, even in recent cases. If the disease MENINGITIS. 599 have continued several days, the liquor puris may be mostly absorbed, and the pus-cell, becoming shrivelled, irregular, and aggravated, may resemble closely the cheesy transformation of tubercle-cells. The fibrinous exudation presents features of interest. It does not usually attain much thickness, but by its opacity it conceals from view the brain underneath. If it occur in the fissures of Sylvius, the anterior and middle lobes are united by it. It is usually infiltrated through the substance of the pia mater. Sometimes little masses of variable size, often not as large as a pin's head, appear at the point of inflammation. These masses are firm, of a whitish color or a light yellow, and their number varies in different cases. They consist of a firm, homogeneous substance containing granular matter and cells which often bear a close resemblance to tubercle-corpuscles, but are distinct. These corpuscular bodies are plastic nuclei or plastic cells, often shrunken. It is seen. then, there are two morbid products which may be mis- taken for tubercles — one. pus which has been in great measure deprived of its liquid element, and which may resemble cheesy tubercular matter; the other, plastic nuclei collected in little bodies, so as to resemble the ordinary form of crude tubercle. I once carried to one of the best microscopists and pathologists of Xew York some of the exudation from a case of meningitis, the cellular element in which could not readily be distinguished from shrunken tubercle- corpuscles. The exudation was from a child two years and eight months old, with good health previously to the meningitis, without tubercles in any part of the body, with parents healthy, and with no predisposition to tubercular disease. The microscopist, not knowing the history of the case or character of the family, and ignorant, like all of us at that time, of the true tubercle- cell, pronounced the exudation tubercular after a careful examination with the microscope. In the tuberculosis of young children I have found in a large proportion of cases in which I have had an opportunity to make post-mortem exami- nations miliary tubercles disseminated through the lungs and perhaps other organs in small masses, many of them not larger than a pin's head, and some occurring as mere specks scarcely visible. These minute tubercular formations have ordinarily been semi-transparent, and sometimes even transparent like minute drops of water, and containing the true and unchanged tubercle bacil- lus. Now, if in such a case meningitis occur, we may find the tubercle-cell in or with the fibrin at the base of the brain. But failure to find it, even with protracted microscopic examination, does not prove its absence from this locality, for I consider it almost impossible to discover in the midst of the fibrinous exudation such minute points of tubercular matter as are seen in the lungs, liver, or elsewhere. The pia mater is often firmly adherent to the brain at the seat of inflam- mation, so that on raising it a portion of the brain may be detached and re- moved with it. The extent of the inflammation varies much in different cases. There may in extreme cases be pretty general inflammation of the pia mater. In cases of such extensive meningitis the symptoms are usually severe and the course of the disease rapid. Thus, in the month of April, 1866, a girl eleven years of age, in the Protestant Episcopal Orphan Asylum of this city, had complained occasionally of dizziness, but was otherwise in good health, cheerful and w 7 ith excellent appetite, till Thurs- day, when she was affected with vertigo, more persistent than previously, and with headache. At 2 p. m. on the following day she was seized with general convulsions, and continued insensible or nearly so, with occasional convulsive movements, till Monday, when she died comatose. The pia mater at the vertex, sides, and base of the brain had a cloudy appearance, and underneath it in places was a thick, creamy substance in small quantity, which, examined by the microscope, proved to be pus 600 LOCAL DISEASES. the largest amount being near the pons Varolii. There was no tubercle under the meninges or elsewhere, and no appreciable fibrinous exudation. The meningitis, though of brief duration, was nearly general. The only additional lesions noted were moderate congestion of the brain and an increase in the quantity of the cerebro- spinal fluid. If the disease be protracted three or four weeks, which is rare, or even less time, the exuded substance may undergo further changes, such as occur in simple exudations in other parts of the system. Thus, on the 30th of April, 1860, we made the post-mortem examination of an infant at the Nursery and Child's Hos- pital who had symptoms of cerebral disease, it was stated, for several weeks, but the exact time was not ascertained. Prominent among the symptoms referable to the cerebro-spinal system toward the close of life were the hydrocephalic cry and rigidity of the neck. The appearance at the autopsy was remarkable. The ante- rior half of the brain was completely encased in a deposit which had nearly the appearance of lard. It filled the fissures of Sylvius and appeared slightly on the anterior aspect of the cerebellum. Examined under the microscope, this substance was found to contain numerous cells, among which could be distinguished some resembling pus-cells, but nearly all had undergone more or less fatty degeneration. Here and there was seen a large cell containing numerous small oil-globules, the compound granular cell of pathologists. The brain itself in meningitis is usually hyperaemic. On making an in- cision through it red points are seen upon the cut surface, which indicate the seat of the congested vessels. The inflammation rarely extends to the walls of the ventricles, but the choroid plexus is injected. In exceptional in- stances pus or fibrin is found in the lateral ventricles. In the infant two and a half weeks old whose case has already been alluded to about two ounces of purulent fluid escaped on opening the left ventricle. A small amount of liquid of a similar character was contained in the right ventricle. The distention of the lateral ventricles with serum is one of the common results of meningitis. This fluid is clear or straw-colored, or it is turbid. The quantity does not exceed two, three, or four ounces, and is often not more than one ounce or an ounce and a half. The distention of the two ventricles is ordinarily uniform, as they are united by the foramen of Monro, but now and then one ventricle is found more distended than the other. If there be considerable effusion, the brain is compressed and the convolutions have a flattened appearance, unless the cranial bones are still separated so as to yield to the pressure. If the sutures and fontanelles be open, the cranial arch is expanded, sometimes quite perceptibly to the eye. From the same cause the anterior fontanelle, if open, is elevated. The foramen of Monro is enlarged according to the amount of effusion, and the portions of the brain which separate the ventricles are sometimes lacerated. In many cases the cerebral substance surrounding the lateral ventricles is softened. The soft- ening is found in all degrees, from the least appreciable deviation from the normal consistence to a state of difnuence, so that the brain-substance pre- sents the appearance of cream. Hypotheses have been advanced to explain the cause of this change in consistence which are not entirely satisfactory. Whatever the explanation, the fact is attested by all observers, though there are exceptional cases. Thus Dr. West has records of the condition of the brain in 59 cases, in 37 of which there was considerable softening, and in the remaining 22 the consistence was normal. Since a majority of the cases of meningitis in children are basilar, and portions of all the cerebral nerves lie at the base of the brain, it is easy to understand why the functions of these nerves are so seriously impaired in this malady. Compression of these nerves or extension of inflammation to their sheaths affords explanation of many of the symptoms, as the sighing respiration, abnormalities of the eye, etc. Although the above remarks relating: to the anatomical characters of 3IENINGITIS. 601 meningitis are applicable to a large majority of the cases, sometimes at the autopsies of young infants who died with all the symptoms of meningitis, the phvsieian is surprised in not finding more lesions. Moderate hyperaemia of the pia mater, slight opacity or cloudiness at the base of the brain or elsewhere, with the presence of a few wandering white corpuscles, without any fibrinous exudation, with no increase of liquid external to the brain, but a considerable increase of it in the lateral ventricles, and hyperaemia of the choroid plexus, with nearly natural appearance and consistence of the brain, have in some instances been the only lesions when I had expected to find marked anatomical changes. I am fully convinced from my observations that in some instances physi- cians who supposed that they were treating tubercular meningitis, and at the autopsies discovered within the cranium tubercles, without any inflam- matory lesion, but with an increase of the cerebro-spinal liquid, have been treating cases in which, in addition to the meningeal tubercles which were latent, the bronchial glands were tubercular and cheesy, so that by their increased size they compressed the venae innominatae within the thorax, thus preventing the free flow of blood from the brain, and causing, as I have elsewhere stated, cerebral and meningeal congestion, with more or less trans- udation of serum, but with no meningitis. In tubercular meningitis the anatomical characters are like those in simple meningitis, with the addition of tubercles, which at first are minute and transparent, and are most easily detected when the inflammation has been slight. Located in the pia mater, they cause some prominence of the arachnoid, and are best seen when so minute by an oblique light. Causes. — The causes of non-tubercular meningitis are not fully ascer- tained. Active cerebral congestion frequently occurring, however produced, appears to be one of the common causes in young infants. In at least three instances I have known meningitis to occur in infants between the ages of four and eight months after severe and protracted bronchitis, which had been attended with the usual heat of head. This disappearance of eruption upon the scalp at or immediately before the commencement of the menin- gitis has also been observed. I have witnessed it at the commencement of non -tubercular meningitis, as well as of meningitis which, if not tubercular, occurred at least in a decidedly scrofulous state of system. The direct effect of the solar rays upon the head and the prolonged action of a high atmospheric temperature are believed to be an occasional cause of meningitis. I once attended a child with this disease who had been much exposed bareheaded to the direct rays of the sun in August and Septem- ber, and at his death, which occurred toward the close of the hot weather, found hyperaemia, opacity, and fibrinous exudation in the pia mater at the summit of the brain, while the base of the brain seemed nearly or quite normal. Dr. Soltmann * of Breslau reports three cases in which intense cerebral hyperaemia, and probably meningitis, occurred from solar heat. In all three children the attack was sudden, the febrile movement and heat of head in- tense, and the progress rapid. The first had convulsions, the second auto- matic movements, and the third, the oldest, aged four years, when able to speak complained of violent headache. The statistics of New York City show that congestive and inflammatory maladies of the brain and its covering are more common during July and August, which are the months of maximum atmospheric heat, than in other months of the year. For example, in July and August, 1875, 167 died of these maladies, or 1 in every 9.8 who died from local disease, while during 1 Jahrbuchf. Kinderkrank., for October, 1875. 602 LOCAL DISEASES. the entire year only 710 died from the same, or 1 in every 15 who perished from local diseases. July, 1876, in New York City was characterized by excessive and long- continued atmospheric heat, the temperature of the Central Park Observatory in the shade never falling below 61°, though never above 98°, and having a mean of 82.9°. There was also unusual dryness of the atmosphere, since during the entire month prior to July 30th there were only fourteen hours of rain with a rainfall of 0.77 of an inch, and the average atmospheric humidity was represented by 65, saturation being denoted by 100. During this month I treated in my private practice four fatal cases all between the ages of two and seven years, which I diagnosticated meningitis, none of them presenting any symptoms of otitis or tuberculosis. It would seem that the atmospheric heat had much to do with the development of the disease in these cases. One died in two days, but in the others there was the usual duration. Gowers also mentions insolation among the occasional causes. A not infrequent cause, especially among the strumous families of cities, is otitis media and caries of the petrous portion of the temporal bone, the inflammation extending to the meninges. Any suppurative inflammation occurring outside the dura mater, but in immediate proximity with it, may by extension cause meningitis ; but the most common cause of this kind is purulent otitis. The external discharge of pus from the ear usually ceases when the meningitis begins. Gowers states that several cases are on record of meningitis occurring from traumatic inflammation of the eye, the inflam- mation probably passing along the sheath of the optic nerve. He also states that the following acute diseases occasionally sustain a causal relation to meningitis : measles, scarlet fever, smallpox, typhoid fever, pneumonia, and acute rheumatism. But the meningitis occurring with or from pneumonia is probably cerebro-spinal fever, and meningitis occurring from the acute infectious diseases mentioned by Gowers is certainly rare, and perhaps its coexistence with them is in at least some instances a coincidence. Septic processes in any part of the system occasionally cause meningitis from microbes, which, entering the circulation, are conveyed to the meninges. Since tubercular meningitis is due to the irritating effect of tubercles in or under the pia mater, it usually occurs where tubercles are most abundantly developed ; that is, at the base of the brain and along the course of the vessels in the intergyral spaces. The inflammation is commonly excited when they are still small, even minute. Premonitory Stage. — Meningitis is usually preceded by symptoms which, if rightly interpreted, are of the greatest value. In most cases of this malady which I have seen there was a prodromic period varying from a few days to several weeks. The symptoms of this period are obscure, and are liable to be mistaken for those of other and distinct affections. The child in whom meningitis is approaching loses his accustomed vivacity and cheerfulness. He has a melancholy and subdued appearance, being quiet a few minutes, and then fretful, without apparent cause. He can sometimes be amused by his playthings or companions for a brief period, when he turns from them with evident displeasure. Unexpected and loud noises and bright lights are evidently painful. If old enough to describe his sensations, he complains of transient dizziness, and at other times of head- ache. His ill-humor, if his wishes are not immediately gratified or if they are denied, is often scarcely endurable on the part of friends who are ignorant of the cause. There is great difference, however, in different cases as regards this symptom. Some are inclined to be taciturn and quiet, while others are almost constantly fretting. The appetite is capricious ; at one time it is pretty good, at another it is poor or even entirely lost. The patient may MENINGITIS. 603 take a few mouthfuls of food, or. if an infant, may nurse a moment, when his hunger appears satisfied and he will take nothing more. The bowels are regular or inclined to constipation. The pulse is natural or it has times of acceleration, especially in the latter part of the day and toward the close of the premonitory stage. The duration of this stage is very different in different cases. Upon an average it is perhaps about two weeks, but it is often longer. In tubercular meningitis the symptoms, both during the inflammation and previously, are often complicated by those which arise from . tubercles in other parts of the system. Of the symptoms premonitory of the disease and present in its first stages, headache and vomiting are especially prominent. Unless the prodromic period be of short duration the effect of imperfect nutrition is obvious before it closes. The flesh becomes soft and flabby or there is emaciation, though generally slight. The patient loses his strength, becoming less able to stand or to walk, and more easily fatigued. Occasion- ally, especially in the non-tubercular form, premonitory symptoms are absent or are slight and of short duration. Symptoms. — Dr. Whytt, living in the last century, when the tendency was toward refinement rather than simplicity in classification, divided menin- gitis into three stages, according to the symptoms, especially the pulse. 3Iany subsequent writers, following Whytt's example, have recognized three stages, based not upon the anatomical characters of the disease, but upon the succession of symptoms. Such division of meningitis is in great measure arbitrary, since in one case the same symptoms occur at an earlier period than in another. When the premonitory stage has passed and inflammation is developed, some of the symptoms which were previously present remain and are inten- sified, and other new and more characteristic symptoms appear. There are fewer intervals of apparent improvement. The child is quiet, often lying with his eyes shut. If aroused he has a wild expression of the face, and is irritated by attempts to engage his attention or amuse him. He rarely smiles or takes his playthings, or he notices them for a moment, when he turns away with disgust. During sleep there is often at first a placid expres- sion of countenance, but when aroused he has the aspect of real sickness ; the eyebrows are sometimes contracted, as if from headache ; the features wear a melancholy look, and are turned away to avoid the gaze of the observer or to shun the light. If the anterior fontanelle be open, it is observed to be prominent and pulsating forcibly. If consciousness be not lost and the patient be of sufficient age, he complains of headache or of pain in some part of the body. The tongue is moist and covered with a light fur ; the appetite is lost or poor ; there is seldom much thirst ; more or less nausea and constipation are present. As the inflammation continues, and usually within three or four days from its commencement, symptoms arise which dispel all doubts, if there were any, as to the nature of the disease. The vital powers are now evidently beginning to yield. The surface generally is more pallid, and there is the curious phenomenon of the sudden appearance — and after some minutes disappearance — of spots or patches, or even streaks, of active congestion upon the face, forehead, or ears. These, having a bright- red color, contrast strongly with the general pallor. Ordinarily they are irregularly circular or oval, and from one inch to an inch and a half in diameter. A red spot or streak is also produced if the finger be pressed upon the surface or drawn forcibly across it. It continues a few minutes. and then gradually fades. Trousseau calls attention to this met as a diag- nostic sign. It is known as the tdche cerebrate of Trousseau, and it affords some aid in diagnosis, but the tdche cerebrale is common in some other diseases. 604 LOCAL DISEASES. Another curious phenomenon is the variation in temperature. The face and limbs at one time feel quite cool, and after some minutes, without any excitement or other appreciable cause, the temperature rises, so that the sur- face is warm to the touch. Consciousness in severe cases may be lost at an early period. On the other hand, I have known it in a case of moderate severity to remain, though partially obscured, till within twenty-four or thirty-six hours of death. The patient will usually open his mouth for drinks which are placed to his lips when there is no other evidence of intelligence and when sight and hearing are evidently lost. The loss of the senses constitutes an interesting but melancholy feature of the disease. Among the first unequivocal signs, and frequently the very first, are such as pertain to the eye. This organ should be watched from day to day when the diagnosis is uncertain. Deviation from its normal state affords evidence of meningitis. The pupils are seen to dilate or contract sluggishly by variations in the intensity of the light, or they are not of the same size with those of another individual to whom the same amount of light is admitted. Sometimes the first perceptible deviation from the normal state is an inequality in the size of the pupils, while in others oscillation of the iris is observed. Later, when convulsions have occurred, the parallelism of the eyes is lost. After effusion has taken place the pupils are commonly dilated. As death approaches the eyes become bleared and a puriform secre- tion collects in the inner angle of the eye and between the eyelids. This secretion is not abundant, but it is sometimes sufficient to unite the lids. The sense of hearing is probably lost as soon, or nearly as soon, as that of sight, but the sense of touch continues longer. The tongue is covered with a moist fur, unless near the close of life, when it is sometimes dry. The appetite is gradually lost, but often drinks are taken with apparent relish, even when there is no other evidence of consciousness. There are two symp- toms pertaining to the digestive system which are rarely absent, and which possess great diagnostic value : one is vomiting, the other constipation. In some patients irritability of stomach begins at so early a period that it is really prodromic ; it is rarely absent. Barrier collected the records of 80 patients with meningitis, and in 75 of these this symptom was present. It is due to the intimate relation existing between the stomach and brain through the ganglionic system of nerves. The vomiting occurs without effort, and usually at intervals for several days. It is a sudden ejection of the contents of the stomach, apparently without preceding or subsequent nausea. It contrasts, therefore, with the vomiting due to an emetic, which is attended by distressing symptoms. With some it occurs frequently, with others not more than two or three times daily. Commencing in the first stages of meningitis or even prior to it, it occurs less often as the drowsiness becomes more profound, and finally ceases. Constipation is also present, usually from the commencement of the meningitis. It is one of the most constant and persistent symptoms, continuing throughout the entire sickness, unless relieved by medicine or unless there be a coexisting diarrhceal affec- tion. Often, when diarrhoea precedes the meningitis, it ceases the moment the latter commences. The constipation in this disease is easily overcome by purgatives. Several writers speak of retraction of the abdomen as a sign of meningitis. A hollow or sunken appearance of the abdomen, according to Golis, aids in distinguishing meningitis from fever. The anterior abdominal wall approaches the spine, so that the pulsations of the abdominal aorta are distinctly felt. Rilliet and Barthez. who have rarely observed this retrac- tion except in cerebral diseases, attribute it to the state of the intestines rather than to the action of the abdominal muscles. MENINGITIS. 605 The pulse in the first stages of meningitis is accelerated, or it is nearly natural during certain hours and afterward accelerated. When the disease has continued a few days, often not more than three or four, the pulse under- goes a marked change. It becomes slower and at the same time irregular. The irregularity usually consists in an intermittence of the pulse after each six or eight beats. Sometimes the force of the pulse varies, so that a feeble pulsation is succeeded by one of greater volume and strength. The decrease in the frequency of the pulse cannot fail to arrest attention. From 110 or 120 beats per minute in the first stage of the inflammation it often descends to a frequency even less than that of the normal adult pulse. At an ad- vanced period, as death approaches, the pulse again becomes accelerated and feeble. The change in respiration is as marked as that of the pulse. In the beginning of meningitis the breathing is in some patients moderately accel- erated ; in others it is natural. When the disease has continued a few days, the time usually varying from three or four days to more than a week, a marked alteration occurs in the respiratory movements. Their rhythm, like that of the pulse, is changed. The breathing is irregular, intermittent, and accompanied by sighs. The change in pulse and respiration corresponds with the loss of consciousness, and shows that the brain is becoming seriously involved. When the pulse and respiration undergo the changes which have been described, another prominent and grave cerebral symptom is sometimes pres- ent — to wit, convulsions. Their occurrence diminishes greatly the prospect of a favorable issue. The severity and extent of the convulsive movements vary in different cases. They may be partial or general. Their duration is often brief, but they recur three or four times through the day. They are preceded by cephalalgia in those old enough to express their sensations, and often by drowsiness. Each convulsive attack ends in still greater drowsiness. With this group of symptoms another should be mentioned. I refer to the hydrocephalic cry. At intervals the patient, without being disturbed and without any change in symptoms, utters a scream or sharp cry, and immediately relapses into his former state. This cry is more common in the commencement of the meningitis than subsequently, and in many it is absent or is not a marked symptom. The glandular system participates in the gen- eral loss or derangement of function. Tears are seldom shed even when the child is much irritated, and the urinary secretion is diminished. The small amount of urine passed sustains an important relation to the progress of the disease and the therapeutics. The patient usually lingers several days after the pulse and respiration are changed in the manner stated. The drowsiness becomes more profound, the vomiting ceases as well as the convulsive attacks, and sensation and con- sciousness are entirely lost. But even in this state, if nutriment and stimu- lants be administered with regularity, the child often lives several days longer than appeared possible. At length increasing feebleness and rapidity of pulse and coldness of the face and limbs indicate the near approach of death, which occurs in a state of coma. The symptoms described above are such as we observe in ordinary cases of meningitis, and in the order which I have indicated, but this description does not apply to all cases. Meningitis may be so violent and rapid that both the character and suc- cession of symptoms are different from those which have been stated. Thus, I have related the case of a girl who, with no prodromic symptoms excepting occasional dizziness and slisrht headache, was taken sick on Thursday, had 606 LOCAL DISEASES. convulsions on Friday, and from this time continued either in convulsions or coma till her death on Monday. Again, even in cases of the usual duration and anatomical character some of the most prominent symptoms upon which we rely for diagnosis may be lacking. The following was a case of this kind : Case. — On the 5th of April, 1862, 1 was asked to see a boy, two years and eight months old. of healthy parentage, who during the preceding year had been in uni- form good health, but previously had had two or three severe attacks of sickness. His head was unusually large, and whenever much indisposed he often had symp- toms premonitory of convulsions, which were always, however, prevented. One night in the latter part of March his parents noticed that his sleep was restless, but on the following day he seemed entirely well, and the restlessness at night was attributed to a late and hearty supper. On succeeding nights, however, he was restless, and when questioned complained of pain in the abdomen. In a few days he was observed to be drooping in the daytime, and his appetite was not quite so good as previously. He had continued in this way about a week when my first visit was made. The abdominal pain had at this time become more constant, but was never severe or accompanied by moaning. When asked where he felt sick, he placed his hand upon the epigastrium, pressure upon which was sometimes tolerated, but at other times painful. The following symptoms were noted: tongue slightly furred, anorexia, thirst, constipation, scantiness of urine, no headache or unusual heat of head during any part of his sickness. He vomited at intervals from about the 7th to the 10th of April, when the irritability of stomach ceased and there was no return of this symptom. About April 7th the respiration was first observed to be irregular and sighing, and the pulse intermittent. These symptoms, so tardily developed, were the first which indicated cerebral disease. He now lay most of the time in bed with eyes closed, surface commonly pallid, with occasional rose-colored spots or patches upon the cheek or forehead. The pupils responded to light in the usual manner till near the close of life, but bright lights were painful : the last two or three days of his life the left pupil was more dilated than the right. He had no convulsions or any spasmodic movement, and was conscious till within a few hours of death : the mother states that there was unequivocal evidence of his recognition of her on the last day of his life. He died April 17th, nearly three weeks after the commencement of the disease and ten days after the commencement of symptoms which were clearly referable to the brain. Autopsy. — Abdominal organs healthy, though epigastric pain had been so con- stant and prominent a symptom ; brain and its membrane somewhat injected. The meninges covering the base of the brain from the most prominent part of the pons Varolii to the first pair of nerves presented evidences of inflammation. There was such opacity of the pia mater in places as to conceal the brain from view. The ante- rior and middle lobes of each hemisphere were glued together by fibrinous exuda- tion, and on the left side, along the fissure of Sylvius, was a thick deposit of the same character. The lateral ventricles contained about an ounce of clear serum, and about half an ounce escaped from the base of the brain. The foramen of Monro was con- siderably enlarged, and the brain-substance surrounding the lateral ventricles was softened. In this case it is seen that the prominent symptom — and, indeed, almost the only marked symptom in the first stages of the disease — was pain in the abdomen, and yet the abdominal organs were healthy. At the very moment when it was highly important that a correct diagnosis should be made, the evidences of cerebral disease were lacking. This case is therefore interesting on account of the variation in symptoms from those in the usual form of meningitis. There were no convulsions, and consciousness was retained, as well as vision, till near the close of life, and yet the lesions were such as are commonly present in meningeal inflammation. It is in such cases that a wrong diagnosis is frequently made, to the injury of the patient and the reputation of the physician. MENINGITIS. 607 Occasionally meningitis may continue so long as almost to justify its "being called chronic, even when there is a large amount of exudation upon the pia mater. In the few cases which end favorably the symptoms abate gradually. I shall describe more fully the termination in speaking of Prognosis. Diagnosis. — It is of the utmost importance to diagnosticate meningitis in its first stages, since treatment to be successful must be commenced early. Certain writers describe at length the means of diagnosticating the simple from the tubercular form of the inflammation. Differential diagnosis is often difficult, and sometimes impossible ; but it matters little, practically, whether the form of the disease be ascertained. On the other hand, it is very im- portant, in order that the treatment be appropriate, to diagnosticate the pre- monitory or initial stage of meningitis from certain other affections not located within the cranium. Sometimes remittent or continued fever or constitu- tional disturbances arising from irritation in the digestive system simulate closely incipient meningeal disease, so that the greatest care and discrimi- nation are required in order to make a correct diagnosis. Within a compara- tively recent period I have known in three different instances experienced physicians of this city to mistake commencing meningitis for fevers, not aware of the serious error they had made till the inflammation had reached a stage from which recovery was impossible. In order to avoid error in the diagnosis in the premonitory or initial stage of meningitis, the physician should take time to observe the physiognomy and note every symptom. More than one protracted visit is often required to remove doubt as to the exact pathological state. Meningitis is usually preceded, and in its commencement accompanied, by greater restlessness, fretfulness, intolerance of light, and a greater varia- tion of symptoms, than most other maladies. One familiar with the physiog- nomy of infancy and childhood will discover in the features indication of greater suffering, of more serious sickness, than is commonly present in other maladies which simulate this. The eye should always be carefully observed. Inequality of the pupils, their oscillation, strabismus, nystagmus, and espe- cially the altered state of the optic disks, which a distinguished oculist has designated " outlying portions of the brain, ' ; will often assist in making the diagnosis positive. Sometimes the sudden disappearance of a chronic eruption upon the scalp will aid in the diagnosis. This is a sign of importance, taken in connection with the symptoms. Headache and vomiting, symptoms of early occurrence, should especially arrest attention, or in absence of headache, pain of a neur- algic character in some other part. But we may repeat that familiarity with the symptoms of meningitis will not protect from error, if the visits of the physician are hasty and his examinations imperfect. When the eyes become affected, the respiration and circulation irregular, and especially when convulsive attacks begin, diagnosis is easy. In fact, an incorrect diagnosis would then be unpardonable ; but, unfortunately, if proper treatment have not been commenced till this period it will be of little service. Prognosis. — Meningitis is one of the most fatal maladies of early life. Whether the form be tubercular or not, if the initial stage have passed with- out proper treatment, death may be considered inevitable. Tubercular men- ingitis, however early recognized, is rarely amenable to treatment. M. Guer- sant x believes that recovery from the first stage of this form of meningitis is possible. " In the second stage," says he, " I have not seen one child recover out of a hundred, and even those who seemed to have recovered have either sunk afterward under a return of the same disease in its acute 1 Diet, mid., t. xix. p. 403. 608 LOCAL DISEASES. form or have died of phthisis. As to patients in whom the disease has reached its third stage, I have never seen them improve even for a moment. " The very few reported cases which resulted favorably may have been, as M. Guersant has intimated in the context, cases of the non-tubercular form. Rilliet and Barthez believe that in a few instances tubercular meningitis has been cured in its first stage, but they state also that it is likely to return. The PROGNOSIS in non-tubercular meningitis is not so unfavorable, provided that treatment be commenced at a sufficiently early period. It is now gen- erally admitted that it may not infrequently be averted when threatening, and even arrested in its incipiency. In many such cases we cannot, from the nature of the disease, be certain that the diagnosis is correct. But when we see children relieved who present precisely those premonitory and even initial symptoms which occur in meningitis, we must believe that at least some of them would have had the genuine disease if not relieved by the measures employed. That in its commencement recovery is possible is also obvious from the fact that a few recover even in the second stage, when there can be no error of diagnosis. Although a considerable proportion of patients with epidemic cerebro- spinal meningitis recover, even when the symptoms have been most grave, I have known only two recoveries from sporadic meningitis when it had reached that stage in which the functions of the brain and cranial nerves were impaired. One of these recovered with permanent loss of sight, the other with loss of hearing. Both seem to have ordinary intelligence. An- other case has been communicated to me in which the patient, a little child, recovered completely, but for several months after the attack seemed nearly idiotic. Sometimes, even in the second stage of meningitis, treatment properly employed is attended by amelioration of symptoms. Though such improve- ment may serve to encourage physician and friends, it should not be the basis for a favorable prognosis unless it continue three or four days. Apparent improvement during a few hours or a considerable part of a day is not unusual in those who finally die. Thus, in an infant whose bowels were previously confined I have known the pulse and respiration to become more regular and the symptoms generally improve, though only for a brief period, by the action of a purgative. Dr. Watson says of the advanced stage of this disease, it is " often attended with remissions, sometimes sudden and sometimes gradual — deceitful appearances of convalescence. The child re- gains the use of its senses, recognizes those about it again, appears to its anxious parents to be recovering, but in a day or two it relapses into a state of deeper coma than before. And these fallacious symptoms of improvement may occur more than once." Most fatal cases of meningitis terminate between the third or fourth and the twentieth day, the duration varying according to the extent and intensity of the inflammation and the vigor and age of the patient. But there are cases in which it may continue much longer. It is surprising sometimes how long the patient lives when the symptoms are such that death seems impending. Sensation and consciousness may be extinguished, convulsions occur at intervals, and the surface have acquired almost a cadaveric aspect. and yet the patient lives on. Rilliet and Barthez say : " Often have we inscribed upon our notes death imminent, and been astonished the next day to find still alive children to whom we had scarcely allowed two hours of life." The symptom which I have found to be the most reliable prognostic of the near approach of death has been a pulse gradually becoming more frequent and feeble, though other symptoms remain as before. This change MENINGITIS. 609 in the pulse is usually very apparent during the last twenty-four hours of life. Treatment. — Such remedial measures should be prescribed during the premonitory stage as are calculated to relieve the fretfulness or irritability of temper and quiet the action of the brain, and at the same time produce a derivative effect from this organ. To this end the patient should be kept from all causes of excitement, and the bowels should be opened daily — if not naturally, by the use of proper medicines. A mustard foot-bath at night and occasionally through the day is useful, as it produces both a derivative and soothing effect. It will commonly produce a few hours' undisturbed rest, while other measures except medicines fail. If dentition be taking place and the gums are swollen, it has been the practice to employ the gum-lancet, and still is with some physicians, but I for one have discarded its use for this purpose. Restlessness from dentition or restlessness premonitory of meningitis requires large doses of bromide of potassium, which will relieve the symptoms more effectually than the lancet. Three grains should be given to a child of six months, and four grains to one of ten or twelve months, and repeated if necessary in one to two hours. If symptoms indi- cate the near approach of meningitis or its incipiency, the head should be kept constantly cool by a cloth wrung out of ice-water, or, better, an India- rubber bag containing ice. Some physicians have recommended vesication back of the neck or ears, but it is a measure of doubtful benefit, and if em- ployed at all should be restricted to the application of cantharidal collodion behind the ears. All purulent collections near the meninges should be opened and disinfected, and especially should the ear be examined, and if the membrana tympani be bulging or hypersemic, paracentesis should be performed, and followed by washing with a warm and weak solution of boracic acid. Many children who are threatened with meningitis are scrofulous. They have already shown symptoms of tubercular disease. They are perhaps, to a certain extent, emaciated, and may have been affected with a cough. If the premonitory symptoms in children indicate the approach of the tuber- cular form of meningitis, a more sustaining course of treatment is required than in those who are robust. To such children cod-liver oil may be profit- ably given three times daily, together with the syrup of the iodide of iron, and perhaps the bromide. They should also be taken into the open air with proper precautions, and every hygienic measure should be employed which will be likely to invigorate the system without exciting the brain. Loss of blood is not, in general, required during the prodromic period nor in the disease. Those of a strumous cachexia, or those, whether strumous or not, who are under the age of two years, do not, unless in very rare instances, require depletion by leeches, much less by venesection. There is one class of patients in whom the early loss of blood may perhaps be of service — namely, those who in a state of robust health are suddenly seized with inflammation, especially if the cause be insolation. Leeches may then be applied to the head of the patient if he be seen at an early period, but the majority of physicians probably wisely recommend the ice-bag in preference to leeching. Often, notwithstanding the measures employed, the patient grows worse ; the symptoms become more continuous, others more alarming arise, and meningitis declares itself. Whatever the cause of the inflammation, and whatever modifications of treatment were required in the premonitory stage on account of special indications, the purpose now is to subdue the inflam- mation by every resource in our art which does not injure or too much pros- trate the system. In former days calomel was largely employed as the main 610 LOCAL DISEASES. remedy in this disease, but when administered daily it has a very depressing effect, and it is to be borne in mind that in meningitis the vital powers pro- gressively fail on account of the loss of appetite, vomiting, etc. In tuber- cular meningitis depressing treatment is of course strongly contraindicated. .Cases have occurred in which calomel was given at short intervals for several successive days, so as to produce a laxative effect, but. though the meningitis seemed to be controlled, death resulted from exhaustion or from some intercurrent affection due to exhaustion. Thus in one case formerly related to his class by a distinguished New York professor, fatal gangrene of the mouth supervened from the mercurial treatment after the meningeal inflammation had apparently subsided. Although calomel during these last years has been properly discarded as the main remedy and its daily use rejected, nevertheless it is very useful as an occasional laxative in the more robust cases if not given too near the iodide of potassium ; and it is especially indicated as a derivative from the head in children of four or five years, who, previously hearty and strong, have become suddenly affected with meningitis, as from exposure to the sun's rays or from an injury. But I repeat the belief that in ordinary cases calomel should never be employed, except as an occasional laxative. The two remedies upon which we must chiefly rely are the iodide of potassium and the bromide of potassium or sodium. While the bromide quiets the restlessness, prevents convulsions, and diminishes, there is reason to think, to a certain extent, the hyperemia, the iodide is useful as a sorbe- facient, and it probably has some control over the inflammation. The iodide or bromide can be given together or separately. The iodide should, like the bromide, be given early. If by a careful examination the absence of any other local disease or constitutional disease which might give rise to the symptoms be ascertained, and the symptoms indicate the meningeal disease, the iodide should be immediately prescribed. Obscurity often hangs over meningitis at this early stage, but it is better to give the iodide, even if the diagnosis be wrong and no inflammation have commenced, than to err on the other side, and withhold it in the initial period of the true disease ; for it is not an injurious remedy like calomel, and to exert any marked effect it should be given in the commencement of the inflammation. An infant of the age of six to twelve months should take two grains every two hours, and older children a proportionate dose. At the same time the bromide should be given in doses twice as large as that of the iodide if the indications for its use are present — to wit, headache, restlessness, and symptoms which threaten eclampsia. The bromide is a harmless remedy given frequently for a limited time. With the regular and continued use of the iodide and occasional doses of bromide, the quantity of urine is in most cases largely increased. If the patient's condition do not soon begin to improve with such treatment, there is no remedy. If convulsions occur, the bromide should be given every ten or fifteen minutes till they cease. If they be not controlled by the bromide, an injec- tion, per rectum, of three to five grains of hydrate of chloral in a teaspoonful of water should be used in addition. Compresses wrung out of ice-water fre- quently applied to the head, or a bladder containing pounded ice and separated by one thickness of muslin from the head, materially aid in reducing the meningeal hyperaemia. Ergot, recommended by Brown-Sequard for its sup- posed effect in diminishing the hyperaemia in the inflammatory diseases of the nervous centres, may also be employed as an adjuvant in the treatment of this disease, but it has much less effect upon the hyperaemia of the brain or meninges than upon that of the uterine system. In the first stage of simple meningitis the diet should be mild and in SPUMOUS HYDROCEPHALUS. 611 moderate quantity, but in the tubercular form it should from the first be of the most nourishing kind, consisting of beef tea, milk porridge, etc. At a more advanced stage in both forms of the malady the most nutritious diet should be allowed, but alcoholic stimulants should not be given unless near the close of life, when the vital powers are failing. The apartment should be cool and quiet. CHAPTEE VI. SPURIOUS HYDROCEPHALUS. The disease known as spurious hydrocephalus might with more propriety be called spurious meningitis. It received its appellation at the time when meningitis of early life was believed to be essentially a hydrocephalus, and was so called. Attention was first directed to it by London physicians of the last generation, particularly by Drs. Grooch, Abercrombie, and Marshall Hall, and little can be added to their description of its symptoms. Anatomical Characters. — This disease, though resembling meningitis in certain of its phenomena, is not in its nature inflammatory, nor is it primary. It is the result of some malady often chronic, but occasionally acute, which has produced exhaustion, especially of the nervous system. When it commences there is usually more or less emaciation and the symp- toms of the primary disease are present. To this disease the lesions pertain which are found in other organs besides the brain. The state of the brain in spurious hydrocephalus is not the same in all cases. In some there is no appreciable anatomical alteration in this organ. There is no apparent difference, either in the meninges or the brain itself, from the condition which we often observe in those who have died of diseases which do not affect the cerebro-spinal system. In such cases the pathological state is simply deficient innervation, or if there be a structural change in the minute anatomy of the brain, pathologists have not yet discovered it. The following case, which occurred in the Child's Hospital of this city, is an example of this form of spurious hydrocephalus : Case. — A female infant, six months old, died on the 24th day of April, 1862, with the following history : It was wet-nursed, fleshy, and apparently well till six days before death, when symptoms of gastro-intestinal inflammation were suddenly developed. The vomiting especially was severe, continuing forty-eight hours. When it ceased, drowsiness supervened and continued till the close of life. The face during the four days of stupor was pallid and cool ; eyes partly open, pupils sluggish, but of equal size ; bowels rather torpid ; anterior fontanelle depressed. When aroused the infant noticed objects for a moment, and immediately relapsed into sleep ; pulse accelerated and not intermittent, the day before death numbering 150; respiration accelerated, without sighing, numbering on the same day 30. There were no con- vulsions, and death occurred quietly. The brain weighed twenty and a half ounces, and its appearance was perfectly healthy, both as regards consistence and vascu- larity. The amount of cerebro-spinal fluid in the ventricles and at the base of the brain was not notably increased. The stomach, small and large intestines, were vascular in streaks and patches. In this case the cerebral symptoms were obviously due to exhaustion occurring at an early period in consequence of the severity of the gastro- intestinal malady. 612 LOCAL DISEASES. In a majority of cases, however, of spurious hydrocephalus, according to my observation, there is an anatomical alteration in the state of the brain and meninges. This consists in passive congestion of the veins, often with tran- sudation of serum. At the same time, the cranial sinuses are congested, and are found at the post-mortem examination to contain larger and more numer- ous clots than are present in those who die of diseases which do not affect the encephalon. Cases might be cited as examples. The cause of this con- gestion and effusion is in a great measure feebleness of the circulation due to the general exhaustion of the patient. But there is another cause. In pro- tracted diseases, especially those of a diarrhoeal character, there is more or less wasting of the brain as well as of other parts. This naturally, by way of compensation, gives rise to congestion of the cerebral and meningeal veins and capillaries and to transudation of serum. The transudation commonly occurs in this malady over the superior sur- face of the brain and in the subarachnoidal space, perhaps also more or less in the lateral ventricles. So common is it in the last stage of infantile entero-colitis, the summer epidemic of cities, that this stage, which is really spurious hydrocephalus, has been called the stage of effusion. I shall relate in another place examples which show the anatomical character of this intes- tinal disease. . Symptoms. — Spurious hydrocephalus most frequently results from pro- tracted diarrhceal complaints. It may, however, result from any disease which is attended by great prostration. As it ordinarily occurs, the patient has for days or weeks been gradually losing flesh and strength. Finally, drowsiness supervenes, or before the drowsiness there is sometimes a period of irritability. Marshall Hall describes two stages of spurious hydrocephalus. In the first, he says, " the infant becomes irritable, restless, and feverish ; the face flushed, the surface hot, and the pulse frequent ; there is an undue sensitive- ness of the nerves of feeling, and the little patient starts on being touched or from any sudden noise ; there are sighing and moaning during sleep, and screaming ; the bowels are flatulent and loose and the evacuations are mucous and disordered." The second stage he describes as that of torpor. The first stage often, however, does not present those prominent symptoms which have been described by Dr. Hall, and this stage may even be absent or not appreciable, especially in young infants. Whether or not commencing with the stage of irritability, the disease, if not checked, gradually increases. The child soon becomes drowsy. He may be aroused for a moment, but unless constantly disturbed immediately relapses into sleep. He is sometimes fretful when aroused, but in other instances is quite indifferent, observing without apparent interest objects employed for the purpose of amusing him. Often there are indications of cerebral pain or distress, as contractions of the eyebrows, etc., but many of those affected are too young to make known their sensations. Convulsions sometimes occur toward the close of life, but they are not so common in this disease as in meningitis. When they do occur they are generally partial and often slight. The pulse is accelerated in most patients prior to and in the commencement of spurious hydrocephalus. As the disease advances it becomes irregular and intermittent, and toward the close of life it is pro- gressively more frequent and feeble. The respiration at first is not much disturbed, but at length it becomes irregular like the pulse. It is feeble and accompanied by sighs. Occasionally, there is slight cough. The eyelids are partly open, the pupils no longer respond to light, and in advanced cases they have a bleared appearance. The diarrhoea, which in most instances precedes and causes this malady, continues till the stage of stupor arrives, SPUMOUS HYDROCEPHALUS. 613 when the evacuations becomes less frequent or cease altogether. In infants the stools are frequently green, in older children brown and sometimes slimy. The febrile heat of surfaces which preceded the disease, and which was present in its commencement, disappears ; the face and hands become cool, the features pallid, and the anterior fontanelle, if opened, is depressed. Death finally occurs in a state of coma, or if the disease be recognized and proper remedial measures employed, the result may be favorable, even when the symptoms are such that if meningeal inflammation were the malady we would consider the case necessarily fatal. In the following case the result was unfavorable. This case is interesting on account of the anatomical characters of the disease as disclosed by the post-mortem examination : Case. — " A German infant, eighteen months old, had diarrhoea four weeks with- out regular and proper medical attendance ; stools from the first brown and thin : during the last eight or nine days he has been drowsy ; when aroused opens his eyes and is very fretful, but immediately the upper eyelids gradually droop, and unless disturbed he remains asleep with his eyes partially open ; forehead warm, face cool and pallid, and limbs also rather cool : pulse 164, respiration 32 ; has had a slight cough about one week, and slight dulness on percussion over the left infra- scapular region: depression of inframammary region on inspiration. Treatment: Amnion, carbonat.. gr. 1 every two hours ; nourishing diet. " Dec. 20th, has continued drowsy since the last record ; pupils moderately dilated : a thick secretion between eyelids ; right pupil considerably larger than the left : vision apparently lost during the last three days ; pulse over 140 ; respira- tion 44 per minute, accompanied by sighing since the 18th; moans much when awake : rolls the head frequently ; during the last six days the surface back of the ears has been constantly sore by vesication ; takes the most nutritious diet with brandy. The stools remain thin and brown and number three or four daily. " From this date the diarrhoea continued, except as it was restrained by medi- cine. The pulse continued frequent and a slight cough remained. There was on the 21st and 22d partial abatement of the drowsiness, but on the 23d it was greater than ever. The body was somewhat reduced at the commencement of the cerebral symptoms, but it was now markedly emaciated. The prostration increased daily, and the hands were observed to tremble. The face and hands became more cool, while the head was warm. On the 24th partial convulsions occurred, followed by coma and death. •• The cerebral veins and sinuses were generally congested, except in the anterior portion of the brain, where the appearance was normal. Between the brain and its membranous covering, chiefly at the vertex and the base, was an effusion of clear serum. The whole amount of this fluid was estimated at two ounces. On slicing the brain numerous ' puncta vasculosa' were seen, both in the gray and white portions. With the exception of the congestion the sub- stance of the brain presented its normal appearance. No inflammatory lesions were present. We were not permitted to examine the condition of the intestines." Diagnosis. — The only disease with which spurious hydrocephalus is liable to be confounded is meningitis. The points of differential diagnosis are the history of the case, especially the antecedent diarrhoea or other ex- hausting ailment, evidence of prostration when the cerebral malady com- menced, depression of the anterior fontanelle if it be open, and the cool face and extremities. Prognosis.— If the pathological state of the brain be simple exhaustion, the disease can often be arrested by judicious treatment. If an incorrect diagnosis be made and the treatment employed be that appropriate for menin- gitis, which it simulates, death is almost inevitable. If transudation of serum have occurred, unless slight, the result is usually unfavorable what- ever may be the treatment. This disease in childhood is more easily man- aged than in infancy, but is less frequent. The prognosis is better in the cool months than during the heat of summer. It is more favorable if the 614 LOCAL DISEASES. child be over than if under the age of one year. The occurrence of an irregular and intermittent pulse, of respiration accompanied by sighs, of inequality in the pupils or their sluggish movements, with increasing stupor, indicates an unfavorable issue. The cure of the primary disease, with the pulse and respiration still natural or accelerated, without change of rhythm, pupils sensitive to light, drowsiness from which the patient is easily aroused to a state of entire consciousness, render recovery probable with proper medication and alimentation. Treatment.— The indications of treatment are twofold : first, to remove the primary pathological state which is the cause of the spurious hydro- cephalus ; and, secondly, to cure the latter. The first is important, since the successful treatment of a disease requires the removal of the cause. The measures employed for this purpose are pointed out in our description of the diarrhoeal and other maladies which produce spurious hydrocephalus. We may here say that, as spurious hydrocephalus is due in a very large proportion of cases to the exhausting effect of long-continued diarrhoea, regulation of diet, subnitrate of bismuth, pepsin, and stimulation are needed. Active sustaining measures are indicated. Exhausted nervous power, as well as passive cerebral congestion, requires these. The diet should be highly nutritious, comprising such substances as milk and beef juice, and should be given frequently. Brandy is required at short intervals. Dr. Gooch was in the habit of giving the aromatic spirits of ammonia, properly diluted, as a quick and active stimulant. Six or eight drops may be given in sweetened water to a child one year old, and repeated every hour in cases of urgency. If by proper treatment of the cause and by the use of stimu- lants and nutritious food the patients do not within a few hours become less stupid and more conscious, there is that degree of prostration or of serous transudation from the engorged cerebral veins which will render death probable. In some cases it is proper to produce moderate vesication behind the ears. CHAPTER VII. ECLAMPSIA. The term " eclampsia " is used in a more restricted sense by some writers than by others. It is employed in the following pages to designate those convulsive seizures, clonic in their character, sometimes general, sometimes partial, which affect the external muscles, and are due to some exciting cause. It consists in rapid, forcible, and involuntary muscular contraction alternating with relaxation. It is distinguished from chorea in the fact that the latter is a more permanent state, and is characterized by muscular move- ments which are partially under the control of the will and are not so violent. The symptoms of eclampsia closely resemble those of epilepsy, but these diseases are distinguished from each other by characters which will be mentioned hereafter. Eclampsia occurs in a great variety of diseases, some of which are located in the cerebro-spinal system, some in other parts of the body, and some are constitutional. It may also be produced by temporary derangements of sys- tem not sufficiently severe to be considered diseases, and by powerful mental impressions, those of an emotional nature affecting the delicate and sensitive nervous system of the child. Pathologists recognize three different forms of ECLAMPSIA. 615 eclampsia. The term essential or idiopathic is used when the convulsions have no appreciable anatomical character ; that is, when there is no apparent pathological state in the brain or elsewhere which gives rise to the attack. For example, if a child die in convulsions from fright, and all the organs, including the brain, are found in their normal state, the eclampsia is called idiopathic or essential. If the cause be disease of the brain or spinal cord, it is termed symptomatic. If eclampsia arise from local disease elsewhere than in the cerebro-spinal axis, as from pneumonia, the term sympathetic is em- ployed. This is in the main a good division, but eclampsia may be at the same time sympathetic and symptomatic, as when it occurs in consequence of congestion of brain which is induced by severe and frequent paroxysms of whooping cough. Causes. — Eclampsia occurs at any period of infancy and childhood, but it is much more rare after the period of six or seven years than previously. Some children are more liable to it than others. It is produced in one by an agency which in another has no appreciable effect. There are some, gen- erally those of an impressible nervous system, who are seized with convul- sions whenever there is any slight derangement in the digestive or other organs. Eclampsia is frequent in certain families. Thus, Bouchut mentions a family of ten persons all of whom had convulsions in their infancy. One of them married and had ten children, who, with one exception, had convul- sions. The exciting causes of eclampsia are too numerous to be mentioned in full. It is a symptom in nearly all cerebral diseases. It is produced in the nursling by changes in the milk with which it is nourished. These changes are usually due to violent emotions of the mother, as anger, fright, and grief, to the use of acescent or indigestible food, or to derangement, tempo- rary or permanent, in their health. Thus, in a case related to me the cata- menia so affected the milk that? the infant was seized with eclampsia at each monthly period. In childhood the most common cause of clonic convulsions is the presence of some irritant in the primae viae. All kinds of fruit, even the mildest, may produce eclampsia, especially when eaten unripe or taken in undue quantity. I have known an infant to be seized with convulsions from eating strawberries, which parents usually regard as harmless, and one of the most violent and protracted cases of eclampsia which I have wit- nessed occurred in a child over the age of six years from swallowing, in con- siderable quantity, the parenchymatous portion of an orange. Constipation, worms, dysentery, intussusception, and painful dentition are also causes which are located in the digestive apparatus. Inflammation in some part of the respiratory apparatus is a not infrequent cause. Thus, eclampsia occurs occasionally in severe coryza, in consequence, according to some, of the proximity of the inflamed surface to the brain and the consequent afflux of blood to this organ. It is a common complication also of pertussis and pneumonia. It occurs often at the commencement of two of the eruptive fevers — namely, smallpox and scarlet fever, and in the course of the latter disease. Violent emotions of the child may also cause eclampsia. Bouchut relates the case of a girl five years old who was corrected before her companions, and was so affected by anger that convulsions ensued. Residence in close and overheated apartments or in streets where the air is loaded with offen- sive vapors and is stifling, is a predisposing cause, so that there is a larger proportion of deaths from convulsions in the cities than in the country. In young children burns, even when not very severe, are liable to termi- nate suddenly in eclampsia, succeeded by coma and death. Urinary calculi, both renal and vesical, may produce the same result. 616 LOCAL DISEASES. Such are the more common causes of eclampsia. It is seen that they are of two kinds, predisposing and exciting. An excitable or impressible state of the nervous system constitutes the chief predisposition to the dis- ease. Plethora, or its opposite state ansemia, increases the liability to an attack. Premonitory Stage. — In the majority of cases there are prodromic symptoms which the experienced and careful physician can detect so as to forewarn friends. The child is perhaps more or less drowsy, and, when dis- turbed, fretful. The eyes often have a wild or unnatural appearance ;' occa- sionally they are fixed for a moment on an object, and yet apparently with- out noticing it. The sleep is disturbed ; in some there is unusual heat of head, and, if old enough, complaint of headache. At times, especially if the primary disease be febrile or - inflammatory, there is incoherence of thought or expression, or even actual delirium. In some children when eclampsia is threatening the thumbs are seen to be carried across the palms. I have observed this especially during the convulsive cough of pertussis. A very important prognostic symptom is sudden starting or twitching of the limbs. This shows that the nervous system is profoundly impressed, and but slight additional excitation is required to develop eclampsia. This sudden starting not infrequently precedes the attack several hours and gives suflicient fore- warning. The prodromic symptoms are often disregarded by friends who do not understand their significance. Even physicians, in the haste of their visits, in many instances do not notice them. The S} T mptoms which precede symp- tomatic and sympathetic eclampsia are, moreover, blended with those of the primary affection, and hence another reason why they are frequently over- looked. When the convulsions are about to commence the child generally lies quiet ; the eyes are open and fixed. If spoken to or shaken he takes no notice and does not speak. The direction of the eyes is then changed ; often they are turned up ; occasionally there is strabismus. The face may be pale or flushed, and sometimes, especially in cerebral diseases, the features present patches or streaks of a flushed appearance, while around them the natural color is preserved. Immediately before the spasmodic movements, the child sometimes utters a piercing scream, which is probably involuntary, though it seems like a supplication for help. The duration of the prodromic stage is very different in different cases. It may last from a few minutes to several hours, or even more than a day. Symptoms. — Eclampsia is general or partial. If general, the muscles of the face, eyes, eyelids, and of all the limbs are in a state of rapid involuntary contraction, alternating with relaxation. The features lose their natural expression and are distorted ; the mouth is drawn out of shape, often to one side, by the violent muscular action ; the teeth are pressed together by tonic contraction of the masseters, and may be violently struck together, so as to lacerate the tongue if it protrude, or are ground upon each other. Unless the attack be of short duration, frothy saliva, perhaps tinged with blood from the injured tongue, collects between the lips. The eyelids are usually open, and in severe cases the eyes are turned so that the pupils are lost under the upper eyelids, or the muscles of the eyes are involved in the spasmodic move- ment so that the eyeballs are forcibly drawn from side to side. Occasionally strabismus occurs. While the features are thus distorted the head is strongly retracted or is turned to one side ; the forearms are alternately pronated and supinated ; the thumbs and fingers are convulsively flexed, so that the thumbs lie across the palms and are covered by the fingers ; the great toe is adducted, the other toes flexed ; and the toes, as well as legs, participate more or less in the spasmodic movements. ECLAMPSIA. 617 In general convulsions, consciousness is usually lost. The head is hot previously to and during the attack — at least in the first part of it — and the face flushed. In exceptional cases, especially in sympathetic eclampsia, the head is cool and the face pallid. The pulse is somewhat accelerated, as well as the respiration, and the latter is rendered irregular if the respiratory mus- cles, especially those of the larynx, are involved, as they generally are. The sphincters are relaxed during the convulsive attack, so that in many cases the urine and stools are passed involuntarily. Partial eclampsia is more common than the general form ; it occurs in the muscles of the face, including those of the eye, of the face and of one or both upper extremities, or of the face and the extremities on one side. The spasmodic movements may be even limited to the muscles of the eye, and they often occur only in these muscles and those of the face. Rarely, if ever, does eclampsia affect the legs without affecting also the muscles of the arms and face. In partial convulsive attacks sensation and consciousness are in some patients not entirely lost, but in others they are not manifested if present. The duration of an attack of eclampsia varies in different cases from a few minutes to several hours, with an average of not more than from five to fifteen minutes. The movements do not often continue longer than three or four hours in the severest cases. They are sometimes said to last a much longer time, even for days, but in these cases there are intermissions. Violent attacks are usually short. When the convulsion ends favorably the spasmodic movements become less and less strong, and finally cease. The child then takes a deep inspira- tion, after which it lies quiet, and the respiration remains regular or mode- rately accelerated. Some fully recover in a few minutes if the eclampsia have been light and the cause transient, and seem to experience no incon- venience except soreness of the muscles and fatigue. Others soon recover consciousness, and their temperature, respiration, and circulation become natural, but they remain dull for a time, their minds are bewildered, and they are perhaps unable to speak. In a few hours these untoward symptoms pass away. In essential, and in a large proportion of cases of sympathetic, eclampsia, if properly treated and if the cause be recognized and removed, there is no recurrence of the convulsion ; in others it is different. In many cases, especially of symptomatic eclampsia, and of sympathetic in which the cause is grave and persistent, the convulsions return after a variable period of a few minutes or a few hours. Six or eight or more convulsions may occur within twenty-four hours. Rarely they occur several times daily for several consecutive days, but severe convulsions, repeated at short intervals for twenty-four or forty-eight hours, usually end in fatal congestion of the brain or serous effusion. I once attended an infant about six months old who had from four to twelve convulsions daily for eleven days, caused prob- ably by a vesical calculus, as there was dysuria and at times bloody urine. Some days after the convulsions were controlled, while we were deferring exploration of the bladder, death occurred suddenly, and an autopsy was not permitted. This case will be detailed elsewhere. Bouchut has witnessed a case of whooping cough in which there were daily convulsions for eighteen days. In severe eclampsia the respiration is so embarrassed and circulation so retarded that congestion of various organs results. This passive congestion in the respiratory organs is indicated by moist rales in the larynx and bron- chial tubes ; occurring in the brain, it is indicated by profound stupor. It has already been stated that death may occur from the cerebral congestion, which, continuing, is apt to end in effusion of serum or extravasation of blood. 618 LOCAL DISEASES. In these cases the convulsive movements cease, but there is no return of con- sciousness. The child lies quiet, as if in sleep, with pupils not readily acted on by light, and often somewhat dilated ; gradually the limbs grow cool and the pulse feeble, and fatal coma supervenes. Death does not ordinarily occur from one attack. There are several at intervals, during which the stupor is gradually becoming more and more pro- found, till finally total loss of consciousness and sensation results, terminating in death. Apnoaa may occur in the first attack, ending life abruptly and unexpectedly, but in other instances it does not result till after several seiz- ures, when at length one more violent than the others interrupts the respira- tory function and causes death. Occasionally when life is preserved there is some permanent ill-effect of eclampsia. Bouchut says : " The origin of certain permanent contractions which bring on deviation of the head or other parts, retraction of the limb, paralysis, etc., must be referred to the convulsions of the muscles. I have seen several children in whom torticollis had no other cause. The drooping of the upper eyelid, strabismus, irregularity of the mouth, severe contractions of the limbs, often depend on this influence. These accidents are consequences of essential as well as of symptomatic convulsions." Anatomical Characters. — The morbid anatomy pertaining to eclamp- sia is in most cases twofold : first, the pathological states which precede and cause the convulsive movements ; secondly, those which result from them. We have seen that in sympathetic eclampsia the diseases which sustain a causal relation are very numerous ; some are constitutional, others local, and the latter may have their seat in almost any part of the economy distinct from the cerebro-spinal axis. In some cases of sympathetic eclampsia the immediate cause is a too active circulation, a state of hyperemia of the cere- bral vessels. It has already been stated that this hyperemia may be diagnosticated in young infants in whom the anterior fontanelle is open. Such infants, seized with acute inflammation of one of the mucous surfaces, often present a full and rapid pulse and a convex and forcibly pulsating fontanelle before the eclampsia begins. In other cases of sympathetic eclampsia the primary disease induces passive congestion of the brain, and this in turn gives rise to convulsions. Eclampsia occurring during the paroxysms of whooping cough affords an example. In some cases of sympathetic eclampsia the convulsive movements are pro- duced by the primary disease acting directly on the nervous system through the medium of the nerves, without causing any appreciable alteration in the state of the cerebro-spinal axis. Thus, Barrier relates three fatal cases of convulsions occurring in pneumonia, in none of which was there anything abnormal in the condition of the brain or its membranes. The pathological state preceding symptomatic eclampsia differs in differ- ent cases, since convulsions occur in almost every disease of the brain and its membranes. The immediate cause of this form of eclampsia may be active or passive cerebral congestion, with or without effusion ; it may be compression of the brain from various causes ; it may be a deficiency as well as excess of the cerebro-spinal fluid. The congestion resulting from eclampsia may give rise to extravasation of blood and the formation of a clot. If this accident occur, there is often paralysis affecting more or less of one side permanently, or gradually disap- pearing. It may be difficult to decide whether the cerebral congestion precedes the eclampsia or is its result ; but in those cases in which it precedes and operates as a cause it is no doubt increased during the convulsive period. The spas- ECLAMPSIA. 619 modie muscular action, by rendering respiration irregular and imperfect, also leads to congestion of the lungs, and sometimes of other organs. Diagnosis. — The only disease which resembles eclampsia is epilepsy, but the diagnosis can ordinarily be made by recollecting the following facts : — Eclampsia is most common in infancy. If it occur after the age of three years there is some manifest exciting cause which renders the child seriously sick independently of the convulsions, and prior also to their occurrence. But in epilepsy first attacks are very often mild — the petit mat of writers ; in other cases they are tolerably severe from the first; but, whether mild or severe, they occur with no previous or coexisting sickness and with little or no warning. The symptoms in eclampsia and epilepsy are identical, except as the causes of eclampsia produce certain concomitant symptoms, and there is every reason to believe that the spasmodic muscular movements proceed from an irritation of the same portion of the cerebro-spinal axis — to wit, the medulla oblongata. Writers like Niemeyer have given reasons for the belief that spasmodic muscular movements are produced by functional disturbance of this part of the nervous centre. I may state the following, to which I am not aware that any one has alluded : If the exposed medulla of an acephalous monster be pressed or pinched, convulsions like those of eclampsia and epilepsy result. These two diseases, therefore, have a close resemblance anatomically and clinically, but by attention to the above facts they can ordinarily be distinguished from each other. In most cases of eclampsia the child has fever or other pronounced symp- toms of the primary disease, which suffice for diagnosis ; but we have fre- quently examined epileptics in the Bureau for the Relief of the Out-door Poor whose first attacks were evidently produced by some exciting cause, and were eclamptic. One attack of clonic convulsions predisposes to another, and therefore eclampsia, if the attack be repeated a few times, not infrequently ends in epilepsy. The convulsions, which at first are produced by an obvious cause, now occur without apparent cause. It is often difficult to ascertain the form of eclampsia, whether essential, symptomatic, or sympathetic — in other words, to determine the cause — till after the convulsions cease. This is especially true when, as is frequently the case, the physician is not summoned till the convulsive movements begin. and it is necessary that he should act promptly, with but little knowledge of the child's previous history. If there be an obvious antecedent disease, as whooping cough or meningitis, the cause is apparent ; but if the previous health have been good or but slightly disturbed, it may be necessary to make more than one visit or examination in order to ascertain the seat and character of the cause. In the majority of cases of convulsions occurring suddenly in a state of previous good health the cause is seated in the intestines, but sudden and unexpected attacks may be due to the commencement of some inflamma- tory affection, as pneumonia, or of a febrile disease, as smallpox. Unless the eclampsia be speedily fatal, the physician, if he examine carefully, will in most cases soon be able to ascertain the nature of the cause and diagnosticate the form of the disease. Prognosis. — Symptomatic eclampsia is always serious. If it occur in the course of a cerebral disease, it indicates the approach of death, but if at its commencement, the patient may recover. Its recurrence, whatever the cerebral disease, is usually prognostic of death. In idiopathic or essential convulsions the prognosis depends on the severity of the attack and on the age, strength, and previous condition oi % the child If there be predisposing or co-operating causes, as a nervous or excitable temperament or dentition, the prognosis is less favorable than when such causes are absent. 620 LOCAL DISEASES. In sympathetic eclampsia the prognosis varies greatly, according to the nature of the primary disease and often according to the stage of that disease. If convulsions occur at the commencement of an eruptive fever, they generally subside without untoward symptoms and the fever pursues a favorable course. Eclampsia after the appearance of the eruption is premonitory of a fatal result. I have not yet known a patient with scarlet fever recover who had convul- sions after the rash had covered the body, and experienced physicians of this city tell me that their observations correspond with mine. Dr. J. F. Meigs, however, relates one favorable case. If the cause of the eclampsia be located in or upon the mucous surfaces, a majority recover with judicious treatment. In convulsions consequent upon pneumonia or a burn, more die than recover. The prognosis in eclampsia is more favorable if the parallelism of the eyes be retained, the pupils remain sensitive to light, and consciousness soon return. A fatal termination may be predicted if, after the convulsion, the child remain stupid, without any evidence of returning consciousness, and the pupils do not respond to light. Treatment. — Fortunately, inasmuch as the physician is often required to treat eclampsia in ignorance of the cause, the same measures are demanded to a considerable extent in all cases, whether the form be essential, sympto- matic, or sympathetic. As early as possible in the attack the feet should be placed in hot water to which mustard is added, or if it can be procured with little delay a general warm bath may be used in its place. This has a sooth- ing effect upon the nervous system and promotes muscular relaxation, while it also produces derivation of blood from the cerebro-spinal axis. It is there- fore useful, especially in those cases in which active or passive congestion precedes the eclampsia ; it is also useful as a preventive of passive conges- tion and consequent cedema of the brain, lungs, and other organs, which are the most serious results of eclampsia. It should be continued from six to fifteen or twenty minutes, according to the severity and duration of the attack ; at the same time cold applications should be made to the head until its temperature, which is usually increased, is reduced. The application of cloths placed upon ice or frequently wrung out of cold water is the most convenient and ready mode of employing this agent. Cold thus employed acts promptly in contracting the vessels of the brain and meninges and diminishing the cerebral congestion. It tends, therefore, to remove one of the chief dangers. Cold applications are also useful for reducing an elevated temperature if it be present. In most cases of eclampsia, if the temperature reach 103°, the necessity for its reduction is urgent, and the cold cloths or India-rubber bag containing ice should be applied not only upon the head, but also along the sides of the face, and sometimes over the great vessels of the neck. Since a large proportion of convulsive attacks originate in the condition of the intestines, either solely or in part, it is advisable to prescribe an aperient unless there be previous diarrhoea. The common enema of soap and water will usually produce a free and speedy evacuation, and will sometimes disclose the cause of the eclampsia in the expulsion of seeds or other indigestible substances or scybala. A cathartic is also often required, especially if the enema fail to produce sufficient evacu- ations. In those that are robust, and especially in those beyond the age of two or three years, calomel is an excellent purgative, is easily given, and is prompt in its action. If the symptoms indicate intestinal inflammation, the milder purgatives, as castor oil, are preferable, as they also are in young or feeble children. If the recent ingesta of the patient consisted of fruit or of substances of an indigestible character, an emetic is appropriate ; a teaspoon- ful of the syrup of ipecacuanha, repeated if necessary in fifteen or twenty ECLAMPSIA. 621 minutes, may be given to a young child, or this syrup mixed with the syrup scillie compositus to one older and more robust. Aside from the ejection of the offending substance which it produces, an emetic has some effect in con- trolling the convulsive movements. But the cases are rare in which emetics are indicated. In addition to the local measures mentioned above, and measures calcu- lated to relieve the digestive canal of any offending substance, a safe medici- nal agent which will act promptly in relieving the convulsions is urgently demanded, since eclampsia, if severe and protracted, involves great danger. Fortunately, such agents have been lately introduced into therapeutics — namely, the bromide of potassium or sodium and hydrate of chloral. These agents, while they are effectual, are safe, and therefore their use has sup- planted that of the antispasmodics — asafcetida, valerian, lavender, and chloro- form — formerly employed ; not one of which, except chloroform, exerts any direct controlling influence over the convulsions, and chloroform is a danger- ous remedy unless used sparingly. The bromide of potassium, which I prefer, should be given every ten minutes, dissolved in cold water, till the convulsions cease, in doses of four grains to a child of one year, and of five to eight grains to a child of two or three years. When the convulsions cease the interval between the doses should be lengthened. In one instance in my practice an infant of eighteen months was suddenly seized with eclampsia, and the mother, in her fright mistaking the directions, gave thirty grains of bromide at one dose. Two hours afterward, when I was able to attend, I found that the convulsions had ceased at once and that the patient was playful. Such cases show the innoc- uousness of a large dose of the bromide and the safety in administering the medicinal dose often. In severe cases the bromide does not always act with sufficient prompt- ness and power. The hydrate of chloral should then be employed, given by the mouth or dissolved in two or three drachms of water and given with a small glass or gutta-percha syringe per rectum. If used in sufficient quantity, per rectum, and retained by pressure with a napkin, it is quickly absorbed, and will usually in about fifteen or twenty minutes control the eclampsia. For a child of one year I employ about two grains, and for one of four years four grains, given by the mouth, or double this quantity given per rectum. With the use of the measures indicated above eclampsia is, in my practice, much more amenable to treatment than in former years. Unless the cause be such that recovery is impossible from the very nature of the case, the convulsions will soon cease with these measures. It is interesting to observe the effect of the chloral enema. In from five to ten minutes the convulsive movements cease in the muscles of the face, a moment later in those of the arms, and lastly in those of the lower extremities. But additional treatment may be required, according to the pathological state which has brought on the eclampsia. If it be an eruptive fever, as scarlatina, and the eruption have receded, active revulsive measures, as hot mustard baths, are required; if in dysentery or other internal inflammation, the flaxseed and mustard poultice should be applied over the parts affected. In those dangerous cases in which symptoms of cerebral congestion con- tinue after the eclampsia ceases additional treatment is required. The child remains drowsy, does not speak or apparently suffer in any way. and the pupils act less readily than in health. If this condition remain after the lapse of a few hours there is probably serous effusion. All attacks of eclampsia, unless the mildest, are followed by a period of drowsiness, but the persistence of it, with symptoms which indicate hyperemia, with per- haps effusion within the cranium, calls for the employment of additional 622 LOCAL DISEASES. measures. Vesication by cantharidal collodion should then be produced behind the ears, mild revulsives be applied to the extremities, the head kept cool, the bowels open, and in certain cases a diuretic like iodide of potassium may be advantageously employed. The utmost care should be enjoined in reference to the hygienic management of those who are subject to eclampsia. The diet should be nutritious but bland, and all causes of excitement be studiously avoided. CHAPTER VIII. EPILEPSY. Epilepsy is a paroxysmal disease. The paroxysms are manifested by impairment or loss of consciousness, and in fully-developed and typical cases also by convulsive movements of more or fewer of the voluntary muscles. Epilepsy is a neurosis or functional affection of the nervous system, not due, therefore, to any appreciable structural change in the brain or spine. The convulsions are tonic or clonic, or most frequently both, the tonic preceding the clonic. Etiology. — In a large proportion of cases we are able to discover both predisposing and exciting causes of the first attack, but one convulsion pro- duces such a change in the nervous system that the liability to another attack is increased. Hence after the epileptic habit is established after one or a few attacks, convulsions usually occur without any apparent exciting causes ; and if such a cause be discovered, it is evidently insufficient without the presence of a strong predisposition. Predisposing Causes. — Prominent among these is a neurotic inherit- ance. Echiverria, whose observations were made in the epileptic wards on Blackwelfs Island, states that 28 per cent, of the 300 epileptic patients examined by himself presented evidences of inheritance. In Reynolds's cases the number was 31 per cent., and in 1218 cases examined by Gowers the number who presented evidences of an inherited predisposition was 429, or 35 per cent. The morbid state in the parent which gives rise to an inher- ited predisposition to epilepsy in the child is most frequently epilepsy or insanity. Less frequently, according to Gowers, the parental disease is chorea, hysteria, or a spinal malady. Inherited predisposition is said to be more frequently from the mother than from the father. The occurrence of epilepsy in a brother or sister renders it probable that the patient has inher- ited a predisposition, although we may be unable to trace it to either parent or any of the ancestry. The evidence of a strongly inherited predisposition is sometimes apparent by the number of near relatives affected by the same dis- ease. Thus, Gowers states that in one instance the patient's mother, aunt, two uncles, and a cousin were epileptic, and in another instance fourteen near relatives had epilepsy. Age. — Statistics relating to the age at which epilepsy begins have been published by Haase, Gowers, and others. These show that three-fourths of the cases begin under the age of twenty years, one-fourth under the age of ten years, and about one-eighth under the age of three years. Exciting Causes. — Immediate or exciting causes of epilepsy are usu- ally most apparent in cases which begin during infancy or childhood. The history of a large number of epileptic children has been ascertained during EPILEPSY. 623 the last twenty years in the children's class in the Out-door Department at Bellevue. and very frequently we were informed that at the first attack the child was feverish or constipated or had some acute ailment, which served as the exciting cause. Often the first convulsions were attributed to dentition, but we now know that most of the cases which were attributed by the parents to teething are due to other causes, as constipation, diarrhoea, the presence of indigestible or irritating ingesta in the intestines, rachitis, or some acute infectious or inflammatory disease. If the child have a succession of dis- eases giving rise to convulsions, they may be sufficient to establish the epi- leptic habit, even when there is no apparent predisposition to epilepsy. Thus. Gowers relates the case of a child of healthy parentage and without any inherited predisposition, that had a fit at the age of six months, attrib- uted to teething ; another at the age of two years, from scarlet fever ; another at four and a half years, from measles ; and another at sixteen and a half years, from a carbuncle. These repeated convulsive attacks ended in a permanent epilepsy. Mental Emotion. — Fright or great excitement, from whatever cause, is the most common and potent of the immediate causes of epilepsy. It pro- duced the first convulsive attack in 157 of Gowers's cases, or in more than one-third of those in which an exciting cause was assigned. This cause is operative chiefly in the periods of childhood and youth, when the emotions are strong, and in females more frequently than in males. Among the enu- merated causes of the mental excitement, authors mention fire-alarms, burg- laries, thunder-storms, and pretended ghosts. Gowers states that a soldier on sentry-duty at night was so frightened by some white goats that appeared suddenly on the wall of an adjacent cemetery that he was seized with con- vulsions and became an epileptic. Sudden and profound emotion has some- times been the exciting cause of chorea, and in some instances of epilepsy, cases which I have observed ; in one instance in an emotional child, the sight of the corpse of a favorite uncle producing this result. In another instance a physician of my acquaintance, in treating a female child with scarlatinous nephritis, ordered a warm bath. The next day, visiting the patient and learning that his directions had not been heeded, he prepared a bath and in a rude manner plunged the child into it. She was much frightened, and imme- diately had a severe convulsion. The scarlatinous uraemia probably predis- posed to the attack, but the fright was the exciting cause. She has been a confirmed epileptic from that day, the fits being frequent and severe. Treat- ment employed at intervals during the last ten or twelve years has had but little effect in controlling them. Gowers states that in an aggregate of 76 cases in which epilepsy resulted from fright, the convulsion occurred imme- diately in 28, within a few hours in 16 others, after the first day, but within seven days, in 19, and at a later period than one week in 13. Protracted cares or anxieties, which prevented the needed mental rest, have also in some instances been the only assignable cause of epilepsy, but this cause is less frequent in childhood than in adult life. Traumatism. — Usually the injury received is upon the head, either from a fall or a blow, by which the patient is stunned or rendered unconscious for a time. The convulsion may occur immediately or not until the lapse of a day or more. Traumatism is ordinarily attended by much mental excite- ment, and this has its influence in producing the convulsive attack. Among the less frequent but occasional causes of epilepsy in infancy and childhood we may mention inherited syphilis, intestinal worms, scarlet fever, measles, pneumonia, rheumatism, exposure to a high degree of heat, especi- ally to the sun's rays, masturbation, renal disease, and peripheral causes having a reflex action, as phimosis, cicatrices, and a decayed tooth. When 624 LOCAL DISEASES. these causes are removed, the clonic convulsions which they have produced may cease, but in other instances they continue, the epileptic habit having been established. Symptoms. — Two forms of epilepsy have long been recognized and described in standard treatises — the mild and severe forms, the epilepsia mitior and epilepsia gravior ; or, in the French language, le petit mal and le grand mal. As the terms imply, this classification is based on the difference in the severity of the attacks. Minor Attacks. — These are characterized by momentary dizziness and usually loss of consciousness. The patient has a bewildered look ; his speech is interrupted, even in the middle of a sentence, and his work, whatever it may be, is also interrupted, so that whatever he is holding drops from his hands. His pallor, bewildered look, and strange actions attract attention, but in a moment he resumes his work and his speech. When the attack is over he may be at once in his ordinary mental and physical condition, and seem quite well, but he does not have a clear recollection of what, has hap- pened. Some patients after the attack ceases remain for a time in a drowsy state and without full perception, or their speech and acts may be passionate and violent until they regain their normal state. Major Attacks. — These begin abruptly with strong tonic contraction of the muscles, which causes rotation of the head to one side, a fixed lateral, and sometimes upward, deviation of the eyes, and a constrained and awk- ward position of the extremities. The facial, thoracic, and abdominal mus- cles participate, causing distorted features and embarrassment of respiration. The face, at first pallid, soon becomes livid, the pupils are dilated, the con- junctiva insensitive, and the eyes are in some patients open, but in others closed. The cyanosis deepens and the surface becomes very livid. In a moment the muscles begin to vibrate and undergo alternate relaxations and contractions. The second stage, or that of clonic convulsions, begins. The head, face, body, and limbs are violently jerked, saliva tinged with blood flows from the mouth, and sometimes the urine and feces are expelled. The patient presents a striking and shocking spectacle, which gave rise in olden times to the belief of demoniacal possession. Presently the muscular relaxa- tions become longer, more air is inhaled, and the blueness, which was in- tense, begins to abate. The muscular contractions, though as severe as at first, are less frequent, and finally cease, and the patient, weak and uncon- scious, sleeps quietly but soundly. Occasionally, instead of a simultaneous commencement of the attack in all parts of the body, it begins in one region and extends to others on the same side, and then, diminishing on this side, it begins on the opposite side. In this form of epilepsy the patient may not lose consciousness until late in the attack, so that he at first is aware of his condition, and the convulsions may be clonic from the first. Aura. — Certain patients exhibit symptoms which are premonitory of the attack some hours before its occurrence. One of these is the sudden jerking of certain muscles, as of the arms or legs. This usually occurs when the patient is awake, but it may occur when he is asleep or is falling asleep. Another occasional premonitory symptom is persistent dizziness, preceding the attack some hours or even days. A ravenous appetite, a stifling sensa- tion in the chest, as if from want of air, numbness, cephalalgia, impairment of sight, the vision of red fiery sparks (Aretaeus), and irritability of temper occasionally precede the attacks, so as to forewarn the patient and friends. Bootius in 16-49 described a premonitory symptom which was observed in rare instances, but which was thought to justify the recognition of a variety of the disease that was designated epilepsia cursiva. The patient ran a short dis- tance and then was seized with the convulsion. Another similar precursory EPILEPSY. 625 symptom immediately preceding the attack is mentioned by some writers. The patient, if walking, even if entering his home, turns around, retraces his steps, and falls down in a fit. The premonitory symptoms described above, which enable the epileptic, with the aid of his friends, to reach a place of safety before the attack begins, occurs in a small proportion of cases. Many epileptic fits begin with an aura — a term first employed by Pelops, the predecessor and teacher of Galen, to indicate a sensation which com- mences in some part away from the brain and ascends toward it. In olden times the aura was supposed to be a vapor, which traversed the vessels to the brain and caused the attack. It is now known that it ordinarily has a cen- tral origin, is due to commencing functional disturbance of the brain, and is a part of the fit. It is true that the immediate application of a ligature or tight band above the aura, which arrests its ascension to the brain, will often prevent the fit, but Odier, Brown-Sequard, and Growers have shown that this occurs in epilepsy due to cerebral tumors, even more frequently than in epi- lepsy which has no appreciable anatomical cause. Therefore, this fact of the arrest of the convulsion by ligation above the aura cannot be employed as an argument in support of the theory of the peripheral origin of the attacks. The statistics of Romberg, Sieveking, and Gowers show that an aura occurs in about half the cases. The aura may begin in any peripheral por- tion of the system, in any of the organs of the special senses, and in many of the internal organs. By knowing from what portion of the brain the nerve arises which supplies the part that is the seat of the aura, we are enabled to state which of the divisions of the brain is probably so affected as to produce epilepsy. The aura varies greatly in its character as well as location. It is a sen- sation of pain, numbness, burning or tingling, or, instead of being sensory, it may be wholly or chiefly motor, as cramps, jerking, twitching of a certain muscle or group of muscles may occur. Sometimes the aura is at the same time both sensory and motor. The sensory aura commonly ascends, as we have already stated, toward the head, but it occasionally descends a limb, and when it reaches a certain point the convulsion begins. The aura often occurs in one side of the face, tongue, or trunk, or in one limb. In other instances it is bilateral or general, commencing simultaneously in correspond- ing limbs of the two sides. Auras in the trunk, and not in the viscera, occur almost entirely in the back, along the spine, and are known as the spinal aurae. General auras are sometimes characterized by faintness, malaise, or powerlessness, or a general tremor or a general sensation of coldness or of heat. Visceral aurae occur for the most part in viscera supplied by the pneumogastric. The most common of these auras is the epigastric, a pain or a sensation in the epigastrium, vaguely described as a " heat," " coldness," " trembling," a " twisting " or "winding up." The epigastric aura may be a little above or below or to the left of the epigastrium. In some cases the aura is located in the chest or throat. A sensation of suffocation or tingling or burning, or an indescribable feeling, is experienced in the chest or throat immediately before the attack begins. The patient perhaps presses upon his chest or throat with his hands and immediately becomes convulsed. The heart also derives its innervation from the pneumogastric, and the aura is sometimes referred to this organ. In some patients the cardiac region is the seat of a vague sensation variously described, or the aura may be manifested by increased action or palpitation, with perhaps more or less dyspnoea. Of the cephalic auras, vertigo is perhaps the most common, attended in some by rotation of the head and occasionally of the body. In certain epileptics there is the sensation of rotation without actual movement, and in some instances objects seem to move. Cephalic auras in a considerable number of 40 626 LOCAL DISEASES. instances consist of headache or a sensation in the head described as heavi- ness, pressure, coldness, burning, etc. In certain cases the aurae are entirely emotional, having usually the form of fear, which is sometimes so great that extreme terror is depicted on the countenance, and yet there may be no remembrance of it after the convulsion is over. In a considerable number of instances the aurae are manifested in the organs of the special senses, and consist in an aberration of their functions. The olfactory aura is usually an unpleasant smell, as of sulphur, putrid mat- ter, pus, decaying animal substances. The gustatory aura is a bitter, sour, metallic, or nauseous taste. The ocular aura is an unusual sensation in the eye — diplopia, an apparent change in the size of objects viewed, sudden blindness, or the perception of unusual or striking objects, as a flash, sparks, colored lights, or persons or things not present, sometimes quiet, sometimes in motion. The auditory sensations occurring as aurae are sounds of many kinds — of music, of bells, thunder, a whistle, the wind, an explosion or any other startling sound. It is seen that the aurae, although having a central origin, occur in almost every part of the system, remote from as well as near the brain, and are of many different kinds. In some epileptics a harsh scream or groan announces the commencement of the fit, but in children, according to my observations, it rarely occurs. It is apparently produced by a spasm of the laryngeal muscles, which causes narrowing of the passage through the larynx, and a spasmodic contraction of the thoracic and abdominal muscles, which causes a rapid and forcible expiration. The patient is unconscious of the scream, or he may be conscious of it, but unable to prevent it. In the fit, when of ordinary severity, consciousness is early lost, and it does not return until the somnolence which follows the attack has abated ; but in the mild disease, the petit mal, the patient, though confused, often retains consciousness during the attack. In the grand mal the attack begins with a tonic spasm of the muscles, causing rotation of the head and deviation of the eyes to one side. Sometimes there is rotation of the entire body, so that the patient turns round one or more times before he falls. The position of the limbs during the tonic spasm varies. Commonly the arms are slightly abducted, the forearms flexed to a right angle, the hands flexed on the wrists, the fingers flexed on the hands, but extended at the other joints, and the thumb is pressed upon the palm or fore finger. The legs are ordinarily extended, but the legs as well as arms may assume different positions. Clonic convulsions, or the second stage of the attack, supervene in a few seconds or after two or three minutes. As the tonic spasm slowly relaxes, the clonic spasms gradually supervene. The clonic convulsions, or alter- nate contraction and relaxation, rapidly succeeding each other, occur in the muscles of the face, tongue, palate, and larynx, as well as in the muscles of trunk and extremities. The tongue is frequently bitten, both in the tonic and clonic spasms, so that the blood oozes, and, mixed with frothy saliva, exudes from the mouth. The pupils are dilated during the attack, and they do not contract by light. As soon as consciousness begins to return, the pupils begin to contract and respond to light, Exceptionally, at the close of the fit the pupils alternately contract or dilate at intervals of one or two seconds, and, as already stated, the conjunctiva loses its sensitiveness, so that it can be touched without producing reflex action of the orbicularis. Relaxation of the sphincters also often occurs during the fit, so that fecal and urinary evacuations take place. The pulse may be normal or rather feeble in the beginning of the attack, but its frequency, and sometimes its fulness, increase during the muscular spasms. The features, usually pallid, but sometimes flushed at the beginning EPILEPSY. 627 of the attack, become congested and even cyanotic in less than a minute. The congested and livid features present an alarming appearance, and fre- quentlv the general surface is bathed in perspiration before the attack ends. Ophthalmoscopic examination of the eyes during the convulsion is difficult, but during the cyanotic stage the retinal vessels have been seen presenting an engorged and dusky appearance. Gowers states that in one instance, in which fits occurred in rapid succession during several days, he observed con- gestion of the discs with slight oedema, which disappeared after the attacks ceased. In the intervals of the paroxysms nothing has been noticed in the appearance of the eyes which throws light on the nature of the disease. The duration of the second stage of an epileptic fit or that of clonic spasms varies from a minute or two to a considerably longer time. When it ceases the patient passes into a sleep or deep stupor, which continues a quarter of an hour or longer. If aroused from the stupor he complains of severe headache, and this continues often for hours after the stupor ceases. Languor and muscular weakness are common after the fit, and they grad- ually pass off. When, as occasionally happens, paralysis occurs after the fit, and continues for weeks or permanently, organic cerebral disease is present, either preceding and causing the fit or resulting from it. If no paralysis or cerebral symptoms have preceded a fit, and it is followed by paralysis of one or more of the extremities, it is highly probable that intracranial hemor- rhage has occurred during the attack. Todd, Hughlings Jackson, and others attribute the muscular weakness following an epileptic attack " to exhaustion of part of the brain by the excessive action," but protracted or permanent loss of muscular power in an epileptic having good general health indicates organic disease in the brain. The above description relates to epilepsy as it ordinarily occurs, but there are many cases which vary from the typical form. Tonic convulsions may occur without the clonic, and clonic convulsions without the tonic, and the convulsions, instead of being general, may be limited to a limb or to one region of the system. Of 155 cases of minor epilepsy, Growers states that in 45 the disease was indicated by momentary attacks of unconsciousness, faintness, or sleepiness ; in 25 by dizziness ; in 17 by sudden jerking of head, trunk, or limbs ; in 17 by loss or aberration of sight ; in 8 by a mental state, as sudden and extreme fright ; and in the remaining 42 by sensations of various kinds, or momentary rigidity, or by tremors or twitching occurring in some part of the system. Automatic movements sometimes occur during the stage of unconsciousness which succeeds the attack, and the attack may be so light that it is not noticed by the bystanders. Gowers relates several such instances. Some patients begin to undress themselves, whatever the sur- roundings ; others make the motions of walking up stairs, although no stairs are present ; some put in their pockets any near object, without regard to its nature or ownership. Trousseau states that an architect during the state of unconsciousness ran from plank to plank on the scaffold where he was at work, shouting his own name. One of Gowers's patients during the uncon- scious state laughed and sang ; another threw her infant down stairs ; a girl of twenty kissed every object within her reach ; and a man struck his friend a severe blow. Many supposed criminal acts have been perpetrated by un- conscious epileptics, for which they have been severely punished. Anatomical Characters. — No information has been obtained in regard to the etiology and nature of idiopathic epilepsy by a study of its anatomical characters. If the patient have died in the attack, intense venous conges- tion is observed of the cerebro-spinal axis as well as of other parts, but in recent cases nothing else abnormal has been detected in the brain or else- where. The thickening and opacity of the cerebral meninges sometimes 628 LOCAL DISEASES. observed in chronic cases, and the induration of the pes hippocampi described by Meynert, are now believed to be results of the repeated attacks, and not their cause. Structural change in the brain in idiopathic epilepsy, if there be such, which sustains a causal relation to the attacks, has thus far eluded detection by the microscope. Pathology. — Epileptic attacks are believed by neuropathists to be due to a sudden and exaggerated functional activity of nerve-cells in some part of the brain. The theory at present accepted is that these cells generate a nerve-force which, transmitted along the nerves, stimulates the muscles to spasmodic contraction. In regard to the part of the brain in which these overacting cells reside, we may state that Brown-Sequard and Kussmaul demonstrated that convulsions may be produced by irritating the pons and medulla when every other part of the encephalon lying above these is removed. Convulsions can also be produced in acranial monsters, as I have stated above, by irritating the exposed medulla and pons. Nothnagel has also shown that there is a " convulsive centre " in the medulla oblongata. On the other hand, injuries of the convolutions more frequently cause con- vulsions than do those of any other part of the brain, and Wilks and others have taught that in ordinary epilepsy the part of the brain which is most frequently in fault, so as to cause convulsions, is the superficial portion or the convolutions. Still, the exaggerated production of nerve-force which causes the convulsions may be at a greater depth than the convolutions, even when the attacks are due to traumatism, since, as Burdon-Sanderson has shown, nerve-cells more deeply seated than the convolutions may be stimulated to increased functional activity by injuries of the superficial regions. Therefore, Nothnagel, aware of the fact that injuries of the cortex often cause convulsions, states that he sees no reason to modify his opinion that the exaggerated production of nerve-force which causes the convulsions is in the " convulsive centre in the medulla oblongata." The above observa- tions seem to indicate that epileptic attacks do in some instances originate in the convolutions or hemispheres, and in others in the medulla. Recently, (rowers and others have endeavored to determine in what part of the brain the nerve-force resides which causes the convulsions, by study- ing the aurse. Since the aurae have a central origin and are the first mani- festation of the exaggerated action of the nerve-cells, the attempt is made to determine the location of these cells by observing the nature and the seat of the aurae. Gowers says that one-fifth of the auras pertain to the special senses, and the nerve-centres of these senses " are certainly situated within the hemispheres, above the pons." Therefore, the inference is inevitable that in these cases the discharge of nerve-force which stimulates the muscles to spasmodic action is in the hemispheres. Moreover, a fit that is preceded by an emotional or mental aura, we infer, originates from the nerve-cells of the hemispheres which are the seat of the mind. The theory is therefore plausi- ble and apparently sustained by clinical observations, that in at least some instances the epileptic centre in the brain is in the hemispheres, though it may in other instances be at the base of the brain — in the medulla or pons. What occurs in the brain to produce the phenomena of epilepsy ? It is the belief of many specialists in nervous diseases that epilepsy results from suddenly developed cerebral anaemia produced by spasmodic contraction of the arterioles. It is also the belief of some that the primary discharge of nerve-force occurs in the medulla at the vaso-motor centre, and that this is followed by spasm of the arterioles in the hemispheres, by which conscious- ness is lost. That cerebral anaemia is present is inferred from the fact that the features are usually pallid when the attack commences. But in many instances, especially in epilepsy of a mild type, no pallor or other sign of EPILEPSY. 629 peripheral anaemia is present, and in such cases there is no evidence what- ever of cerebral anaemia. Besides, as Gowers has forcibly stated, pallor of the features does not necessarily indicate cerebral anaemia, any more than flushing of the face indicates cerebral hyperemia. In experiments on frogs irritation of the brain causes contraction of the peripheral arterioles. Prob- ably in the same manner, says Growers, the contraction of the peripheral arterioles and the pallor result from the irritation of the brain, occurring in the first stage of the fit. That cerebral anaemia occurs in the attack, and that it sustains a causal relation to the phenomena of epilepsy, are assump- tions destitute of proof. As to the pathology of epilepsy, we have said or have intimated that it is the belief of the majority of those who from large clinical experience are most competent to express an opinion that the epileptic attacks are produced by a hyperactivity of nerve-cells in the gray matter in some part of the brain, and an increased discharge of nerve-force, which stimulates the mus- cles to spasmodic action. The spinal cord and the nerves are implicated as carriers of this nerve-force. Farther than this we are unable to express any theory in the present state of our knowledge. Diagnosis. — In a considerable number of instances nocturnal epilepsy is entirely overlooked. Some patients awaken at the beginning of the attack, and have subsequently a vague recollection of its occurrence. Others are aware of the fit by subsequent signs or symptoms, as a bitten tongue, blood on the bed-clothes, a swollen and ecchymotic face, conjunctival extravasation, and perhaps evacuations in the bed. In children nocturnal epilepsy is more likely to be detected than in adults, since they are more closely watched. Gowers states that he has known it to occur twenty years without being sus- pected. In mild epilepsy the symptoms may escape the notice of friends, and when observed by the patients and friends their import is often misun- derstood. Those suffering from petit mat are in many instances supposed to have attacks of faintness. The differential diagnosis between epileptic ver- tigo and syncopal faintness is made by the fact that in the latter the pre- vious health has usually been poor, the action of the heart feeble, and there is some exciting cause of the sudden cardiac weakness ; whereas in epileptic vertigo such conditions do not, as a rule, exist. In epileptic vertigo there is no premonition except the aura, which is momentary, and recovery or return to the normal state is rapid. Syncope, on the other hand, begins and ends in a more gradual manner. The symptoms of eclampsia and epilepsy are identical as regards the convulsive movements. We designate by the term " eclampsia " those attacks which are due to local or general causes, which do not recur when these causes are removed, and the occurrence of which, whatever the causes, is limited to a brief period. But, as we have seen, one attack of convulsions predisposes to another, and one or more convulsive fits that are eclamptic frequently establish the convulsive habit, so that epilepsy results. In a large proportion of the cases of eclampsia, the convulsions have a reflex origin. They are produced by causes located at a distance from the brain and affecting the nervous centres, causing convulsions through the medium of the nerves. Painful and swollen gums in dentition, constipation, irrita- ting ingesta, intestinal worms, scarlet fever, nephritis with albuminuria, are among the common causes of eclampsia. In recent convulsions, when such causes are present, the diagnosis of eclampsia will be proper in the great majority of instances, and the attacks will cease and not recur when the apparent causes are removed. Gowers regards rickets as a common cause of eclampsia in young children, and remarks that when this diathetic state is cured by " cod-liver oil and steel wine r ' the convulsions no longer occur ; 630 LOCAL DLSEASES. but if proper treatment be not employed, if the rickets continue, and with it the frequent convulsive attacks, the epileptic habit may be established and epilepsy continue during the remainder of life. Prognosis. — Epilepsy is rarely fatal, although the symptoms are very appalling to one who has not previously witnessed an attack. Asphyxia has occasionally occurred by the patients falling into water during the fit. Even little depth of water with the face downward is sufficient to cause fatal obstruction to inspiration. Therefore, not a few epileptics die by drowning. If the patient roll upon the face during the fit, or vomit, he may be asphyxiated by the bed-clothes or by the entrance of particles of food into the larynx. The spontaneous cessation of the epileptic fits and spontaneous cure of epilepsy rarely occur, since each attack tends more strongly to establish the epileptic habit. Fortunately, since the therapeutic uses of the bromides have become known, epilepsy has frequently been cured. In infancy and childhood, in the majority of instances, epilepsy is rendered milder, so that the fits occur at longer intervals, even if entire cure be not effected. Moreover, the pros- pect of curing epilepsy is better in children than in adults, in accordance with the law that the shorter its duration and the fewer the attacks which have already occurred the more amenable it is to treatment. Epilepsy in which several days intervene between the attacks is, as might be expected, more likely to be benefited by treatment than when the attacks are frequent. If the mind be not perceptibly impaired, if the fits are uniformly severe, instead of some being severe and others mild, if they occur only during sleep or only during wakefulness, and if hemiplegia be absent, the prognosis is better than when the reverse is the case. In ordinary cases of epilepsy in childhood, the attacks immediately become less frequent by the bromide treatment. If a sufficient amount of the bromide be administered three times daily, months often elapse before a recurrence of the attack ; but if the remedy be discontinued after six months or a year in the belief that the patient is cured, a recurrence of the disease is probable. A patient cannot be pronounced cured until three years have elapsed without any symptoms. Treatment. — No mode of treating epilepsy which will effect an imme- diate cure has yet been discovered, nor is it probable that such success of treatment will ever be obtained. Cure is effected by treatment which dimin- ishes the hyperactivity of the nerve-cells that are in fault, and prevents the exaggerated production of nerve-force. Medicines designed to effect this object must be given daily for a prolonged period, since their use for a few days or weeks does not suffice to produce the desired change in the nerve- centre. Since the bromides have come into general use in the treatment of nervous diseases, the first place is universally accorded to them among the remedies for epilepsy. The bromides of potassium, sodium, ammonium, and lithium have probably nearly the same effect, but the potassium and sodium bromides are usually prescribed. No advantage results from the use of bromine or hydrobromic acid, even if it were safe and convenient, for it becomes a bromide as soon as it enters the alkaline blood (Gowers). All the bromides produce acne, but this can be prevented to a considerable extent by the simultaneous use of arsenic in small doses. The bromide should be given daily for weeks or months in the smallest dose which is found to arrest the fits or, if it do not entirely arrest them, produces the most decided effect upon them. If the fit occur at a certain hour, one daily dose, administered pre- viously, may suffice to prevent it, but usually it occurs irregularly, and a morning and evening dose or three daily doses are required. Bromism, indicated by a weak pulse, cold extremities, and mental and physical dulness, EPILEPSY. 631 has never, according to my observations, seriously interfered with the treat- ment. During my connection with the children's class of the Bureau for the Relief of the Out-door Poor at Bellevue almost every week new cases of epilepsy have been presented for treatment, and it has seldom been neces- sary to discontinue the use of the bromide on account of bromism. A girl had her first attack of clonic convulsions at the age of four months. When she reached the age of three years and a few months she began to have attacks of the petit mat. manifested by pallor and an epigastric aura, followed by sleep lasting one or two hours. These attacks occurred at irregular inter- vals. In her fourth year she had measles and scarlet fever. In her seventh year she came under observation. A strict milk diet was ordered, and she took one teaspoonful in the morning and two at night of the following mixture : R. Sodii bromidi oiii ss l Aquae, ^ x vj. — Misce. The treatment was continued with scarcely an interruption during her seventh, eighth, and ninth years, with complete cure of the disease, and with bromism only on one occasion. Gowers, writing of adults, remarks that few patients can take more than one and a half drachms of the bromide daily without bromism. But, according to my observations, children can take larger proportionate doses than this without injury. Although prescribing the bromide of potassium daily for children of all ages during many years, I have seldom observed any ill effects which were clearly attributable to its use except the occurrence of acne. Bromism soon disappears when the dose of the bromide is diminished or its use is discontinued. In general, this medi- cine should be given twice or three times daily during as long a period as two years after the last paroxysm, without diminishing the dose which is found sufficient to cure the disease ; and, to make sure of a cure, it should be employed a third year in a gradually diminishing dose. In the case related above, the patient, a girl then at the age of nine years, had taken the bromide of sodium two years in two doses of thirteen and twenty-six grains with complete arrest of the attacks, when she had symptoms of bromism. The bromide was discontinued, and she remained well for some weeks, but finally she stated that the furniture at times seemed to move. Half the previous dose was now employed for a month or two, when it was discon- tinued, and she has remained well without medicine during the six or eight months which have since elapsed. In slight bromism during the first and second years of treatment it is usually better, I think, to diminish the dose of the bromide, but not to discontinue its use, and at the same time to employ a vegetable tonic with alcohol. In great cerebral depression due to the bromide, it is probably better to entirely discontinue its use for a time, even if convulsions occur. Occasionally, the bromide employed alone does not cure epilepsy. It may then be given in combination with another drug which is believed to exert some controlling influence upon the disease, as digitalis, belladonna, cannabis indica, or zinc. These remedies were prescribed with apparent benefit in certain instances before the bromides came into use. Digitalis has been employed as a remedy for epilepsy since Parkinson recommended it in 1640. It is not very efficient when used alone, but in some instances when given with the bromide it evidently increases the curative power of this agent. Gowers says : " In many cases attacks which continued on bromide only. ceased entirely on bromide and digitalis." He observed good results from the use of this combination, especially in epileptics who had cardiac disease, as dilatation, valvular insufficiency, hypertrophy, and a too rapid pulse. 632 LOCAL DISEASES. Benefit also occurred in some instances in which the heart's action was nor- mal, as in the following case : Jesse . aged twelve years, was, when an infant, rachitic, backward in teething and the use of his limbs. He had the first epileptic fit at the age of sixteen months. The attacks occurred at intervals of one week, and were preceded by a visual aura, a red ball of fire, that approached the eye. Fifteen grains of the bromide of ammonium, with five minims of the tincture of belladonna, were prescribed, to be given twice, and subsequently three times, daily. With this treatment the intervals between the fits were lengthened to one month, but they still occurred after six months' treatment. Five minims of the tincture of digitalis were then substituted for the belladonna, and no fit occurred for eleven months. On diminishing the dose of digitalis one fit occurred, but on resuming its use in five-minim doses seven months elapsed without an attack. A girl of eighteen years had a convulsion at the age of two years, another at seven years, and confirmed epilepsy since her tenth year. The attacks occurred about every second day, without an aura. The bromide alone and bromide with bella- donna were employed, with slight diminution in the frequency of the attacks. Digitalis with the bromide was then employed. Immediately the fits were reduced to four, then to two, in the month, and then four months elapsed without a fit. A girl aged eleven years, greatly frightened by a thunder- storm, began to have nocturnal epileptic attacks. At the age of fourteen years, when treatment was commenced, the attacks occurred nearly every night. One scruple of the bromide of potassium and ten minims of tincture of belladonna reduced the attacks to one in ten days. Then the treatment was changed to two scruples of bromide of ammonium and five minims of tincture of digitalis, taken once daily at night, and two months passed with- out an attack, when she was lost sight of. These cases, to which more might be added, show that digitalis combined with the bromide increases the efficacy of the latter in certain cases. Belladonna has been employed in the treatment of epilepsy during the last two centuries. It was recommended by Mardorf in 1691, and by Hufe- land. Stoll. and others in the eighteenth century. Its proper use is in com- bination with one of the bromides, when the latter is inadequate to arrest the attacks. Used alone, it does not cure epilepsy, though occasionally it renders the attacks less frequent. But Growers relates cases which show that it increases the efficiency of the bromides in certain cases when combined with them. It is believed to first stimulate and then depress the functions of the nervous system, acting not upon one part only, but upon various parts of the brain and spinal cord, affecting their functional activity. To show the effect of the combination of belladonna with the bromide, Gowers relates the case of a boy in whom epilepsy commenced at the age of thirteen years without known cause. The attacks began usually in the morning without an aura, at intervals of three weeks. Fifteen grains of the bromide administered night and morning reduced the attacks to one a month. After three months of treatment twenty grains of the bromide and five minims of tincture of belladonna were given three times daily, and two months elapsed without an attack, when two occurred. Subsequently, he took the same medicine four- teen months without an attack, when treatment was discontinued. Six months later he was still well. Other cases have been related in which belladonna, combined with the bromide, produced a more decided curative action than the bromide employed alone ; but in some instances, as we have seen, when these two agents fail to cure, this result is accomplished by the bromide and digitalis. The liquor atropine, one minim of which contains t 4-q of a grain of atropine, may be used in place of the tincture of bella- donna. EPILEPSY. 633 Stramonium, cannabis indica, and gelsemium sempervirens have been pre- scribed with some apparent benefit in certain instances, but it is the common belief with those who have employed them that they are no more efficacious than digitalis and belladonna, and they seldom if ever cure the disease when used alone. When employed with the bromide, good results have followed, but the improvement has probably been due almost entirely to the bromide. Zinc has been recommended in the treatment of epilepsy for more than a century by good observers. In experiments on animals it has been found to dimmish reflex action, and it exerts some controlling effect on the functions of the hemispheres and the medulla oblongata. It diminishes the frequency of the epileptic attacks in many patients, but not usually so certainly as the bromides, or to such an extent. In exceptional instances zinc prevents the epileptic attacks to a greater extent than the bromide, especially when they present the hy steroid form. The oxide, lactate, and citrate are commonly prescribed, and a child of eight years can take from one to two grains three times daily. It should be given after the meals, since it sometimes irritates the stomach and causes nausea. It is believed by Gowers to be slowly con- verted into the chloride in the stomach. He relates the case of an adult epileptic who took five grains of the oxide of zinc morning and evening, and had no attack during the five months in which he was under observation. A girl of eight years having inherited epilepsy, after four months of treatment with the bromide was still having two fits each week. Oxide of zinc in doses of three grains was ordered, and in two months the fits ceased. Nine months elapsed with only one attack, when the patient was lost sight of. Gowers also relates the following case, showing that the addition of the zinc to the bromide sometimes plainly increases the efficiency of the latter: A boy of eleven months, belonging to an epileptic family, had a fit at the age of eleven months. At the age of fourteen years, when he was presented for treatment, the convulsions occurred every two weeks. One scruple of bro- mide of ammonium administered three times daily caused some improvement, as did the bromide with digitalis, but the disease was not cured until the zinc was employed with the bromide. In obstinate cases, therefore, zinc is sometimes useful as an adjuvant to the bromide. Opium, or its alkaloid morphia, has been long employed in the treatment of epilepsy, but its use has now given place, for the most part, to that of other remedies. Occasionally, especially in the hysteroid forms of epilepsy, morphia given at the commencement of the warning has apparently pre- vented the fit. The effect of iron in epilepsy is equivocal and uncertain. Brown-Sequard and Jackson discountenance its use, and they think it increases the frequency of the attacks. Gowers says that he has given iron to several hundred epileptics, and that it only rarely increases the severity of the fits. In most instances it produces no ill effect, and it sometimes improves the general health. He states that occasionally bromide with iron arrests the attacks, when the bromide alone has little effect. A considerable number of remedies which we have not mentioned have been employed, but they have been for the most part discarded by recent observers, either because they have been found to be inert or have been use- ful only in rare cases, and less useful than other remedies. According to my observation, the treatment which has been found ade- quate to arrest the fits should be continued at least two years after the last paroxysm, being omitted for a few days or its quantity reduced if symptoms of bromism occur. Even after a cure for two years occasional symptoms of the petit mod may occur, so that it will be necessary to resume the use of the medicine in smaller doses. 634 LOCAL DISEASES. Hygienic Treatment. — It is necessary that an epileptic child should lead a quiet and regular life, free from excitement and all perturbating influences. The diet should be plain and easily digested. In some instances a diet con- sisting almost entirely of milk has seemed to be a very important remedial measure. CHAPTEK IX. INTERNAL CONVULSIONS (SPASM OF THE GLOTTIS ; LARYN- GISMUS STRIDULUS). Young children are liable to temporary suspension of respiration, induced by violent emotions, especially by anger. In the midst of their excitement, while they are crying or screaming, their breath is suddenly held, as if from tonic spasm of the respiratory muscles. In a few seconds respiration returns and is natural. There is no stridulous inspiration or other unusual sound, and there is no apparent ill-effect, unless occasionally a degree of languor. External convulsions, which seem to be threatening, seldom occur, and when they do are ordinarily mild. Some writers consider dentition the predispos- ing cause of this arrest of respiration by inducing a sensitive state of the nervous system ; such an effect is possible, but certainly many infants are affected in this manner before the age of dentition. A much more serious state, and one which is recognized as a true disease, is that variously designated by writers as internal convulsions, spasm of the glottis, child-crowing, laryngismus stridulus, etc. Manifest difficulties attend the investigation of the pathological state in this disease. There can be little doubt that it is not precisely the same in all cases. That there is, dur- ing the paroxysms, tonic or clonic spasm of more or fewer of the respiratory muscles is inferred not only from the symptoms pertaining to the respiratory apparatus, but from the fact that in severe cases spasms of the external muscles, as those of the limbs and face, often occur. L T sually, also, the movements of the eyeballs indicate spasmodic contractions of the motor mus- cles of the eyes. The fact of spasmodic muscular action in parts that are visible justifies the belief that it occurs in other parts which are concealed from view, especially as the characteristic symptoms cannot be readily ex- plained except on this supposition. Trousseau says : " Internal convulsions consist, then, principally in a spasm of the diaphragm and of the respiratory muscles of the abdomen and chest ; but it occurs also that the muscles per- taining to the larynx are affected with spasm at the same time with these." Rilliet and Barthez conclude from the symptoms that the " heart is not always a stranger to this internal convulsion, which perhaps prolongs itself even to the intestines." The muscles of the pharynx appear to be involved in some cases, as well as those of respiration, rendering deglutition difficult. In one form of internal convulsions — namely, that which is principally referred to by writers — there is not complete arrest of respiration, but the inspirations during the paroxysms are difficult and are attended by a stridu- lous noise. Again, the respiration may cease entirely, but when it com- mences it is stridulous and difficult during a few inspirations. In still another form of the disease respiration ceases, but there is no symptom or sign indicative of glottic spasm or of an obstacle to the ingress of air ; the inspirations which succeed the paroxysm are easy and noiseless. It has been suggested that in these cases there is paralysis rather than spasmodic con- INTERNAL CONVULSIONS. 635 traction of the respiratory muscles ; but the symptoms may be explained in accordance with the commonly accepted opinion — namely, that there is spasm of the diaphragm and perhaps of certain muscles of the chest and abdomen, while the laryngeal muscles are not affected. M. Herard, indeed, who has written one o*f the best monographs on internal convulsions, describes three forms of the disease according to the supposed location of the spasm — - namely, laryngeal, diaphragmatic, and another which consists of a blending of the two. Internal convulsions are not frequent in this country ; they are rare in France, more frequent in Germany, and quite common in England. They occur, with few exceptions, before the age of two years. Dr. West observed 31 cases under the age of two years, and only 6 above that age. The fact has been established by many observations that the rachitic are especially liable to spasm of the glottis. Causes. — Spasm of the glottis has been attributed to enlargement of the thymus gland, and also to enlargement of the cervical and bronchial glands. It is presumed that this effect is due to the pressure of these glands on the par vagum or the recurrent laryngeal nerve. It is certain, however, that there is no such enlargement of the thymus gland which could possibly pro- duce glottic spasm or any other form of internal convulsion at the age at which these convulsions commonly occur. This gland is largest in the new- born, and, having no function after birth, it gradually becomes atrophied. If an enlarged thymus could produce glottic spasm, it would certainly occur most frequently in the new-born. Abnormal development of the thymus gland seemed to be the cause of atelectasis in two infants who died soon after birth in my practice, but I have not seen a case in which a convulsive attack was referable to this cause. M. Herard examined the thymus gland in 6 chil- dren who died of internal convulsions and in 60 who died of other affections, and was not able to discover in its condition any causal relation to this dis- ease. Indeed, cases have been reported in which the thymus had undergone more than its usual atrophy at the time when the convulsions occurred (Haase). Enlargement of the lymphatic glands in the vicinity of the pneu- mogastric or recurrent laryngeal nerve may possibly give rise to glottic spasm, but this is doubtless an infrequent cause, if it be a cause at all, since these glands are often greatly enlarged in strumous and tubercular diseases without such a result. The cause is occasionally located in the cerebro-spinal axis. Thus, Dr. Coley relates a case in which an exostosis arising from the internal surface of the occipital bone pressed upon the cerebellum, while nothing abnormal was discovered in other organs. Examples are also related in which the cause was located in the spinal cord. Thus, Marshall Hall relates the case of a child with spina bifida who was attacked with croup-like convulsions whenever it lay so as to press on the tumor. Internal convulsions are also frequent in rachitic softening and absorption of the calvarium, since, when this is present, undue pressure occurs upon the brain by the weight of the head of the child upon the pillow. In some patients there is evidently an hereditary predisposition to this disease, those affected belonging to families in which a tendency to convul- sive maladies is manifested. Thus, Toogood states that five infants of the same family were affected with spasm of the glottis ; and Reid relates, on the authority of Powel, that of thirteen infants of the same parents only one escaped internal convulsions. The common predisposing cause is an excitable state of the nervous sys- tem, often associated with impaired general health. Hence the disease is more prevalent in cities, where antihygienic conditions abound, than in the 636 LOCAL DISEASES. country. Hence, too, the frequent improvement when the patient is removed to the pure and bracing air of the country. The use of insufficient food or food of a bad quality must for the same reason be considered a cause, since it leads to impoverishment of the blood and renders the nervous system more impressible. Facts mentioned by Reid and others show conclusively the influ- ence of premature weaning and the use of indigestible or otherwise improper aliment in the production of this disease. The causes enumerated above are for the most part predisposing ; occa- sionally they are the only apparent causes, since this disease sometimes occurs when the child is tranquil, even in the midst of quiet sleep or when it is at rest in its mother's arms. In other cases and more frequently there is an exciting cause, often trivial. Anything that requires exertion on the part of the infant or that excites strong emotions may be a direct cause, as anger or any of the violent passions : so may even coughing, or, in rare instances, attempts to swallow. One author has known it to occur from excitement produced by examinigg the throat with a spoon. In a case in my practice, hereafter related, it occurred whenever the infant cried violently. It appears from the above facts that the etiology of internal convulsions is very similar to that of eclampsia. The same spasmodic muscular contraction may occur from a variety of causes. Anatomical Characters. — While, therefore, structural changes in various parts of the system may give rise to internal convulsions, this dis- ease, so far as ascertained, presents no anatomical characters, and must conse- quently be considered one of the neuroses. The lesions of the respiratory apparatus which are seen at post-mortem examinations are due to the convul- sions or are coincidences. Emphysema has sometimes been observed as a result, it is believed, of the spasmodic and irregular respiration. It was pres- ent in all of Herard's cases, and Rilliet and Barthez consider it common in those who die of this affection, although they did not observe it in any of their cases. Slight emphysema in the upper lobes is, however, a common lesion in feeble infants, whatever the diseases of which they die. Therefore its occurrence in internal convulsions is probably due more to molecular change in the lungs, since these patients are cachectic, than to the irregular breathing, which is only momentary. In fatal cases of internal convulsions the blood is darker than usual, from an excess of carbonic acid ; and in some cases the cavities of the heart and large vessels are engorged with blood, but in others they contain no more than the normal amount. More or less passive congestion occurs in the inter- nal organs ; and congestion of the cerebral vessels is in some patients so great that transudation of serum occurs. Symptoms. — I have said that the symptoms vary according to the seat and function of the muscles which are affected. There is generally previous ill-health. The child is drooping, and is sometimes restless, for days before the disease appears. Finally, if the muscles of the glottis become affected, the peculiar crowing sound is heard now and then during inspiration. It is observed especially when the child is crying or is agitated. It may be loud and well defined from the first, but in most patients it comes on gradually, so that several days elapse before its full stridulous character is developed. The attacks are more frequent and severe at night, in or after the first sleep, than in day-time. Under favorable hygienic conditions the malady may pass off without becoming more serious. In other cases the paroxysms gradually increase in frequency and severity. The dyspnoea in the attack is such that the features are livid, the head forcibly retracted, and death seems imminent from apnoea. In these severe paroxysms respiration often ceases entirely for INTERNAL CONVULSIONS. 637 a moment. When the spasm ends a deep stridulous inspiration occurs, after which the breathing is natural. I have stated also that internal convulsions are often associated with those — usually tonic, but sometimes clonic — of the external muscles. In the tonic form the thumbs are flexed across the palms of the hands, and sometimes are grasped by the fingers ; the great toes are adducted and the other toes flexed. In severe cases the hands, forearms, feet, and legs are also somewhat flexed and rigid. At first the contraction of the external muscles is temporary, either corresponding with the internal spasm, or it is most intense at the time of the spasm, though commencing sooner and subsiding later. After a while, however, if the disease continue, the spasmodic action of the external muscles becomes more persistent. In severe cases nearly every inspiration is accompanied by the whizzing sound, and the paroxysms of dyspnoea are excited by trifling causes. Anything that suddenly disturbs the mind or body may bring on the attack, as anger, the impression of cold, or currents of air. Dr. West calls attention to the fact that an anasarcous condition is sometimes present, accompanied by albuminuria. If the convulsions affect other muscles, as the diaphragm or the pectoral and abdominal muscles, which are concerned in the respiratory function, while those of the larynx escape, respiration is irregular or even suspended for a moment, but the stridulous laryngeal sound is absent, as there is in the larynx no obstacle to the entrance of air. In this form of the disease the inframammary region may be strongly retracted during the paroxysm from tonic contraction of the diaphragm. In severe paroxysms, whether the spasm be laryngeal or diaphragmatic, consciousness is nearly or quite lost, the features may be pallid, or, if respiration be suspended, may be more or less livid. Relaxation of the sphincters of the bowels and bladder, with involuntary evacuations, often occurs in this disease during the attack. The duration of the paroxysm may be a quarter, a half, or even a whole minute. Total suspension of respiration for even half a minute involves danger. In mild cases there may be but few paroxysms, and these slight. In other instances they occur in a severe form almost daily for several weeks or even months. The general health in internal convulsions is more or less impaired, except in mild forms of the disease, in which the convulsive attacks soon cease. Pallor or a sickly and cachectic aspect, irregular, usually constipated bowels, poor appetite, and moroseness or irritability of temper are common symptoms of severe and protracted cases. Diagnosis. — This disease is easily diagnosticated, unless when its symp- toms are masked by those of external convulsions ; it may then escape notice. Spasm of the glottis may be mistaken for spasmodic laryngitis, and vice versa. In some of the published cases this mistake appears to have been made. Spasmodic laryngitis is, however, so different not only in its nature, but in its clinical history, that a differential diagnosis is not difficult. It is an inflammatory disease, and is attended with feeble reaction and a sonorous cough ; it commences at night after the first sleep and from exposure to cold — particulars in regard to which it contrasts with true spasm of the glottis, which in complicated cases is not attended by any febrile symptoms. Prognosis ; Modes of Death.— Statistics show great mortality in this disease. Dr. Reid, in a monograph on " Infantile Laryngismus," states that of 289 cases which he collated, 115 died. Rilliet and Barthez met with 1 favorable case in 9 unfavorable, and Herard 1 in 7. If the paroxysms be mild, infrequent, and dependent on a cause which can be easily removed, recovery is probable with proper treatment. The cause may, however, be such, even when the spasm is mild, that the case is necessarily unfavorable, as when it is due to disease of the cerebro-spinal axis. We should, not. how- 638 LOCAL DLSEASES. ever, in any case consider the patient entirely safe, since grave symptoms may suddenly arise, so as to change entirely the prognosis. Long and severe paroxysms, with lividity of face and symptoms of suffocation, indicate an unfavorable result. The same should be predicted also if the infant gradually lose flesh and strength, especially if the face be pallid, the pulse feeble, and the appetite poor. There are three modes of death in internal convulsions. The first is by apncea. The infant dies suffocated in the attack. Respiration is first arrested, and then the pulse ceases, and at the autopsy the lungs and the cavities of the heart are found engorged with dark blood. Death may also result from the state of the brain. In such cases passive congestion of the brain occurs from obstruction to the return of blood from this organ to the heart and lungs ; and if this congestion be not soon relieved serous effusion also occurs. Death results from the congestion and consequent cedema or dropsy. The third mode of death is from exhaustion. Repeated and severe attacks undermine the constitution ; the infant gradually grows pallid and thin, and dies of inanition or of some disease which this state induces. Treatment. — The treatment of internal convulsions has varied according to the theories which physicians have held in reference to its cause. Gland- ular enlargement is no longer regarded as a common cause, and therefore treatment directed to its removal is less frequently prescribed than formerly. The causes of internal convulsions are in part very similar to those of eclamp- sia, and the remedies employed in the one affection are, in a measure, appro- priate in the other. That dentition is sometimes a cause is usually admitted, and two cases, one of which occurred in my practice and the other was reported to me, appeared to show that it may operate as a cause. The effect of dentition is especially observed in weakly infants when several dental fol- licles are undergoing active evolution. Thus, in one of the cases to which I refer five teeth pierced the gums in the course of two weeks ; after which no convulsive attack occurred. If, therefore, the gums are swollen, the propriety of scarification should be considered, especially if the convulsions be so severe as to endanger life. In all cases of internal convulsions a careful examination should be made in order to detect any aberration from the normal state .which might cause nervous excitation. The condition of the digestive organs should be ascer- tained, and evacuants or other remedies prescribed if there be evidence of their derangement. Sometimes the alimentation of the infant is at fault. It is perhaps bot- tle-fed and the stools have an unhealthy appearance. Attention should be given to the preparation of its food and the times of its feeding, or if it nurse the mother or wet-nurse who suckles it should have plain but nutri- tious diet, live with regularity, and give the breast to the infant at regular intervals. If there be a torpid state of the intestines, Dr. Meigs recommends ' : castor oil and aromatic syrup of rhubarb rubbed up together, three parts of the former and five of the latter." A simple enema answers well in such cases, and in debilitated infants this is preferable to medicine administered by the mouth. If diarrhoea be present, and it persist after the requisite changes are made in regard to the diet, remedies calculated to relieve it, which are mentioned elsewhere, should be employed. Marshall Hall states that he has ordinarily succeeded in curing the disease by attending to the condition of the gums and digestive organs. Since rachitis is a not uncommon cause, the child should be examined in reference to rachitic manifestations, and if they appear the treatment appro- priate for rachitis is required. In pallid and cachectic infants tonics are indicated. The elixir of cali- INTERNAL CONVULSIONS. 639 saya-bark with iron, in half-teaspoonful doses three or four times daily to an infant of two years, is an eligible preparation. The preparations of iron are frequently to be preferred to the vegetable tonics, as the citrate of iron and bismuth, citrate of iron and quinia, the syrup of iodide of iron, or the wine of iron. To an infant of one year the syrup may be given in doses of three drops, the citrates in one-grain doses, and the wine in doses of one teaspoonful, every four hoars, or the liquor ferri peptonati may be employed. Antispasmodics, as asafoetida, valerian, and oxide of zinc, are often pre- scribed in this malady, but they are less efficacious than the general tonic measures which I have mentioned. The salutary effect of bromide of potas- sium in eclampsia and epilepsy certainly justifies the trial of this agent in internal convulsions if they persist after the employment of invigorating remedies. Hygienic measures are of the utmost importance. The infant should reside in dry and airy apartments, and should be kept much of the time through the day in the open air. Remarkable success sometimes attends this simple expedient when medicines have entirely failed. Mr. Robertson l of Manchester relates five severe cases in which this disease was cured by exposure of the infants several hours daily to a cool atmosphere. These cases were treated in the winter months, and were kept outdoor even during strong winds. Mr. Robertson has records of forty cases, all occurring between December and April, while he has seen no case in the summer months. As the result of such extensive experience the writer recommends " the free exposure of the infant out of doors for many hours daily to a dry, cold atmosphere, and, if the air be dry, the colder the better." Dr. Marshall Hall's experience was similar. Says he : " The curative influence of the air, and especially of the sea-breezes, is not less marked in this affection than in whooping cough." Mr. Robertson recommends also, as part of the tonic treatment, " free sponging of the body every morning with cold water." In February, 1867, I attended a nursing infant five months old with internal con- vulsions, the paroxysms being attended with lividity of the face and at times tonic convulsions of the limbs. Among the remedies employed was bromide of potassium, but more benefit obviously accrued from keeping the infant much of the time in the open air than from the medicines employed. The disease passed off in six or eight weeks. Unless the cause be of such nature that it cannot be removed, the above hygienic and therapeutic measures will, in a large proportion of cases, be fol- lowed by a satisfactory result. The mother or nurse may abridge the paroxysm by raising the infant, blowing upon it, sprinkling water in the face, or gently stroking it. Dr. Hall recommends tickling the nostrils with a feather to produce respiration, or the fauces to occasion vomiting, and thereby interrupt the paroxysm. Anything which causes a sudden and profound effect upon the system may abridge the attack. This was effected in one case in the practice of Dr. C. C. Meigs by applying a cloth wrapped around ice over the epigas- trium and the lower part of the sternum. The chief danger during the attack is from congestion of the brain, with effusion of serum or extravasa- tion of blood. If the attack be severe and the features congested, so that there is evident danger of such a result, cold applications should be made to the head, derivatives applied to the extremities — as sinapisms or mustard foot-baths — and the bowels should be speedily opened by enemata. 1 London Med. Gazette, Jan. 14, 1865. 640 LOCAL DISEASES. CHAPTER X. TETANY. The disease known as tetany has probably always existed, for its recog- nized causes are of common occurrence, but the attention of the profession was first directed to it by a memoir bearing the title " Observations sur une Espece de Tetanos intermittent," published by M. Dance in the Archives generates de Medecine in 1831. He described it as it occurs in the adult. In the following year (1832) M. Tonnele published in the Gazette medicale an essay on tetany, which he designated a new convulsive disease of childhood. In the same year Constant and Murdoch also published their observations on. this malady in French medical journals, the former designating it ,; Contrac- tures essentielles," and the latter '• Retractions musculaires et spasmodiques." In 1835 the memoir of De la Berge on tetany, bearing the title " Retractions musculaires de courte duree," was published in the Journal Hebdomadaire. From this time the disease was fully recognized in France, and several addi- tional monographs relating to it appeared in medical journals prior to 1850, among the most notable of which was the thesis of Delpech in 1846. The term tetany (tetanie) was first employed by Dr. Lucien Corvisart in an interesting and instructive paper published in 1851. The term tetany is applied to a disease which is characterized by tonic contraction of muscles, commonly those of the extremities, but sometimes also those of the face or trunk, produced by causes external to the nervous system, and usually of temporary duration. The exception to this definition might be as regards such causes as are psychical or emotional, if such exist. Following this definition, we would exclude cases of tonic muscular contrac- tion, however close the resemblance, which arise from disease of the brain r spinal cord, or their meninges, or from disease of the nerve supplying the affected muscle. The contractions in these cases are not the malady itself, as in tetany, but are merely symptoms of some important disease located in the nervous system at a distance from the affected muscles. Causes. — Tetany may occur at any age, but is most frequent in infancy, in early childhood, and in early adult life. Of 28 cases observed by Rilliet and Barthez, 1 was at the age of nine months, 13 between the ages of three and fifteen years, 5 at the age of three years, and the remaining between the ages of three and fifteen years. Eustace Smith says that the period during which the largest number of cases occur is between the first and third years. In 142 cases collated by Gowers the ages were as follows : Between one and four years, 34 ; between fory and nine years, 8 ; between nine and nineteen years, 36 : between nineteen and twenty-nine years, 24 ; between twenty- nine and thirty-nine years, 23 ; between thirty-nine and forty-nine years, 13 ; and between forty-nine and sixty-one years, 4. Erb remarks that a strong tendency to tetany is exhibited in early childhood, and the next most common period of its occurrence is at the age of puberty and early youth. The statis- tics of different observers show that tetany is more common in males than females. Of Rilliet and Barthez's 28 cases. 20 were boys. Of the 142 cases embraced in the statistics of Gowers, 76 were males and 66 females. Accord- ing to Gowers, in the first and second decades, in which a large majority of the cases occur, more males are affected than females, but between the ages of twenty and fifty years, females preponderate, while above the age of fifty years all the recorded cases have been males. It is seldom that the most thorough investigation elicits any inherited predisposition in cases of tetany TETANY. 641 to nervous or other diseases. Most of the observed cases have occurred singly in families, and in families which exhibit no special tendency to nervous or other ailments. Rarely, however, multiple cases have occurred in families, from which we infer that there may be an inherited neuropathic tendency. The only instances of this sort which I have been able to find in the literature of tetan}^ were two cases observed by Murdoch in one family, and cases alluded to by Abercrombie, who states that at different times 4 cases occurred in each of two families, and 2 cases in another family. Although in many instances different causes appear to act simultaneously in causing tetany, nearly all writers who have contributed to the literature of this malady assign the most important place in the causation to diseases of the digestive apparatus. Trousseau states that in the cases which have fallen under his observation diarrhoea has been commonly present. He says that in 1854 he met many cases following cholera, but in one instance occur- ring in his practice the cause seemed to be obstinate constipation. The patient at the age of seventeen years was suddenly seized when travelling. His fingers were bent and he could not extend or use them. The tetany subsided in two or three hours, but it recurred every day for three months. He was treated by bleedings, but the tetany was uniformly worse after each loss of blood, the contractions becoming more severe and also more general. Not only were the muscles of the extremities in a state of tetanic contrac- tion, but also those of the face and trunk, so that respiration and speech were embarrassed. Although the contractions were aggravated by bleeding, and were never so bad as after the fourth venesection, they ceased entirely for a period of ten months after cupping along the spine. Subsequently they recurred every year at the close of winter and continued two months. The patient was habitually constipated, and the torpid state of the bowels seemed to be the chief factor in producing the tetany. In the following case, which I have recently had under observation, constipation appears also to have been the chief cause : George C , without teeth and at the age of seven months when tetany commenced, was taken from the breast at the age of two months. He lives in a tenement-house, and from the time of weaning has been fed with condensed milk, one heaped teaspoonful of large size to fifty of water. Besides this, he has taken once daily a tablespoonful of Nestle's food in ten of water. With this diet his growth has been about like the average, but he has been habitually very constipated, so as frequently to require assistance in obtaining an evacuation. Recently, groups of muscles in all the extremities have undergone tonic contraction, producing deformities, as shown in the photograph (Fig. 190), and brief attacks of laryngismus stridulus. These attacks of spasm of the glottis occur both by day and by night, causing for a moment the characteristic stridulous respiration. The mother states that at times he is feverish, probably from the constipation, but usually he seems entirely well, except as regards the sluggish state of the bowels and the contractions. Attempts to straighten the fingers and toes elicit cries from the pain. The mother also says that at times both thighs and both legs are flexed, and he resists attempts to straighten them on account of the pain. The treatment employed consisted in the use of bro- mide of potassium and measures designed to relieve the constipation. When these remedies were perseveringly employed, the contractions gradually diminished and ceased, but they returned when the treatment was discon- tinued. Four months have elapsed since the commencement of the disease, and it is only in the last week or two that the contractions have entirely ceased. The important factor in producing the tetany in this case appears to have been the habitual constipation. One tooth pierced the gum during the four months of tetany. 41 642 LOCAL DISEASES. Erb says that all forms of intestinal diseases may cause tetany, but it especially occurs after " protracted and exhausting diarrhoea." Gowers also remarks that .the most common cause of tetany is diarrhoea, usually long- Fig. 190. Photograph of a child, showing tonic contraction of groups of muscles of the extremities as the result of tetany. continued and exhausting, but sometimes acute and brief." Among the rarer intestinal causes of tetany may be mentioned the presence of worms. I have not found in the literature of tetany any instance in which lumbrici or ascarides caused the contractions, but Growers alludes to three cases in which they were produced by the tape-worm. From the nature of tetany, and from the important part long assigned to dentition in producing nervous ailments, it is perhaps remarkable that the teething process has so seldom been regarded as a factor in causing tetany in young children. But, so far as I have been able to learn from memoirs and recorded cases, those who have made special study of tetany agree for the most part with Trousseau, who says that in nearly all instances pathological conditions distinct from dentition are present, " on which tetany would seem rather to depend." Nevertheless, in the following case which was treated by Professor E. G. Janeway and myself, after repeated and thorough examina- tions, teething was regarded by both of us as the chief cause of the contrac- tions : Case.— B- aged twenty months, well-nourished, has during the last few days been unable to use the left lower extremity. The thigh is flexed at an angle of about forty-five degrees and the leg at about the same angle, and attempts to overcome the rigidity of the flexors and straighten the limb are resisted and are TETANY. 643 painful. The muscles in the other extremities, and those which move the foot and toes of the affected limb, appear to have their normal functional activity, as do those of the face, neck, and trunk. The gums were swollen and congested over the crowns of five advancing teeth, which appeared to be in nearly the same stage of development, and were evidently soon to protrude. It is possible that a rather sluggish state of the bowels may have been a factor in causing the tetany, but the chief agent was apparently the cutting of so many teeth. There was not at any time any notable elevation of temperature, loss of appetite, or derangement of the functions of important organs, but the contractions continued three weeks, when all or nearly all the imprisoned teeth escaped and the limb was quickly restored to its normal state. There has been after the lapse of two years no return of the tetany. Tetany is more liable to occur in those whose systems are enervated by pre-existing disease than in those who are robust. Billiet and Barthez state that in cases which have come under their observation the patients were often in poor health, resulting from disease which they had had, as pneumonia, bronchitis, or enteritis. Bouchut also remarks that tetany occurs as a sequel of various enervating maladies, among which he enumerates cholera, typhus and typhoid fevers, and dysentery. Erb mentions the following diseases which sustain a causal relation to tetany or in the convalescence from which tetany is liable to occur : typhoid fever, measles, cholera, Bright' s disease, febris intermittens, in addition to the diarrhceal maladies which have been alluded to above. Eustace Smith goes farther, and states that tetany is rare in robust subjects — that it ordinarily occurs in those who have delicate con- stitutions by inheritance or disease or are imperfectly nourished. Gowers, enumerating the maladies which are followed by tetany, mentions " typhoid fever, cholera, smallpox, rheumatic fever, measles, febricula, catarrh, and pneumonia ; " and he states also that in young children the indications of rachitis are rarely absent. Another recognized cause of tetany is taking cold. Exposure to wet and cold has in numerous instances been followed by tetany. From this mode of origin the opinion arose that tetany is a rheumatic affection. Hence, Eisen- mann applied to it the term " brachiotonus rheumaticus," and Benedict desig- nated it •• rheumatische contractus " Erb says : "Amongst the exciting causes, catching cold is both the most important and the most common ; and this statement," he adds, "is supported by the fact that many physicians have regarded it as an exquisite example of rheumatic disease. Working in the wet or cold or in water, sleeping on the damp ground, have very often been regarded as causes, and the swelling in the joints which occurs in many instances indicates that this disease has a somewhat close relation to true rheumatism." It must be recollected that Erb's observations have been chiefly with adults. As regards infancy and early childhood, other causes of tetany are apparently more common than taking cold. Adults with tetany often attribute the attack to exposure in wet and inclement weather, and probably correctly. At the present time, in Charity Hospital, a female aged thirty-nine years is under treatment for tetany. She said that her sick- ness was produced by exposure in wet and cold weather. She was employed as a seamstress, and, being insufficiently clothed, sat at her work with feet chilled and wet. At the same time her menstruation had been irregular, and she had diarrhoea, apparently produced by the exposure. Tonic contractions occurred in the muscles of the fingers and toes on both sides, accompanied by pain, especially in the affected muscles of the lower extremities. Several months have elapsed since the commencement of the disease, and the fingers have regained nearly or quite their normal state, but the toes are firmly flexed. The chief cause of the tetany in this case appeared to be taking- cold, from which probably the diarrhoea resulted, which, as we have seen, is 644 LOCAL DISEASES. one of the most common causes of the tonic contractions. Trousseau also relates cases in which exposure to cold was apparently the exciting cause. Growers states that next to diarrhoea the most common causes are " exposure to cold, acute disease, and lactation." Among the other recognized causes of tetany we may mention suckling, pregnancy, and the development at the time of commencing puberty. The first cases seen by Trousseau in Necker Hospital occurred in women recently confined who were wet-nursing, so that at first he designated the disease rheumatic contraction occurring in nurses. Gowers says that the frequency of the disease in adult women is chiefly due to maternity. The following are occasional causes mentioned by various writers : anaemia, prolonged muscular effort, alcoholism, onanism (Gowers), ergotism, violent excitement (Erb), irri- tation of uric-acid calculi (Eustace Smith). From the nature of tetany it would seem probable that it might occa- sionally result from preputial irritation, but I have not been able to find the history of any case in which this cause was assigned, either in the literature of tetany or in monographs relating to a narrow, irritated, or inflamed pre- puce. Tetany does not result, or very rarely results, from burns or ordinary wounds ; but Weiss in 1883 reported 13 cases in which it occurred from excision of the thyroid, and, according to Wolfler, in 70 cases of this opera- tion tetany resulted 7 times. It is remarkable that this disease appears to occur as an epidemic — a fact not easy of explanation, unless upon the supposition that the rheumatismai cause due to atmospheric conditions, or the psychical or emotional cause giving rise to imitation, is operative at the time. Bouchut says that tetany occurred as an epidemic in Germany in 1717, in Belgium in 1846. and in Paris in 1855. In the Paris epidemic it occurred equally among children and adults, and was the occasion of interesting observations by Aran and Barthez. Another epidemic occurred in Paris in 1876 and in its. environs, especially at Gentilly, where in a school the teacher and thirty pupils were affected ; but some of the pupils afterward confessed that they had feigned the disease. In New York City, in the first quarter of 1889, I saw so many cases that it seemed to me that tetany might properly be regarded as an epidemic. Symptoms. — Ordinarily, tetany occurs without any marked premonitory symptoms, but in some instances it is preceded by pain in the head or spine, vomiting without any previous indigestion or gastric derangement, and a general feeling of indisposition. Usually, in those old enough to express their sensations, tetany begins with tingling, burning, or other unusual sen- sory manifestations in the limbs. The tonic contractions occur suddenly, sometimes in the upper and lower extremities simultaneously. Rarely, the contractions occur in the upper extremities alone or in the muscles of the trunk. At first a feeling of stiffness is experienced, and this is followed by tonic contractions, with the fixing of the affected part in a state of per- sistent flexion or extension. Usually, as regards the upper extremities, the contraction of the thenar and hypothenar muscles causes hollowness of the palms of the hands ; the first phalanges of the fingers are flexed, the second and third phalanges extended, and the thumb adducted and flexed so as to press against the index finger or lie underneath it. The fingers sometimes incline toward the ulnar side, and sometimes are pressed against each other. Usually the hand is slightly flexed, as is also the forearm. The muscles which move the arm usually escape, but exceptionally there is adduction of the arm on the shoulder. The hand may be extended instead of flexed, and all the joints of the fingers extended, or they may all be flexed and the fist closed. TETANY. 645 The thighs may be adducted or flexed, the legs extended or flexed, the foot extended, forming a talipes equinus, and the toes flexed, as in the fol- lowing interesting case now in Charity Hospital, which has been alluded to above. Though the patient is an adult, her case is related here since it aids in throwing light on the nature of the disease : Case. — Mary F. . native of the United States, seamstress, married, and of apparently healthy parentage, states that her health was good previously to the present sickness. She says that she has never had venereal disease and never taken stimulants in excess, though in the habit of using whiskey at breakfast. She had been married four years, and three years ago had a stillborn child at the seventh month, but has had no other miscarriage and has had no confinement at term. Her catamenia, which formerly were scanty and at unusually long intervals, have dur- ing the last four months been normal in regard to time and quantity. She has been subject to afternoon headaches for years. She has had the average appetite, has partaken largely of rye bread at her meals, and her stools have been normal. In January, 1888, the patient, being employed as a seamstress in a shop at a distance from her residence, began to experience unusual fatigue, and on returning from her day's work she frequently noticed a painful burning sensation p IG -j^ in her feet, the pain extending up- ward along the calves of her legs. This pain in the feet and legs gradu- ally increased until March 12, 1888, at the time of the deep snow accom- panying the " blizzard." After walk- ing through the snow she sat all day at her work with wet feet, and at this time she began to experience a dull intermittent pain extending from both ankles to the knees, and accompanied by great lassitude, so that walking re- quired an effort. In July the pain became more constant, but at the time of her admission into Charity Hospi- tal (August 17th) it was not so con- stant or severe. Soon after her ad- mission the feet became strongly extended, forming a talipes equinus, and the toes of both feet were also strongly flexed. Sensation in the toes, but not in the feet, was almost completely lost. A few days subsequently the fingers on both sides were similarly flexed, but without pain or loss of sensation. In about six months the flexion of the finger ceased, and she can now use them nearly as well as before the attack. The toes also are not so strongly flexed as at first, and they have re- gained sensation. The bladder has never been affected, but the sphincter ani was paralyzed for a time in August, so that the feces escaped involuntarily in bed. The patient's memory was considerably impaired after the exposure at the time of the "blizzard," but is now (June, 1889) apparently nearly or quite normal. Otherwise no impairment of the mental faculties has been observed. The tetany in this case has been, as usual, bilateral and for the most part equal on the two sides, with a little more acuteness of sensation in the right than left limbs. The feet continue in the position of talipes equinus, with toes flexed, and the contracted muscles hard to the feel, almost like cartilage. No oedema has been observed, but perspiration occurs from the extremities during sleep. In mild cases or those of ordinary severity the contractions are limited to the muscles of the extremities, and are more marked and persistent in those that move the hands, feet, fingers, and toes than in other muscles ; but in severe cases the muscles of the trunk and head participate. Contraction of the abdominal muscles produces rigidity of the abdominal walls. Spasm of certain of the thoracic muscles occasionally occurs, causing dyspnoea and even lividity. In some of these cases of embarrassed respiration the dia- phragm is probably involved. Opisthotonos, retention of urine, anteflexion 646 LOCAL DISEASES. of the neck from contraction of the sterno-mastoids, fixation of the jaws from spasm of the masseters, retraction of the angles of the mouth, stiffness of the tongue, and indistinct articulation are occasional symptoms in severe cases of tetany. The contractions render the affected muscles hard and unyielding, and the child cries from pain when attempts are made to straighten the limb. If the spasm be slight some voluntary movement of the affected muscles is pos- sible, but it is restrained and difficult. In severe cases, with the muscles tense and unyielding, voluntary motion is impossible. Except in the mildest forms of the disease pain is felt in the contracted muscles, such as all people experience when a spasm occurs in the calf of the leg, and the pain may pass upward along the limb. The pain may occur in paroxysms with distinct intermissions, or, without ceasing, it may vary in severity at different times, probably from some variation in the degree of spasm. Certain subjective symptoms, such as numbness and tingling, which sometimes occur in tetany, may continue during the intermission or remission. After some hours or days the rigidly-contracted muscles relax and the disease disappears, except perhaps that a degree of stiffness remains. But the respite is usually not- long. The spasms recur, and several successive recurrences and intermis- sions take place, running over months, before the disease is permanently cured. During the intervals in the contractions the affected nerves and muscles are in ordinary cases unduly excitable, so that sudden pressure or percussion causes some contraction. Trousseau was perhaps the first who noticed and called attention to the fact that compression of the artery and nerve supplying the contracted muscles in tetany causes or increases the contraction. Occasionally this result cannot be obtained. It is an interesting fact that in cases which I have observed the spasms do not cease in sleep, though the contraction of the muscles may not be as great as when the patient is awake. The electrical excitability of the nerve which supplies the contracted muscles is increased. Gowers states that he has obtained contractions in the muscles of the face by the voltaic current from a single cell. The increased excitability of the nerves is apparent if either the direct or induced current be used. According to Erb, when the circuit is closed the earliest contrac- tions occur at the point of application of the positive pole. Both opening and closing the circuit cause a more prolonged contraction of the muscles in tetany than in health. When the contractions are strong, oedema sometimes occurs, especially upon the dorsal surfaces of the hands. It was present in cases treated by Henoch, who attributes it to compression and consequent passive congestion of the veins, produced by contraction of the interossei muscles, the congestion giving rise to serous transudation. When the parox- ysms are severe, perspiration sometimes occurs, and an erythematous redness may appear over the affected muscles. Occasionally in acute attacks the temperature is moderately increased, but ordinarily it is normal. Tetany does not usually affect the functions of the internal organs, but in a case related by Kussmaul and another by Nonchen albuminuria was for a brief period present, and in one recorded instance the urine exhibited traces of sugar during the paroxysms. Occasionally in long-continued tetany the con- tracted muscles undergo a degree of atrophy which is attended by dimin- ished electrical irritability. Gowers states that " general muscular atrophy " has also been observed following tetany. The following may be regarded as typical cases in tetany in infancy as I have observed it in New York. The first case occurred in the New York Infant Asylum during my term of service, and the resident physician, TETANY. 647 Dr. Virginia M. Davis, has kindly furnished me the history from her note- book : Case 1. — Gertrude A , born in the New York Infant Asylum, April 30, 1888, was well except a mild attack of pertussis until March 9, 1889, when she had a prostrated appearance, and the thermometer indicated a temperature of 105°, and a little later 105.5°. During the following six hours she had five large, watery, and yellow stools. She was restless, her features sunken, extremities cool, her sur- face covered with a clammy perspiration, and her pluse feeble. Her diarrhoea was checked, and she slept during the following night. From March 9th to 14th she had slight fever (100.4°-100.6°) and her stools were normal, but during the week ending with the 14th she lost one pound in weight. The following are the subse- quent notes of the case : March 14th.— Is restless; temperature in the morning 100.4°, in the evening 103° : has had no stool in the last twenty-four hours. To-day has had for the first time contraction of the flexor muscles of the hands, feet, fingers, and toes, so that in the evening all the fingers and toes are firmly flexed. The dorsal surface of the hands and feet, and the fingers and toes as far as the articulations of the first and second phalanges, are oedematous. The flexions can be overcome by the employ- ment of considerable force, but the attempt is painful. An erythematous eruption has appeared over the upper part of the chest and upon the back. March 15th. — Temperature 100.6° ; thumbs extended, voluntary movement of fingers returning ; toes still flexed ; oedema as before ; rash fading ; stools normal. March 16th. Temperature 99°-99.8°. The contractures have entirely disappeared during the day. Had four stools. 17th. Bowels constipated ; slight contractures of the fingers. 18th. Morning temperature 103°; evening, 101°. In the evening contractures of both extremities disappearing ; stools normal ; gums swollen. From this time the constipation was relieved by small doses of calomel, and the tetany ceased. Some elevation of temperature was a prominent symptom previous to and during the tetany, and on one day (May 17th) an attack of general clonic con- vulsions or eclampsia occurred. The tetany ceased on the 18th or 19th, but between the 20th and 30th, maculae and papules appeared on the surface, due per- haps partly to the medicines employed, which were chiefly the bromides and chloral. Case 2. — Edward Mel , aged fifteen months (practice of Dr. Vineberg, but examined by myself), has healthy parentage, and no other child in family has had any nervous ailment, except a single attack of eclampsia during measles in one of the children. Edward is nourished in part at the breast and in part from the table. He has four teeth, all having cut the gum since the age of twelve months. He has had diarrhoea much of the time since birth, and during the last two months has had free perspiration from the head. The mother states that during the first months of his life he occasionally held his breath, especially at night, but with this exception no symptoms resembling a convulsive attack were observed until recently, when, during an attack of' coughing, his face grew red, his eyes turned upward, and his respiration ceased for a moment. When he was at the age of twelve months the mother first noticed that the toes were flexed and the feet extended as in talipes equinus. Considerable force was required to overcome the tonic contrac- tion of the affected muscles, and when the pressure was relaxed the feet imme- diately assumed the former position of talipes. The thumbs were strongly flexed across the palms of the hands, the index and middle fingers forcibly extended and separated from each other, and the ring and little fingers were flexed against the palm. These abnormal flexions and extensions continued more than three months, with occasional intervals of two or three days, during which the action of the affected muscles was nearly normal. The child presents evidences of rachitis in the shape of its head and enlargement of the epiphyses of the extremities. The treatment employed by Dr. Vineberg consisted in change of diet and in the use of the following prescription : R. Zinci sulphat., gr. ^ ; Atropise sulphat., gr. T ^. — Misce. To be taken three times daily. With this treatment the spasms of the muscles entirely disappeared within a week, and two weeks later had not returned. 648 LOCAL DISEASES. The following case, related by Trousseau, gives a clear and vivid idea of the symptoms of severe tetany as it occurs in the adult. A dissipated young man was found one morning lying in the street, " stiff as a poker " from the occurrence of tetany during the night. He was conscious and complained of great pain, but spoke indistinctly from the clenched state of his jaws. Muscles in his extremities were rigidly contracted, and being unable to walk, he had fallen down and could not rise. The rigidity of the muscles of the chest and abdomen, and probably of the diaphragm, rendered respiration difficult. His face was livid, and he had paroxysms of dyspnoea that threatened suffocation. The tetany finally abated, and he was able to walk and attend to light duties, but at intervals he had recur- rence of the spasms, and finally died of phthisis. Adults, unlike young children, give a clear description of their subjective symptoms. Frequently — probably in a majority of instances in the adult, as in the child — tetany is preceded by certain sensory symptoms, as formi- cation, a sensation of weight or dragging, of heat or cold, or even of pain. Soon afterward in using the limbs the patient observes some stiffness or that the movements are not so free and easy as previously. The spasms succeed, and, as in children, their duration and severity vary greatly in different patients. In the adult, as in the child, in mild tetany the contractions are limited to the muscles of the hands, feet, fingers, and toes, and the severe disease usually attacks first these muscles, and afterwards extends to the muscles of the head, face, neck, and trunk. Cases might be cited from the literature of tetany in which the contractions occurred in the muscles of the face, causing unsightly visage, the motor muscles of the eye, causing strabis- mus, the pharyngeal and laryngeal muscles, the muscles of the tongue and diaphragm, causing embarrassment of speech, respiration, and deglutition, sterno-cleido and other muscles of the neck, changing the position of the head, and in the various muscles of the trunk. In a case observed by Dr. Herard the recti muscles in the abdominal walls stood out like two tense cords. However severe the disease may be, a marked remission or distinct intermission soon occurs, the progress of tetany being characterized by intervals of complete relief. In not a few of the reported adult cases tetany has reappeared at varying intervals during a series of } T ears, being due to the recurrence of the causes which first produced it. Pathology. — Since tetany in itself is rarely fatal, only a few post-mortem examinations have been made, and in these no lesions have been discovered which appeared to sustain a causal relation to the disease. In the spinal cord minute hemorrhages, points of apparent myelitis, lymphoid cells, hyperemia of the spinal meninges and of the cords in their upper portions (Boucbut), and softening of the cord in the cervical region, have been observed in certain cases, but these lesions are believed to result from the excessive functional activity of the cord. The exaggerated excitation of the motor nerves is probably also attended by some change in their nutrition. Growers says that change in their nutrition consequent on their excited action is undoubtedly present. He states that a nutritive change in the motor nerve-fibres is usually consequent on, and secondary to, a similar change in the motor cells of the spinal cord, the axis-cylinders of the nerves being prolonged processes of these cells. Slight changes have been observed in these cells in those who have had tetany severely, and the fact that this disease is bilateral indicates that it has a central origin. Gowers adds that the sensory nerves are also probably implicated, from the fact that sensory symptoms often precede the spasm of tetany. As to the seat of the disease, nothing fur- ther is at present known ; but Gowers after a careful survey of the facts relating to the pathology of tetany, remarks : " On the whole, our present TETANY. 649 knowledge of the pathology of the disease points to the nerve-cells of the spinal cord and medulla as the parts chiefly deranged, and the way in which the cells in rare cases seem to undergo subsequent atrophy suggests that the disturbance is a primary one of the cells themselves, and is not produced by the agency of any vaso-motor mechanism. It is difficult to conceive that symptoms of such definite and uniform character can be the result of any vascular spasm. The occasional wasting, with diminished irritability, is especially important as suggesting that the nutritional changes in the motor- cells and fibres, causing the increased excitability, may sometimes go on to structural degeneration." Diagnosis. — It may assist in the diagnosis to ascertain that the attack has immediately followed the occurrence of one of the recognized causes of tetany, as diarrhoea or other intestinal ailment or exposure to cold. We may diagnosticate tetany from tetanus from the fact that it is very rare under the age of one month, if indeed it ever occur in the newly-born, whereas tetanus almost never occurs in infancy after the first month or in childhood, nearly all cases occurring during the first three weeks after birth. It is also dis- tinguished from tetanus by the fact that it begins in the extremities, has periods of cessation or intermittence, and the masseters, which in tetanus early undergo the peculiar tonic contraction, are not affected or are affected only at a late stage and in the most severe cases. In organic disease of the brain the contractions do not, as a rule, intermit, and they are frequently limited to one side ; besides, other symptoms clearly referable to the brain are usually present. The bilateral and symmetrical nature of tetany, the occurrence of the contractions in corresponding groups of muscles on the two sides, distinguish the disease from those contractions which occur from lesions in the course of the nerves. Prognosis. — Tetany, whether intermittent, remittent, or occurring with little variation in the spasms, soon ceases in some cases and never returns. In other instances it does not cease entirely for months, though varying in severity at different times. Certain patients have attacks of it at intervals during a series of years, their health being good when not affected by it. Thus the case of a woman is related whose first attack was at the age of twenty-two years, and who had a recurrence of the disease every winter, and was still having it at the age of thirty-four years. This appears to have been one of those cases which have been attributed to a rheumatismal cause inci- dent to cold weather. Lussana relates a similar case in which tetany occurred each winter during ten successive years. In some instances years elapse between the attacks, as in a case related by Choostek. Maccall states that a woman had tetany five times when wet-nursing five successive children, and ivas well in the intervals. During infancy and childhood tetany, when uncomplicated, ends favor- ably, with possibly now and then a rare exception. In this respect it con- trasts with tetanus, which, whatever the age, is, with few exceptions, fatal. The few cases found in the literature of this disease in which death appar- ently resulted directly from tetany have been, so far as I have been able to ascertain, adults. Dr. Blondeau states that in Lourcine Hospital, Paris, a young woman whose health had been greatly impaired by syphilis and a mis- carriage had an obstinate diarrhoea. Tetany set in with great violence. The muscles of the face, neck, and chest were rigidly contracted. The face was livid, the eyes fixed, the pulse could not be counted, and the breathing was labored and stertorous. She was bled from the arm, and subsequently twelve leeches were ordered to be applied behind the ears, but during their appli- cation she died. The post-mortem examination, conducted with great care. revealed an apparently healthy state of all the organs except " trace of con- 650 LOCAL DISEASES. gestion in the meninges, the veins of which contained a little more dark blood than usual." Gowers states that death may occur in consequence of pulmonary congestions and a low form of pneumonia which result from repeated attacks of tetany. Tetany following excision of the thyroid is more likely to be fatal than when it occurs from other causes. But, we repeat, so rarely is tetany fatal that most of those who have contributed to the litera- ture of this disease have never observed a fatal case. Muscular weakness for a time, and even more or less muscular atrophy, occasionally follow an attack of tetany. Treatment. — The cause or causes of the attack, so far as they can be ascertained, should obviously be promptly treated, and if possible removed. Especially should diarrhoea or any other abnormal state of the digestive sys- tem receive appropriate treatment, If the patient have been exposed to cold, and the cause be apparently of a rheumatismal nature, warm baths and diaphoretics, such as are employed in breaking up a cold, may be advantage- ously employed. In the treatment of the tetany of children the bromide of potassium is a most useful remedy. Four grains dissolved in cold water or any convenient vehicle may be given every third or fourth hour to a child of from one and a half to two years. It is a safe remedy, and it usually causes a diminution or cessation of the spasms. Cannabis indica, chloral, and hypodermic in- jections of morphia which have been employed in adult cases with apparent benefit should not be recommended for young children. It will be recollected that in the case treated by Dr. Vineberg, related in a preceding page, the infant at the age of fifteen months took one-quarter of a grain of sulphate of zinc and yl^ of a grain of sulphate of atropia three times daily, and with this treatment and a change of diet recovered within a week. Chloroform inhalation has been used, and during the narcosis produced by it active massage treatment of the affected limbs has been employed with apparent benefit. Growers states that faradism is contraindicated, and that the best results have been obtained from the voltaic current, either with both poles applied to the spine or with the negative pole to the spine and the positive over the affected muscles. But the treatment by electricity, by chloroform, and, we may add, by ice over the spine, as practised by Trousseau, is more applicable to adult cases than to children. A large proportion of children having tetany exhibit rachitic symptoms, and when such symptoms are present cod-liver oil and iron should be pre- scribed, and at the same time that the bromide of potassium and other reme- dies designed to relieve the tetany are employed. CHAPTER XI. CHOKEA. Chorea, St. Vitus's or St. Guy's dance, is a neurosis which is charac- terized by irregular and involuntary muscular movements, without loss of consciousness. The movements occur in the muscles of volition, and there is probably no one of them that may not be engaged, though some are more frequently affected than others. It is not known that any involuntary mus- CHOREA. 651 cle is ever involved, though Sir William Jenner has expressed the opinion that occasionally the papillary muscles of the heart are, so that by their spasmodic contractions they produce insufficiency of the mitral valve. This, according to him, affords explanation of the fact that in certain instances a mitral regurgitant murmur is heard, which disappears about the time that the external movements cease. It is rare, however, that a mitral regurgitant murmur, heard during chorea, ceases when the latter terminates, and it is not improbable that in such cases there is, after all, a lesion of the valve, due to recent endocarditis, whether of a rheumatic or other origin ; for a valve may be so thickened by recent inflammation as to cause a murmur, and after a few weeks or months the infiltrating substance be so absorbed that the murmur is no longer audible. If we admit the fact that cardiac bruits occasionally appear and disappear with chorea, this explanation seems to me more plausible than that of Jenner. Hillier says in reference to this sub- ject : ,k My own experience leads me to doubt the existence of dynamic apex- murmurs in chorea ; that is to say, murmurs produced in hearts entirely free from organic change. If such murmurs ever occur, they are certainly rare. Organic murmurs of the heart, on the other hand, are common in chorea, and I am inclined to believe that organic disease of the heart often exists in chorea when there is no murmur." We shall see, by a case presently to be related, that this opinion is correct. Hillier also calls attention to the fact that choreic movements are irregular ; but a cardiac bruit occurring regu- larly and uniformly, if not due to organic disease, would require rhythmical contractions of the papillary muscles to produce it. We infer from this that the bruit does not have a choreic origin. In the class of children's diseases in the Bureau for the Relief of the Out- door Poor in New York City, 16,986 children were treated in the two years and three months ending with March 31, 1877. Of these cases 82, or 1 in every 207, had chorea. The patients were all under the age of fifteen years. Statistics published by observers in Europe show that the relative frequency of this disease is probably about the same in the large European cities as in New York. Thus, according to Hillier, among 122,621 out-patients treated at the Hospital for Sick Children in London, 406, or 1 in 322, had chorea, while of the in-patients, 174 in 5585, or 1 in every 32, were choreic. In the Parisian Hospital for Sick Children, of 84,968 admitted in twenty-one years, 531 had chorea, or 1 in every 161. Age. — Chorea may occur at any period of life, but a large majority of the cases are in childhood. It is rare in infancy and it rarely begins after puber- ty. Under the age of five years the proportionate number diminishes as we approach the time of birth. The youngest in the statistics of Hillier was three months. In 1870, in the Bureau for the Out-door Poor a child was presented for treatment who, the mother said, had had chorea from birth, and in 1877, I treated a young woman with severe general chorea who, repeatedly questioned, uniformly said that she had had the disease, without any assignable cause, from the first week of her life, and her friends corrobo- rated the statement. The following table exhibits the relative frequency of chorea at different ages : 6 years. 6 to 10 10 to 15 and under, years. years. Children's Hospital, London, Hillier, none over 12 years admitted 81 237 104 M. Bufz 10 61 118 Bureau for Out-door Poor (prior to 1875) 2 26 16 At and under 3 to 5 5 to 10 10 to 15 3 years. years. years. years. Bureau for Out-door Poor (since January 1, 1875) 5 30 337 3 30 652 LOCAL DISEASES. M. See collected the statistics of 531 cases occurring in the Children's Hospital, Paris, and from them concludes that the maximum frequency of chorea is between the sixth and tenth years. Only 28 of his cases were under six years, the remainder, 503, occurring between the sixth year and puberty. Causes. — The profession are nearly agreed in regard to certain causes of chorea, while there is a diversity of opinion in reference to others. It is admitted that in a large proportion of cases there is a neuropathic state which antedates and predisposes to chorea. This state is often manifested in the family history by a proneness to affections of the nervous system, and in the individual by a highly excitable state of the emotions, so that he evinces joy, grief, or anger from slight causes. All writers admit that there is often an inherited predisposition to chorea. In 27 of -48 cases, Radcliffe found that father, mother, brother, or sister had been or was the subject of one or other of the following disorders : paralysis, epilepsy, apoplexy, hysteria, or insanity. The children of parents who when young had chorea or who exhibit proneness to ailments of the nervous sys- tem are more liable to chorea than other children. Hence the fact, some- times observed, of different children in the same family becoming affected with chorea when they attain the age at which this disease ordinarily occurs. In one family in my practice three girls at different times were affected. Sex. — The emotions are strong in girls, since in them the nervous system predominates, while the muscular power is weaker than in boys. Hence a partial explanation of the fact which statistics fully establish, that the pro- portion of choreic boys to girls is about in the ratio of one to two and a frac- tion. I have remarked, in this city, the large proportion of cases in school- girls between the ages of six and twelve years, the severe discipline and confinement of the public schools no doubt increasing the strength of the emotions, and weakening the control of the will over the muscles. Proportion of Males to Females. 27 to 73. Hughes's Digest of Cases in Guy's Hospital, 1846. 138 to 393. M. See. 50 to 94. Out-door Department, Bellevue. 276 to 499. Children's Hospital, London, West (Lumleian Lectures). 491 to 1059=1 to 2.15. The cases treated in the Out-door Department, Bellevue, since those contained in the above table occurred, give a larger percentage of females. Between April, 1878, and December, 1883, 288 choreic cases were treated in this department, and of these the proportion of boys to girls was 1 to 2.4 (Chapin). Uterine Irritation. — The peculiar changes occurring in the female at puberty constitute an important cause. Hence another reason of the excess of female cases. Dysmenorrhea and pregnancy are causes of a large pro- portion of cases in the first years of puberty. In the male, on the other hand, the changes of puberty do not appear to increase the liability to the disease, directly or indirectly, and male cases after the age of twelve years are comparatively rare. Radcliffe x states that after the ninth year females are more liable to chorea than males, in the proportion of 5 to 2, while before the ninth year the two sexes are equally liable to it. Carefully prepared statistics, however, notwithstanding the high authority of Radcliffe, show a preponderance of girls under the age of nine years, though not so great as over that age. In the Out-door Department at Bellevue, of 35 patients under 1 Reynolds' System of Medicine. CHOREA. 653 the age of ten years, 22 were girls, while of 20 from the age of ten years to sixteen. 15 were girls. According to West, 1 in 775 children with chorea, under the age of ten years, treated in the London Children's Hospital, 64 per cent, were girls. Ansemia. — Among the most common predisposing causes of chorea is anaemia. It is present in so large a proportion of cases, exhibiting itself by pallor of the countenance and other characteristic signs, that medicines designed to improve the quality of the blood are among the most efficient remedies. The peculiar neuropathic state already alluded to, which needs only a slight additional cause for the development of chorea, is no doubt largely dependent on impoverishment of the blood, if it be not sometimes due entirely to it. Among the poor of a large city like New York or in hospital practice the proportion of anaemic cases of chorea is, for obvious reasons, much larger than would appear from the general statistics. Rheumatism. — Dr. CopelancL, M. Bouteille, and afterward M. Germain See in a more extended monograph, directed the attention of the profession to rheumatism as a cause of chorea. Subsequent observations have estab- lished the fact that rheumatism or the rheumatic diathesis is so frequently present that it obviously sustains an important relation to chorea, though in what manner is not fully ascertained. This relation between the two is more frequently observed in some countries than in others. In England and France so large a proportion of choreic patients present a history of rheu- matism, either in themselves or family, that certain physicians of these coun- tries believe that rheumatism is the most common cause of the disease. In Germany, on the other hand, according to Romberg, in the majority of cases no relation can be traced between chorea and rheumatism. Probably the largest number of choreic cases treated in one institution in this country is in the Bureau for the Relief of the Out-door Poor in this city ; and it has been our practice during the last few years to examine each patient for heart dis- ease and question the parents as regards rheumatism. Without referring to the exact statistics, I should say that at least one-third give the history of rheumatism in themselves or parents or had unequivocal signs of heart dis- ease. One of the physicians of the class found that 22 in 38 consecutive cases of chorea gave the history of rheumatism or of heart disease in them- selves or parents. Various theories have been promulgated in explanation of the relationship of the rheumatic and choreic diseases. It has been suggested that chorea is due to rheumatism of the brain or spinal cord. This is simply an hypothesis, the truth or falsity of which can only be ascertained by carefully-conducted necropsies ; but the theory appears improbable in view of all the facts. Another theory attributes chorea to the state of the blood which is present in those having rheumatism or the rheumatic diathesis, as well as in certain other conditions. This theory is enunciated by Dr. Ogle as follows : " Recog- nizing the frequent existence of these fibrinous deposits or granulations on the heart's valves in chorea, I should be much inclined to look upon these post-mortem appearances rather as results of some antecedent general con- dition of the blood common also to the choreic condition. It is very freely recognized that this affection is frequently in some way or other, connected with that condition of blood which obtains in what we call anaemia or that existing in rheumatic constitutions. In both of these states we know that the fibrin of the blood is much in excess (as also it is in pregnancy, another condition looked upon as obnoxious to chorea) ; and in these states we know that the fibrin with which the blood is surcharged is very prone to be readily precipitated, either owing to its superabundance or from other obscure and 1 Lumleian Lectures. 654 LOCAL DISEASES. acquired properties, .... upon the heart's walls or valves. May not this hyperinosis be the explanation of the coincidence alluded to?" 1 — namely, the occurrence of chorea in those affected with rheumatism. Others still hold that chorea is the result of the heart disease, and not directly of rheumatism, occurring when the heart is affected from other causes as well as when the lesion has a rheumatic origin. This theory is plausible, and probably to a certain extent correct. Heart lesions observed in children result from scarlet fever in a considerable proportion of cases, though it is true that the endo- carditis and pericarditis of scarlet fever are believed often to have a rheumatic origin, occurring in some instances from scarlatinous rheumatism, but in other cases from scarlatinous uraemia. Occasionally also the heart disease appears to have occurred independently of both rheumatism and scarlet fever. Thus in a fatal case of chorea with valvular disease related to the London Patho- logical Society, April 6, 1869, the child was always healthy up to the present illness (chorea), and there was no history of rheumatism in the family. The more observations accumulate the more important does heart disease in itself appear as a cause of chorea. In nearly all recorded cases of fatal chorea which were supposed to be due to rheumatism, and in which post-mortem examinations were made, endocardial and usually valvular disease has been found. We shall see that certain eccentric causes of irritation aid in pro- ducing chorea, and may not the valvular disease or the endocarditis which causes the valvular lesion operate in a similar manner as a cause ? We know that in the adult severe cardiac disease often profoundly affects the nervous system, perhaps in consequence of the irregular and embarrassed circulation, and certainly in the child a similar cause would be likely to produce a more decided effect. But there is an ingenious theory which attributes chorea to minute emboli detached from vegetations on the valves, and arrested by capillaries in the corpora striata or other portion of the cerebro-spinal axis. Since attention was directed to this matter, emboli have been found in one case in the medulla oblongata, although this portion of the spinal axis appeared healthy to the naked eye. Further observations are necessary in order to determine how much truth there is in this theory ; but it seems probable, for reasons to be stated, that if capillary embolism do cause chorea, it is only in a limited number of cases, and that therefore those British observers who regard it as the common cause have been led into error by the large proportion of choreic cases which in their climate are complicated by valvular lesions. That embolism is not a common cause, if indeed a cause at all, appears probable from the following facts : First. In many cases of chorea there are no vegetations or other appreciable lesions which could give rise to emboli. Secondly. Most patients recover, and some speedily, by treatment, which we would not expect if the cause were embolism. Thirdly. Embolism is not infrequent in the cerebral vessels of the adult without the occurrence of chorea. Indeed, the conditions which produce embolism are much more common in adults than in children, while the reverse is true as regards the liability to chorea. Fourthly. Dogs sometimes have chorea, but the injection of minutely divided fibrin or other substance into the veins of the dog is not followed by chorea as one of the phenomena. Fifthly. Were capillary emboli the cause, we would expect to find an occasional embolus in the larger vessels of the brain, so as to be appreciable to the naked eye ; but I find no examples of this in all the recorded autopsies which I have been able to consult. Moreover, it seems improbable that capillary embolism, when producing no lesion appreciable to the naked eye, would so arrest the circulation and dis- turb the function of the brain or spinal cord as to cause chorea, for the ill- 1 British and Foreign Med.-Chir. Rev., January, 1868. CHOREA. 655 effects of such an obstruction would be likely to be obviated by the numerous anastomoses. In 1877 the unusual opportunity occurred in my asylum practice of deter- mining whether there are any fixed anatomical characters in the cerebro-spinal axis in chorea ; in other words, whether chorea is a neurosis, as we have designated it in our definition, and the case is so interesting in other respects that I shall relate it entire : Case. — Charles , a foundling, born October 15, 1874, was received in the New York Foundling Asylum soon after his birth. When two weeks old he was removed to a family in the city to be wet-nursed. His health continued good till the age of three months, when he had bronchitis and keratitis, the former mild and lasting only a few days, but the latter continuing nearly two months, being- attended by moderate injection of the conjunctiva, with some purulent discharge, which caused adhesion of the eyelids during sleep. From this time he remained well, with the exception of a slight attack of dysentery, till the age of about nine and a half months, when he began to have febrile symptoms. In the morning hours he seemed in tolerable health, but at mid-day or a little later than mid-day of each day he was observed to have slight irregularity or embarrassment of respiration and lividity, with coolness of the extremities ; which state, supposed at the time to be the algid stage of a somewhat irregular intermittent fever, lasted from one to two or three hours, and was succeeded by fever, which continued during the remainder of the day : sometimes the fever abated in perspiration. On August 4, 1875, a few days after the commencement of these irregular febrile symptoms. Charles was brought to the dispensary of the institution for treatment, and Dr. Reid, who was on duty that day, carefully examined the case and pre- scribed the sulphate of quinia. This medicine, continued a few days, relieved the symptoms, but every four to six weeks, for more than a year, the febrile attacks returned, and were uniformly relieved by the same medicine. In other respects the patient had the usual health. On or about February 1, 1878, the nurse noticed that Charles had what she designated " spells of trembling," in which he seemed excited and feverish, and which were sometimes attended or followed by perspiration. In the course of another week the irregular muscular movements became more marked and constant, and they increased in severity till near the time of the admission of the patient into the asylum, about March 1st. The nurse had noticed in February slowness and some difficulty of micturition, and Dr. Reid examined him with a catheter for calculus, and also his prepuce for any source of irritation, but nothing abnormal was discovered, either in the condition of the bladder or the external organs. In the latter part of April the chorea had become so severe that irregular muscular action occurred in all the limbs and in the muscles of the eyes, producing such grimaces and contortions, with strabismus, that the woman with whom he was boarding became alarmed, and returned him to the asylum, stating that he had become crazy. On March 12th my attention was first called to this child, when I made the fol- lowing entry in my note-book : Family history unknown ; no history of rheumatism in patient's case ; he may or may not have had it ; heart sounds normal ; pulse 104 ; all the limbs and the muscles of the face, eyes, and eyelids involved in choreic movements, which continue constantly except during sleep. The patient cannot walk or stand without support : appetite good, apparently better than in health, for he eats every kind of food handed to him, and carries the food with his own hand to his mouth, although these movements are very irregular and jerking. Three drops of Fowler's solution ordered after each meal. March 17th. — Condition not much changed, but perhaps slight improvement ; in addition to other choreic movements the eyes twitch spasmodically ; pulse 84. temperature 98 J° ; bowels irregular ; no cough ; appetite good : increase medicine to five drops. 30th. — The urine examined since the last record was found very pale and abundant ; its specific gravity low, 1004, without albumen. When an equal quan- tity of nitric acid was added to it, after twelve hours crystals of nitrate of urea occupied about one-half of the volume of the urine. The patient's sleep is quiet, but the choreic movements recommence as soon as he awakens, but in a milder 6oQ LOCAL DISEASES. form ; is able to walk without support, but with unsteady gait. My term of service ended March 31st. On the following day laryngo-tracheitis was suddenly developed, ending fatally in forty-eight hours at the age of two years five and a half months. Autopsy, April 4th. — Slight oedema about the aperture of the glottis; general and intense redness of mucous membrane of larynx, trachea, and bronchial tubes •, as far as they can be traced, posterior portions of lungs greatly congested. The heart, lungs, brain with one eye attached to it by optic nerve, and the entire spinal cord were sent to Prof. Francis Delafield, for microscopic examination. They were, as soon as removed, placed in a solution of bichromate of potassium. The follow- ing is a brief statement of the examination which was made : Microscopic Appearances. By Prof. Francis Delafield. — Brain presented no change apparent to the naked eye except a considerable degree of congestion. It was hardened in bichromate of potassium and chromic acid. Minute examination of the convolutions of the brain, the large ganglia, the cerebellum, the pons Varolii, and the medulla oblongata showed nothing except a uniform filling of the vessels with blood, as if they were injected. There were no apoplexies, no changes in the walls of the vessels. Spinal cord appeared to be entirely normal. The Heart. — The auricles and ventricles were of normal size. The aortic valves were atheromatous and somewhat rigid ; the mitral valves were thickened and insuf- ficient ; the endocardium of the left ventricle was thickened. The Lungs. — The capillaries in the walls of the air-vesicles were dilated, and there was an increase of epithelial cells within the air-vesicles. In this case there seemed to .be no lesion associated with the chorea except the organic disease of the heart and the changes in the lungs secondary to this condition of the heart. The above microscopic examination was made with sufficient minuteness, and it is seen that no emboli were discovered and no lesion of the cerebro-spinal axis except congestion, which was attributable to the mode of death — namely, by obstructed respiration. Moreover, it will be recollected that there were no cardiac bruits, and apparently not sufficient roughness of the edge or surface of the valves to cause precipitation of fibrin, which would be necessary in order that emboli should form. Fright. — A not infrequent cause of chorea is sudden and profound emo- tion, especially fright. All statistics give fright as the cause of a certain proportion of cases, though there are usually other potential co-operating causes, as anaemia or valvular disease. Fright was stated as the cause of chorea in 31 of the 100 cases occurring in Gluy's Hospital reported by Hughes, or nearly 1 in 3. But the statistics of other observers do not give so large a proportion of cases originating in this way. Chorea may commence within a few hours after the fright or not till the lapse of several clays (eight or ten). If several weeks have passed since the fright, as in some reported cases, the chorea is probably due to other causes. In rare instances chorea is said to have been caused by sudden and excessive joy. Imitation. — Under unusual circumstances, especially in a state of great mental excitement, imitation has been known to cause a form of chorea. Hecker describes an epidemic of it occurring in the Middle Ages and spread- ing through villages. In modern times it is rare that chorea originates from this cause, nevertheless occasional examples have been recorded. But the disease which occurs from imitation differs from the ordinary form and has been termed chorea major, while the chorea which is the subject of this article is sometimes designated, in contradistinction, chorea minor. In chorea major the patient leaps, dances, or whirls like a top. It has its origin commonly in religious excitement, and spreads by imitation almost in the manner of an infectious disease. The epidemic of the Middle Ages was a chorea major. I have not been able to find any account of cases spreading by imitation in modern times which were not examples of the same form of chorea. Thus in the Edinburgh Journal of Medicine and Surgery, for July, CHOREA. 657 1839. there is a clear description of chorea major occurring successively in five children in the same family. Dr. Dewar, the attending physician, states that one of the children whom he was called to see was sitting near the fire- place, when her head dropped on her chest and she appeared to doze for some minutes. In the mean time the respiration became a little accelerated, the face altered and flushed, the eyes wild. In less than one minute she bounded from one extremity of the apartment to the other, leaping over chairs, a chest, and then throwing herself upon the floor ; she attempted to stand upon her head, rolled upon the floor, and then, rising, ran with extreme swiftness in the room, till she finally fell again upon the floor, where she remained motion- less some minutes. Then, recovering, she noticed those who surrounded her, and asked of her sister a toy which she had allowed to fall. The whole paroxysm lasted twenty minutes. Obviously, the symptoms of chorea major differ materially from those of chorea minor, and it is a question whether it should have the same generic name. It is a curious and interesting disease in its psychical and pathologi- ical aspect, but it is so rare in modern times that a knowledge of it is of little practical importance. Intestinal Irritation. — In rare instances intestinal worms cause chorea, though in these cases there have usually been some co-operating causes. The following is an example related by Mr. Ogle : 1 " Ellen L , nine years old, had been under treatment about a month with chorea, rheuma- tism, and worms. She had not slept in four days, and there was constant spasmodic movement of the body and face. Her general condition was very unpromising. As she had passed portions of a tape-worm at intervals during the last three months, one drachm of the oleum filicis maris was administered in mucilage, which caused the expulsion of the entire worm. From that time she fully and rapidly recovered from the chorea, though a mitral murmur remained." Lesions of Brain and Spinal Cord. — Although we reject the theory that cerebral emboli are the common cause of chorea, and believe that in a large majority of cases there are no cerebro-spinal lesions, nevertheless experi- ments and also occasional cases establish the fact that if not true chorea, at least choreiform movements now and then result from a structural affection of the nervous centres. Experiments on certain of the lower animals demonstrate that irregular muscular movements may be produced by traumatic injury of certain por- tions of the cerebro-spinal axis, as the corpora quadrigemina, crura cerebri, pons Varolii, crura cerebelli, thalami optici, parts of the medulla oblongata, and the upper portion of the spinal cord. Pressure on the projecting part of the medulla oblongata of an acephalous monster also causes convulsive movements. At the meeting of the New York Academy of Medicine, April 20, 1871, Professor Post related the case of a child who was struck over the occiput with a billet of wood, and chorea followed, due, in all probability, to the injury of the brain which resulted. If irregular muscular movements, choreic or choreiform, result from trau- matic injury of certain portions of the nervous centres, may they not also occasionally occur from lesions of the same parts produced by disease ? Sir Benjamin Brodie 2 relates the case of a choreic girl dying in St. George's Hospital, in whom, after a careful post-mortem examination, the only morbid appearance observed was a tumor the size of a hazlenut connected with the pineal gland. Dr. Broadbent 3 described another case before the London Pathological Society in which a tumor was found arising from the centre of the spinal cord ; and Chambers one in which tubercles were imbedded in the 1 London Medico- Chir. Bev., Jan., 1868. 2 London Lancet, Dec. 19, 1S40. 3 Transactions London Pathological Society, vol. xiii. p. 246. 42 658 LOCAL DISEASES. cord. Romberg quotes from Frerichs a case in which the medulla oblongata was pressed upon by an enlarged odontoid process ; and Dr. Aitkin ] one in which the specific gravity of the thalamus opticus and corpus striatum was greater on one side than on the other. Rilliet and Barthez relate other simi- lar cases, and they remark : " We may conclude from these different cases that there exist two species of chorea — the one essentially a simple neurosis, while the other depends on an alteration of the encephalo-rachidian system. In a word, it is of chorea as of convulsions, that it is sometimes idiopathic, sometimes symptomatic." Still, the cases in which it is symptomatic are so few that it is proper to consider chorea, as it ordinarily occurs, one of the neuroses until the microscope detects some anatomical cause in the cerebro- spinal system of which we are now ignorant. Anatomical Characters. — We have seen that chorea has no constant anatomical characters. Lesions which probably sustain a causal relation to the disordered muscular action are sometimes present, and others are some- times observed which are neither a cause nor a result, their presence being a coincidence. But there are two lesions which, though often absent, have been observed in so large a proportion of fatal cases that they are justly regarded as an occasional result when chorea is severe. Dr. Hughes of London collected records of the post-mortem appearances of 14 cases, with the following result as regards the cerebro-spinal axis : Brain, 14 cases ; healthy, 4 cases ; only congested, 3 cases ; softened in part or entirely, 6 cases (some of these 6 also congested). In some of the 14 cases those occa- sional results of congestion — to wit, transudation of serum and extravasa- tion of blood in greater or less quantity — were also observed. Spinal cord : healthy, 3 cases ; congested, 2 cases (one slightly, in the other the engorged vessels were large and numerous) ; softening in medulla oblongata, 1 case ; softening opposite fourth and fifth vertebrae, 12 cases. In 1 there was soft, in another firm, adhesion of the spinal meninges, and in 1 it is stated that the rachidian fluid was opaque. Of 16 fatal cases of chorea occurring in St. George's Hospital, " congestion (more or less complete) of the nervous centres (brain or spinal cord, or both) was met with in 6 cases." Softening of certain parts of the brain was observed in 1 case, and of the spinal cord in another. 2 Other statistics of the anatomical character of fatal chorea correspond, in the main, with those of Hughes and Ogle. The lesions observed by them are probably not present in ordinary cases, occurring only when the choreic movements are so severe that the patient is deprived of needed repose and the important functions of the economy, as circulation and nutrition, are seriously disturbed. The post-mortem examination of other parts besides the cerebro-spinal axis furnishes a negative result, if we except such affections as have been ascertained to act as causes of chorea. What portion of the nervous centre is chiefly involved in chorea is uncertain. Some, as Sir Benjamin C. Brodie, 3 consider chorea a disease of the nervous system generally, while others have attributed it to disease or disorder of a certain part, as the corpus striatum, cerebellum, etc. Finally, it is stated that in late experiments on choreic dogs the movements do not cease when the spinal cord is severed from the brain, nor also on division of the posterior roots of the spinal nerves. 4 In these cases, therefore, the part of the axis which is in fault would appear to be solely the spinal cord. 1 Glasgoiv Medical Journal, vol. i. 2 Ogle : Brit, and For. Medico-Chir. Rev., Jan., 1868. 3 London Lancet, Dec. 19, 1840. 4 Legros et Onimus : "Rech. sur les Movements choreiform^ du Chien," Acad, des Sci., 9 Mai, 1870, Lyons Med. Jour., June 5, 1870. CHOREA. 659 Symptoms. — Chorea is partial or general. It is partial when it affects a few muscles or groups of muscles, as those of one arm, the face or neck, or of one eye. It is designated general when all the limbs and certain of the muscles of the face and trunk are involved. Statistics show that partial chorea occurs more frequently on the left than on the right side, and in gen- eral chorea the movements on the left side usually predominate. The com- mencement is in most cases gradual. Even when finally chorea becomes general, certain muscles only are affected in the commencement in ordinary cases. The child in whom this disease is about to begin is observed to be fretful and impatient from slight causes, and the irregular muscular action is sometimes misunderstood by the parents, who reprimand him for his sup- posed fidgety habit. In exceptional instances, especially when the cause is a sudden and profound emotion, the commencement is abrupt, and the disease is severe and general from the first. In a majority of cases the muscles which are primarily affected are those of the face, neck, fingers, or hand on the left side. Sydenham erred, unless the clinical history of chorea has changed during the last two centuries, when he stated as the common fact that a tottering gait is its first manifestation, but now and then such a case does occur. Whenever choreic movements appear other muscles besides those first affected are soon involved, so that in the course of a few weeks, sometimes of a few days, all the muscles that participate are engaged. A muscle affected by chorea alternately contracts and relaxes, but less forcibly and rapidly than in eclampsia, and the movement is partly controlled by volition. This produces an unsteady and tremulous action of the part, whether a limb, the neck, or the face, which at once arrests attention and indicates the nature of the disease. The result is similar, as regards the muscular action, whether the patient wills a movement or attempts to control those which chorea produces. If the case be of ordinary severity, the movements continue with but momentary intermissions, except during sleep, when they ordinarily cease. In grave cases patients are often deprived of the proper amount of sleep in consequence of the severity and persistence of the muscular action, and in exceptional instances, especially when the result is fatal, the movements con- tinue in sleep, but the sleep is not sound and is frequently interrupted. In profound sleep the muscles are always in repose. The older writers have left us graphic descriptions of those diseases which have striking external manifestations, though often with somewhat of exag- geration. Sydenham says of chorea : " The patient cannot keep it (his hand) a moment in the same place ; whether he lay it upon his breast or any other part of his body, do what he may, it will be jerked elsewhere convulsively. If an}^ vessel filled with drink be put into his hand, before it reaches his mouth he will exhibit a thousand gesticulations, like a mountebank. He holds the cup out straight, as if to move it to his mouth, but has his hand carried elsewhere by sudden jerks. Then, perhaps, he contrives to bring it to his mouth, and if so, he will drink the liquid off at a gulp, just as if he were trying to amuse the spectators by his antics." In severe general chorea a similar description is applicable to the move- ments of the legs and features. Grimaces and distortions of the features occur, while the gait is halting and unsteady, or it is impossible to walk, and the patient lies or sits. The speech is slow, thick, and indistinct in conse- quence of the muscles of the tongue and larynx becoming engaged, and even mastication and deglutition are rendered difficult. The imperfect speech in chorea is attributed partly, however, to the mental state in severe protracted cases. Chorea, except when mild, is accompanied by other symptoms refer- 660 LOCAL DISEASES. able to the nervous system. More or less impairment of the mental faculties occurs in chronic cases when severe, exhibiting itself in dulness or apathy. The countenance sometimes presents in aggravated cases almost the appear- ance of idiocy. The muscles, instead of becoming hypertrophied and more powerful by their frequent contraction, grow softer, more flabby, and weaker. Indeed, a partial paralysis sometimes results, so that a degree of numbness is experienced in the affected part and the limb when raised cannot be sustained. Pain is not a symptom of chorea, but fugitive rheumatic or neuralgic pains are sometimes experienced. Derangement of the digestive function, exhibited by a poor or capricious appetite, constipation, etc., are common. In rare instances chorea affects the respiratory muscles so as to produce a peculiar involuntary barking or squeaking voice by the forcible expulsion of air over the tense vocal cords. In a case treated by Dr. L. C. Gray in the N. Y. Polyclinic the patient, a boy of fifteen years, had been choreic since his seventh year, and chorea in its usual form had continued one year when the barking sound commenced, and this has continued until the present time. Dr. French of Brooklyn also treated a similar case, having the following his- tory : A boy of nine years had choreic twitchings of the facial muscles at the age of five years. After continuing several months, they ceased during an entire winter, after which the peculiar sound of the voice, resembling the squeak of a young turkey, commenced. It occurred at the beginning, middle, or end of respiration. It alternated with choreic movements of other parts of the system, so that when they ceased it returned. By the laryngoscope the irregular action of the vocal cords was observed, but the expiratory mus- cles of the chest were also involved, so as to produce the peculiar sound by the forcible expulsion of air. In Dr. French's case these vocal sounds ceased, except at rare intervals, after three months of medicinal treatment. 1 The urine of choreic patients has been examined by Drs. Walsh, Ford, Bence Jones, Handfield Jones, Badcliffe, and others, and its elements have been found in most cases to vary from their normal quantity. Dr. Handfield Jones 2 read a paper before the Clinical Society of London in 1871 on two cases of chorea in which he had made careful chemical analysis of the urine, with the following result : During the height of the disease the amount of the urine was much in excess of what it was when the disease had ceased ; the urea excreted during the choreic period was in excess, as was also the phosphoric acid excreted when the choreic symptoms were at their maximum, but the quantity of this acid was less than the average during convales- cence ; a moderate amount of uric acid during the disease was also observed, but none upon recovery. Prognosis ; Course. — Chorea, though obstinate and often incurable in adults, usually terminates favorably in children in two to four months. Bouchut considers its ordinary duration at from thirty to fifty days, which is certainly shorter than the average duration in this country, except when the disease is materially abridged by treatment. The same author states that it may continue only a few days, as he has observed in cases which occurred during convalescence from scarlet fever. But tremulousness of the muscles, occurring in the state of weakness following a grave disease and abating as the general health is restored, I should not consider as properly choreic, any more than that occurring from over-fatigue. As the choreic movements gradually increase in the initial period till a certain maximum is reached, so their decline is gradual. Temporary variations also occur throughout the disease as regards the extent of the movements, which are aggravated by mental excitement, bodily fatigue, certain functional derangements, especially of digestion, and sometimes from causes which are not apparent. 1 N. Y. Med. Becord, Dec. 15, 1883 : Dr. Chapin. 2 London Lancet, July, 1871. CHOREA. 661 Though, as a rule, chorea in children ordinarily terminates favorably under different and even injurious modes of treatment there are exceptional cases. Romberg relates the history of a patient who died at the age of seventy-six years, having had chorea since the age of six years. In chorea limited to a few muscles or a group of muscles the prognosis is more doubt- ful than when it affects a large number, since in the former case the cause is more likely to be some lesion of the cerebro-spinal axis. Thus, chorea involving only certain muscles of the neck or of the eyes is sometimes due to this cause, and is then very obstinate. Again, observations demonstrate that chorea, when at first, in all prob- ability, strictly a neurosis, but of a protracted and grave character, may give rise to a central organic disease. This is the course of most of the fatal cases, congestion, softening, or other lesion occurring over a greater or less extent of the nervous centres. Radcliffe has known cerebral meningitis to supervene in two instances. With the occurrence of a lesion of the cerebro- spinal axis new symptoms arise, such as headache, convulsions, delirium, and paralysis, and the choreic movements cease or continue according to the nature of the lesion. Chorea, like certain other diseases either of a nervous character or having a nervous element, is more or less modified by intercurrent inflammatory and febrile affections. The oft-quoted expression from Hippocrates, febris acce- dens solvit sjKismos, observations show to be founded on fact, the most frequent example of which occurs in pertussis. In chorea the movements, as a rule, are either rendered milder or they cease as long as the febrile excitement continues ; but there are exceptions, and the subsequent course of the disease is not modified. Diagnosis. — This is not difficult in ordinary cases. The irregular move- ments with consciousness preserved enable us to make a diagnosis at sight. In its commencement and when it continues in an unusually mild form chorea may be overlooked by the physician, as it often is by the parents, the movements being attributed to a fidgety habit ; but medical advice is seldom sought till the movements are so pronounced that it is impossible to err, except through gross ignorance or carelessness. It is important to determine when chorea occurs in an organic disease, and also whether there is a local cause of the chorea. A careful and intel- ligent study of the symptoms and history of the case is requisite in order to obtain a correct diagnosis in these particulars. Treatment. — Regimenal. — As chorea in a large proportion of cases occurs in a state of anaemia, and the vital forces are ordinarily more or less reduced, obviously the regimen should be such as invigorates the system. Fresh air and out-door exercise, active or passive according to circumstances, with the avoidance of undue excitement, are requisite, and the diet should be nutri- tious, but plain and unirritating. The various functions should be preserved so far as possible in their normal state. In exceptional instances, when the choreic movements are violent, the patient should lie in bed, and some writers have recommended the use of splints to restrain muscular action in such cases. I have found chloralamid an effectual remedy in these severe cases, allaying the muscular contractions and producing quiet sleep. It may be given in the following formula : R. Chloralamid, £j ; Spts. frumenti, 5j ; Syr. rubi idsei, gij. — Misce. Give one teaspoonful to a child of five years every two hours until the desired effect is produced. 662 LOCAL DISEASES. Medicinal. — Sometimes among the co-operating causes is one of a local nature which is susceptible of removal, as a carious and painful tooth, intes- tinal worms, etc., and measures calculated to effect this are obviously required. Allusion has already been made to a case in which the employment of the oleoresina filicis and the expulsion of a tape-worm effected a speedy cure. The remedy which has been most employed in chorea, and which in consequence of the anaemia is plainly indicated in a large proportion of cases, is iron. It does not interfere with the employment of other remedies which have a more specific effect. Nearly all the ferruginous preparations have been prescribed in different cases with benefit. Radcliffe gives the preference to the iodide of iron, believing that iodide as well as iron exerts a curative influence. I have prescribed the ammonio-citrate, since it is easy of administration in simple syrup and is well tolerated ; but I now prefer liquor ferri peptonati or the pepto-mangan, recently introduced from Germany. It should be given in doses of one to three teaspoonfuls three times daily. But iron must not be regarded as the main remedy, but rather as an adjuvant. Observations during the last few years in both continents have more and more established the claims of arsenic to be regarded as the most efficacious of all medicinal agents in the treatment of ordinary chorea. Properly administered, it abridges the duration of this disease more certainly than any other agent, and within a few days begins to modify the choreic movements in the severest cases. It is conveniently given in the form of Fowler's solution. It is better tolerated by children than by adults, and should be administered to them in a larger proportionate dose. A child of eight years can take five drops, diluted in water, three times daily after eating, and the dose may be increased, if needed, to eight, ten, twelve, or even fifteen drops. I seldom observe any gastric irritability or other un- pleasant effect from its use when it is administered largely diluted and after the meals, but if such occur, it should, of course, be suspended for a time. While not hesitating to recommend iron and arsenic as superior to all other medicines in the treatment of chorea, it is not proper to ignore the opinions of other members of our profession who have had ample experience and recommend other agents instead. Trousseau gave the preference to strychnine, increasing the doses in some cases until it began to produce its poisonous effects. Professor Hammond 1 says: " My main reliance is on strychnia, which, I think, should be given in gradually increasing doses, somewhat after the manner recommended by Trousseau This plan of treatment certainly shortens the duration of the disease very materially, and causes great improve- ment in the general health of the patient. Sometimes the effect is so well marked and is so immediate that it is not necessary to increase the doses to the extent of causing muscular cramps, but generally the full therapeutical effect of the drug is not obtained till the calf of the leg or the nucha has slight tonic spasm. I have never seen the slightest ill-consequence follow this mode of treatment, and the doses are increased so gradually that with careful watching danger need not be apprehended." Dr. Hammond has treated thirty-two children with this agent without a single failure. But as chorea terminates favorably with smaller and safe doses, even if the time required be longer, it does not seem proper to recommend its employment to the extent of producing physiological effects for general practice. Bouchut, speaking upon this point, says : " But with these pre- cautions strychnia is extremely dangerous, for I have seen at the Hopital des Enfants Malades a young girl of thirteen years die in tetanus'' produced by an increased dose of this drug (article on Chorea). Dr. West, in his 1 Diseases of the Nervous System, page 617. CHOREA. 663 Lumleian Lectures, also says : " I have seen one instance in which its employment, while it failed to benefit a somewhat severe case of chorea, was followed by two attacks of violent tetanic convulsions, which nearly proved fatal ;" and he adds : ki The twitching of the limbs of itself prevents our becoming aware of the dose being excessive." Therefore, Dr. West does not favor the employment of this agent. Still, any agent may be given in an overdose, and it is not difficult to prescribe strychnia in a dose which may be efficient, and yet safe for children, at the age at which chorea ordinarily occurs. I have employed bromide of potassium in a few cases, but with so little benefit that I am not inclined to continue its use for this disease. Others have not been more successful. However efficacious the bromide may be in epilepsy, it does not appear to be a remedy for chorea. Cimicifuga. first employed by Jesse Young of this country, is highly esteemed by Philadelphia physicians in the treatment of chorea. I have employed the fluid extract in doses of half a drachm, increased to one drachm, for a child from six to ten years of age, and, though it benefits some cases, it has no appreciable effect either in moderating the movements or abridging the duration of others. Ether, asafoetida, valerian, musk, the oxide and sulphate of zinc, turpen- tine, tartar emetic, opium, and numerous other remedies have been recom- mended, and some of them have seemed useful in certain cases. In this city sulphate of zinc has been frequently employed as a remedy for chorea, and in gradually increasing doses till more than twenty grains were administered three times daily ; but it has not appeared, so far as I have been able to ascertain, to exert any marked influence either on the severity or duration of the choreic movements. Justice, however, requires us to state that Dr. West, who has written recently on the nervous diseases of children, thinks that it has been beneficial in certain cases in which he has employed it, and he regards it on the whole as the best remedy. Radcliffe, who has had ample experience in the treatment of nervous affections, writes : " In an ordinary case of chorea the plan of treatment which I have now adopted as a rule for some time is to give cod-liver oil in conjunction with hypophosphite of soda, making the draught containing the latter salt the vehicle for the administration of the cod-liver oil." Sometimes camphor or the sesquicarbonate of ammonia is added. Of more than thirty cases treated in this way, the average duration was under three weeks. Rad- cliffe began to prescribe these remedies on theoretical grounds, believing that phosphorus and cod-liver oil were required to restore " nerve-tone," and the result of this treatment has certainly been such as to commend it to the pro- fession. To children he gives from five to eight grains of the hypophosphite of sodium three times daily. In those severe cases in which choreic movements prevent the proper amount of sleep, a moderate dose of hydrate of chloral, or, better, as stated above, chloralamid may occasionally be advantageously administered. Electricity has been many times employed in the treatment of chorea, and though some, chiefly electricians, believe that it has a curative effect, others, and the majority, fail to see any material benefit from its use. Cold general baths, the shower-bath, frictions along the spine, etc.. have been employed ; but the local treatment which has so far been most success- ful, and which promises to supersede all other local measures, consists in the application of ether spray over the spine. About two ounces of ether are employed at each sitting, the spray being applied from an atomizer up and down the whole length of the spine if the chorea be general. The opera- tion, which occupies from ten to fifteen minutes, should be repeated daily or 664 LOCAL DISEASES. every second day. A considerable number of cases have been reported in which the spray has apparently had a good effect in controlling the disease. But I repeat my belief, from the large number of cases seen in the Bureau for the Relief of the Out-door Poor, that the arsenical and ferruginous treat- ment gives more satisfaction than any or all other measures. CHAPTER XII. PARALYSIS. Paralysis in young children, especially infants, is in most instances due to causes which seldom produce it in adults. The principal cause of it in the adult — namely, cerebral apoplexy — is indeed rare in children. Paralysis in children has the following recognized causes : 1st. A change in the blood, not fully understood, induced by certain grave diseases, as diphtheria, typhoid fever, measles, scarlet fever, etc. 2d. Reflex influence. The function of some part of the system is in some way disturbed, and paralysis occurs in certain muscles, perhaps at a distance from the cause, and it disappears when that cause is removed, unless it have continued too long. The only rational explanation is found in the fact of a continuous connection between the local cause and the paralyzed muscles through the afferent and efferent nerves and the nervous centres. 3d. Compression or injury of a nerve-trunk. These cases are rare. Pressing of the portio dura by the blades of forceps during birth, described in the next chapter, is an example. 4th. An anatomical alteration in the muscular fibres, the nerves and nervous centres remaining unaffected. This has been designated myogenic paralysis. This form of paralysis is probably often of a rheumatic nature. Paralysis of the face or other portions of the surface, which sometimes occurs in children and adults from prolonged exposure to cold winds, is of this nature. 5th. Some anatom- ical change in the nervous centres, as congestion, hemorrhage, inflammation, emboli, compression and laceration of brain, whether by tumors, inflamma- tory products, or other causes, etc. If there be hemiplegia, the presumption is that the disease causing it is cerebral ; if paraplegia, that it is spinal. Paralysis occurring as a symptom or sequel of some obvious local or gen- eral disease, as diphtheria, lesion of the nervous centres, etc., and which may occur at any stage, need not detain us. It is described in connection with the primary diseases on which it depends. CHAPTER XIII. POLIOMYELITIS ACUTA ANTERIOR. This form of paralysis occurs, with few exceptions, between the ages of six months and seven years. Symptoms. — The previous health of the patient is usually good. The paralysis does not always commence in the same manner. In a few instances it begins suddenly in the day-time when the child is apparently in perfect health. In others it begins abruptly, after sound sleep. The child goes to POLIOMYELITIS ACUTA ANTERIOR. 665 bed well, sleeps through the night, and awakens in the morning paralyzed. I have known it to occur in one instance after sleep in the middle of the day. In these cases there has sometimes been an exposure before the sleep to wind or rain or from sitting on a cold stone. But in the majority of cases the paralysis is preceded and accompanied by a very decided elevation of temperature, which comes on suddenly without appreciable cause, and after a few days the power of motion is found to be lost in one or more of the limbs. Xo symptom occurs during the fever indicative of disease of the brain ; consciousness is retained, and the headache or apparent liability to convulsions is no greater than in other pathological states accompanied by an equal amount of fever. The paralysis is at its maximum in the commence- ment. Occurring as by a stroke, the full extent of the paralytic state is exhibited at once, and so far as there is any subsequent change it is an im- provement as regards the number of muscles affected and the degree of the paralysis. Most frequently the muscles of one or both lower extremities are affected. Occasionally one of the upper extremities is also paralyzed in addition to the lower, but paralysis of an upper extremity is less in degree, and disappears sooner, than of the lower. The bladder and lower bowel remain unaffected, since only the muscles of volition are involved. Sensation is unimpaired in the affected limbs, and in the commencement there is even in some cases a state of hyperesthesia (West). The fever which precedes and accompanies the paralysis in certain cases gradually abates, and in a few days nothing abnormal remains except the loss of power in the affected mus- cles. These muscles are flaccid and relaxed, so that the limb falls by its weight when unsupported, and they are usually free from pain. The number of muscles paralyzed varies greatly in different cases. Only one muscle or a single group of muscles may be affected, or, on the other hand, both the extensor and flexor muscles of two or more limbs may be paralyzed. In the opinion of Mr. Adams, the following table exhibits the groups of muscles and single muscles most frequently involved, and in the order stated : Groups. 1. Extensors of toes and flexors of the foot. 2. Extensors and supinators of the hand. 3. Extensors of leg, and with them usually the first group. Single Muscles. 1. Extensor longus digitorum of toes. 2. Tibialis anticus. 3. Deltoid. 4. Sterno-mastoid. The following is an example of infantile paralysis as it not infrequently occurs when the result is favorable : A. K , German, female, aged three years and four months, fleshy ; had been in the habit of sitting on the ground near the house and on the door-sill. On July 2, 1871, she had a sound sleep in the afternoon, having been entirely well previously, and awoke trembling and with a high fever at 3J p. M. At 8 P. M., the febrile excitement con- tinuing, general clonic convulsions occurred, lasting about ten minutes. At this time I was called to see her, and found her face flushed, surface hot, and pulse about 130. Consciousness returned after the convulsion. Her intelli- gence was good, tongue moist and slightly furred, bowels rather constipated, and the urine freely passed. The fever continued two days, when it grad- ually and entirely abated, but before it ceased paralysis of the left lower extremity was observed. No weight at first could be sustained upon this limb, and it hung powerless when we endeavored to make her walk. The 6QQ LOCAL DISEASES. attempt roused her to cry, as if in pain, and pressing upon the thigh or moving it had the same effect. The thigh of this limb appeared slightly swollen on inspection, but measurement did not indicate any notable enlarge- ment. The difference in circumference was not more than one-eighth to one- fourth of an inch. There was no appreciable increase of heat in the thigh over the general temperature of the body. Sensibility remained in every part of the limb, and the loss of power was not complete, for on the first day, as soon as the paralysis was observed, slight and imperfect movements could be produced by pinching the limb. In three weeks the use of the limb was fully restored by mildly stimulating liniments and simple medicines to regulate the bowels. The tenderness which was observed in this case is only occasionally present, and has been attributed to hyperesthesia. Prognosis ; Progress. — The paralysis in nearly all cases soon begins to abate. The power of motion returns little by little, and whatever improve- ment occurs is permanent. There is no retrogression in the convalescence. The sooner improvement commences the more favorable is the prognosis. In the most favorable cases there is complete restoration in from three to four weeks. In other patients, while certain of the muscles regain the power of motion, other muscles, oftener those of the lower extremity than of the upper, do not recover their function, and, unless proper remedial measures be employed, and even with them in certain instances, atrophy soon commences. The temperature of the paralyzed limb falls three, five, or even eight degrees, and the amount of blood which circulates in it is diminished, so that the pulse of the limb is feebler and its vessels smaller than in health. With the atrophy the contractility of the muscular fibres by the electric current dimin- ishes, and in unfavorable cases after a time powerful induced and even pri- mary currents have no appreciable effect. The nutrition of a paralyzed limb is always imperfect, and if the paralysis occur in a child its growth is retarded. Therefore, in cases of contracted or permanent infantile paralysis of one limb a disproportion occurs both in diameter and length between it and that on the opposite side. If the paralysis continue, the ligaments of the paralyzed limb become relaxed and lengthened. West mentions a case of paralysis of the deltoid in which the humero-scapular ligaments were so extended that the humerus dropped from the glenoid cavity, so as to increase the length of the limb three-fourths of an inch. In the paralysis of certain muscles of the lower extremity and continuance of the contractile power in others we have the conditions which give rise to club-feet, and accord- ingly this deformity is the common result of the paralysis when it is not cured. Etiology. — As this form of paralysis is not fatal, opportunity for post- mortem examination in a recent case seldom occurs. Hence the difficulty in determining the exact anatomical change in the nervous system which pro- duces the paralysis. Medical literature contains records of a considerable number of cases in which autopsies have been made, but death occurred so long after the commencement of the paralysis, usually months or years, that it is difficult to determine whether lesions which have been observed were a cause or consequence. In a majority of these autopsies a spinal lesion of some sort was detected, but in some instances none could be discovered. Mr. Adams in his treatise on club-foot relates a case in which the spinal cord, carefully examined, probably only with the naked eye, seemed normal. Robin examined the spinal cord microscopically in one case, but discovered nothing abnormal, and Elischer made autopsies in two cases of this paralysis in which death had occurred from variola, but with a negative result as regards the nervous system. 1 The examinations by Robin and Elischer r 1 Jahrbuch fur Kinderh., 1873. POLIOMYELITIS ACUTA ANTERIOR 667 since they were microscopic, have been justly regarded as important, and they have been related by writers in order to sustain the theory that infantile paralysis is peripheral and not centric. Very little was effected prior to 1863 in determining the cause or causes of this paralysis by post-mortem examinations, because the microscope was so little used, and because in most of the cases reported the clinical history or microscopic lesions were such as to show or to render it highly probable that the paralysis was not of the kind which we have been describing. Thus, Beraud reported a case in which tubercles were found in the spinal cord ; Hammond, a case in which a clot was found in the spinal cord ; and Jaccoud, one of spinal arachnitis with thickening of the meninges. Since 1863. 17 autopsies have been recorded in which the spinal cord was carefully examined, and upon these we must chiefly rely for our data by which to determine what are the anatomical changes in the nervous system which probably cause this paralysis. The reader will find these cases tabulated in a lecture by B. Gr. Seguin, M. D., 1 and the most important of them narrated in a paper on infantile paralysis, showing great research, published by Dr. Mary Putnam Jacobi. 2 It is true that all but 3 of these post-mortem examinations were made many years after the occurrence of the paralysis; but in the 3 cases which were reported by Roger and Damaschino, only two, six, and thirteen months had elapsed. The following were the chief lesions observed in these cases as regards the spinal cord : Cases. 1. Atrophy of motor-cells in anterior cornua 10 2. Nerve-cells, normal 2 3. Atrophy (variously recorded) of anterior columns, or cornua, or part of cord, or roots of anterior nerves 8 4. Sclerosis 9 5. Myelitis, recorded as diffused, central, or slight 7 6. Central softening (the three most recent cases) 3 7. Small clot in cord (Hammond's case) 1 8. Sciatic neuritis 1 The most common lesions in these cases were those of inflammation of the anterior cornua of the spinal cord, or such as are known to result from this inflammation — to wit, atrophy of the nervous substance and sclerosis. With the data furnished by these post-mortem examinations and the clin- ical histories of cases we are better prepared to consider the theories regard- ing the etiology of this malady. The views of MM. Roger and Damaschino are entitled to much consideration, since the autopsies which they made were in cases of shorter duration, and therefore nearer the date of the commence- ment of the paralysis, than those which have been reported by other observ- ers. Roger and Damaschino 3 published a series of papers on this malady, which they conclude with the following propositions : "1. The alteration peculiar to infantile paralysis is a lesion of the spinal marrow, which causes the atrophy of muscles and nerves. 2. The seat of this lesion is the anterior part of the gray substance of the medulla, where softened portions of spinal substance are seen. 3. This softening is of an inflammatory nature — in fact, a simple myelitis. 4. Infantile paralysis should therefore be called spinal paralysis of children, and be classed among the affections of the spinal marrow, as depending on myelitis." The views of Roger and Damaschino, expressed above, seem to harmonize more closely with, and to afford a more satisfactory explanation of, the symp- toms, history, and lesions thus far observed in ordinary or typical cases than 1 N. Y. Medical Record, January 15, 1874. 2 N. Y. Obst. Jour., for May, 1S74. 3 Gaz. tried, de Paris, 1874. 66S LOCAL DISEASES does any other theory. Many neuropathists regard suddenly-occurring active congestion of the anterior cornua as the cause of infantile paralysis ; but there is that affinity between active congestion and inflammation that they may be regarded as having the same pathological effect in this instance, and therefore the two theories of a spinal congestion and spinal inflammation may be considered as one. It is not improbable that in some of the cases which more speedily recover there is simple congestion ; while in the more obstinate cases and those with inflammatory symptoms the congestion has passed into an inflammation or inflammation was present from the first. According to this theory, the atrophy so generally observed in the twelve cases in which autopsies were made must be considered a degenerative change resulting from the inflammation. That so accurate an observer and so excellent a micro- scopist as Robin could detect nothing abnormal in the case which he examined was probably due to the fact that the inflammation or congestion abated with- out producing any degenerative changes in the nervous substance. Professor Charcot regards atrophy of the motor-cells as the cause of the paralysis, but it is much more in consonance with the facts to consider the cellular atrophy a result than a cause. For how could atrophy, which always occurs gradually and by progressive increase, be the cause of a disease which begins abruptly and is most intense in the very commencement ? Besides, atrophy does not occur without some antecedent disease to cause it. In a report to the International Congress at Amsterdam, Drs. Damaschino and Roger give the following summary of the result of their recent study of the pathology of infantile paralysis : 1 1. The anatomical lesions are situated in the motor regions of the spinal cord. 2. They consist of a central myelitis, with a stadium of softening and atrophic destruction of the cells of the gray substance, together with sclero- sis of the lateral columns and considerable atrophy of the anterior roots and the nerves leading to the paralyzed muscles. 3. Atrophy of the cells is not — as Charcot is of opinion — the whole pro- cess, as it is in progressive muscular atrophy. 4. The opinion of Leyden, that there is a circumscribed and diffused mye- litis in children, is worthy of consideration. It remains for future examination to decide whether the myelitis begins as interstitial or parenchymatous in the connective tissue or the nerve-cells. Recent observations by Drunmiond (1885), Gowers (1888), and others have apparently established the theoiy of Roger and Damaschino — to wit, that the paralysis which we are considering results from acute inflammation of the gray matter of the spinal cord, and entirely or chiefly of the gray matter in the anterior cornua, that of the posterior cornua not being affected. All muscular fibres which are in a state of disuse begin in a few weeks to atrophy and undergo fatty degeneration. The transverse striae in the primi- tive muscular fasciculus gradually disappear, and are replaced by granules of fat, and later still by small oil-globules. If we examine with the micro- scope the fibres from a muscle which has been a considerable time paralyzed, but which has still some electric contractility, we will find in places the striae remaining, but numerous opaque granules of a fatty nature within the sarco- lemma wherever the striae are absent, and in other places, where the degen- eration is most advanced, oil-globules occur, always small. If the paralysis be more profound, the striae have all disappeared. At a later stage, usually after some years in cases of complete and incurable paralysis, the fatty mat- ter may be to a considerable extent absorbed, and the fibrous network of the muscle which remains presents a tendinous appearance. There is a great 1 Le Progres medical, No. 39, 1880. POLIOMYELITIS ACUTA ANTERIOR. 669 regards difference, however, in different cases as these changes occur. two cases after the lapse of more than four year nerves of the paralyzed part also undergo atrophy the rapidity with which Hammond states that he found the strise remaining in of decided paralysis. The Figure showing displacement of the humerus in poliomyelitis acuta anterior which came on suddenly, and no proper treatment was employed for months. Diagnosis.— This is easy as soon as the attention of the physician is directed to the state of the limbs. In a large proportion of cases the mother or nurse first observes the paralysis and calls the attention of the physician to it. A knowledge and recollection of the facts in relation to this paralysis should lead the physician to examine the state of the limbs in all cases of fever in young children occurring without apparent cause. Prognosis. — It may be confidently predicted, if the child be seen early and correctly treated, that the paralysis will diminish, if it cannot be entirely cured. If the paralysis have continued a considerable time, and there be no electric contractility of the muscles, there is poor prospect of any improve- ment. The induced current will fail sometimes to cause muscular contrac- tion, when the direct current may produce it ; but if there be no response to the direct current, there is no therapeutic agent which can restore the use of the limb. In cases seen soon after the paralysis commences and before the stage of atrophy the prognosis is most favorable when there is still slight voluntary motion, and improvement commences early. In most instances, even when the paralysis has been mild and of comparatively short duration, the extrem- ity, although its motion be fully restored, is for a long time weaker than before the attack. 670 LOCAL DISEASES. Treatment. — A physician called at the commencement of the paralysis should endeavor to remove every cause which might increase the irritability of the nervous system. The bowels should be kept open and the diet be plain and unirritating. Local treatment is very useful at all periods of the paralysis. In the first days cold applications, as by an India-rubber bag containing ice, should be made over the spine. Stimulating embrocations over the spine and upon the paralyzed limb are appropriate after the cold has been discontinued, and benefit may also be derived from dry cups along the spine. Ergot, the bro- mide and iodide of potassium, which may be administered variously combined or singly, are the appropriate remedies for the first twelve or fourteen days. Administered every three or four hours in proper dose, they are the most effectual of all internal remedies for diminishing spinal congestion and pre- venting effusion and permanent structural change in the cord. Unfortu- nately, this first stage is in many instances far advanced before proper treat- ment is employed to subdue the myelitis, either from an incorrect diagnosis or because the physician is not summoned until structural changes have occurred, which constitute the second stage. If the paralysis continue or if it do not progressively diminish, we should not delay more than two weeks from the commencement of the disease before employing appropriate measures to restore the use of the limbs and arrest atrophy of the muscles. The expectant plan of treatment, which is proper in many diseases of children, is unsuited to this. Muscular atrophy may commence in three weeks, and the farther it has advanced the more difficult and tedious will be the cure. Therefore, by the close of the second week, if the paralysis continue or be not rapidly disappearing, iron as a tonic with strychnia should be prescribed. There is probably no better formula for the exhibition of these agents than the following from Professor Hammond : R. Strych. sulphat., gr. j ; Ferri p yrophosphat. , gss ; Acidi phosphorici dilut., Jss ; Syr. zingib., Jfiijss— Misce. One-third of a teaspoonful or one-ninetieth of a grain of strychnia is suffi- cient for a child of two years, administered three times daily. Hillier, Bar- well, and others have employed subcutaneous injections of strychnia, with, it is stated, a good result. While in the first and second weeks the child has been allowed to remain quiet, he should now be encouraged to use his limbs. Frequent muscular contraction must, if possible, be produced, and the volun- tary movements, when not totally lost, aid greatly in promoting the nutrition of the muscles and restoring their function. Immersing the limb for half an hour in water at a temperature of 110° or 115°, rubbing the limb with a coarse towel, and kneading the muscles aid also in restoring nutrition and tone to them. But, fortunately, we have an invaluable agent in the electric fluid, which can be made to penetrate the muscles and cause their contraction when every other measure has failed. The induced current should be employed upon the limb every day or second day if it cause the muscles to act, but if the loss of power be of long standing or complete, so that the induced current is not sufficiently powerful, the direct current should be used instead. It is not regarded as important which way the current passes, provided that the mus- cles contract. In a large proportion of cases a cure cannot be effected until the lapse of several months, so that the patience of the physician and friends may be put FACIAL PARALYSIS. 671 to the test; but if muscular atrophy can be prevented and the limb kept at nearly the normal temperature, this mode of treatment will ordinarily in the end be successful. The primary affection which caused the paralysis will, with some exceptions, be removed by the treatment indicated above, after which the state of the muscles and their nervous supply demand the whole attention. Observations show that by treatment perseveringly employed fatty degeneration of the muscular fibres can be not only arrested, but the fat which has already been deposited within the sarcolemma may be absorbed and the muscular stride restored. In those cases in which it has been necessary to employ the direct current the induced should be used whenever by the improvement of the case it is found sufficiently powerful. CHAPTER XIY. FACIAL PARALYSIS. Causes. — Facial paralysis in the new-born commonly occurs from pres- sure of the blade of the forceps upon the portio dura at a point external to the stylo-mastoid foramen. It may also occur in children of any age from exposure of the face to a cold wind. The pressure of a tumor upon some part of the portio dura, or even of the fist of the child placed under the face during sleep, may cause it. It may also result from disease of the temporal bone, producing pressure on the nerve, as caries, periostitis, suppuration, or hemorrhage into the aquseductus Fallopii, and also from intracranial disease affecting the pons Varolii or the medulla oblongata. Symptoms. — The portio dura, which is a nerve of motion, supplies the muscles of the face, and therefore its loss of function is at once manifest in distortion of the features. The eye of the affected side remains open in con- sequence of paralysis of the orbicularis palpebrarum, the upper lid being- raised by the levator muscle, which is not paralyzed, since its nerve is derived from the third pair. From the inability to wink, the eye becomes irritated by dust and constant exposure, and in children old enough to have an abun- dant lachrymal secretion the tears are liable to flow over the cheek. On ac- count of the paralyzed and relaxed state of the facial muscles the mouth is drawn toward the healthy side, while the affected side presents a swollen appearance. Movement of the eyebrow or the anterior portion of the scalp on the paralyzed side is also impossible, since the occipito-frontalis and cor- rugator supercilii are supplied by the portio dura. If the cause of the dis- ease is located above the origin of the chorda tympani, the flow of saliva and sense of taste on the affected side are impaired. If the injury be posterior to the gangliform enlargement, those symptoms are superadded which are due to paralysis of the petrosal nerves. Figure 193 represents a case which was under observation in the New York Infant Asylum. The age of the infant at admission was about five months, and its previous history was unknown. The paralysis was perma- nent. Death occurred some months later from an intercurrent disease, and no cause of the paralysis could be discovered in a careful examination. Prognosis. — This depends on the cause. If the cause be peripheral, as from the pressure of the forceps or from cold, the prognosis is favorable. In case of deep-seated lesion, unless syphilitic, the prognosis is usually unfavor- able. A syphilitic lesion can often be removed by appropriate remedies and the paralysis be cured. 672 LOCAL DISEASES. Treatment. — In paralysis of the new-born from pressure of the forceps all that is required is occasional rubbing or gentle kneading over the affected muscles. In those who are older the nature Fig. 193. of the cause, so far as ascertained, must de- termine the treatment. If there be glandular swellings and discharge from the ear from scrofula, cod-liver oil and the syrup of the iodide of iron are required internally, with appropriate external treatment of the glands and ear. If syphilis be the cause, mercurials and the iodide of potassium should be em- ployed. If the patient do not soon begin to improve, the treatment recommended for in- \ \ * I? ' ill V fantile paralysis, modified somewhat on ac- count of the difference in location, is appro- priate. Iron and strychnia may be admin- istered internally. The external treatment should consist of friction, kneading, hot appli- cations, and the electric current. The current should have only moderate intensity, for a high degree of it might injure the vision. It should be ap- plied every second day, with one pole over the mastoid foramen and the other moved slowly over the muscles. CHAPTER XV. PSEUDO-HYPERTKOPHIC PAEALYSIS. This is a rare disease. It was first described by Duchenne in 1861, and since the attention of the profession was directed to it, cases have been observed on the Continent, in Great Britain, and in this country. Though our acquaintance with it is so recent, it has been fully and accurately described by various writers in our language. The Transactions of the Lon- don Pathological Society for 1868 contain a translated paper relating to it, communicated by M. Duchenne, with photographic views and remarks by Lockhart Clarke, and also the histories of two cases occurring in London and exhibited to the Society by Adams and Hillier. In this country an elaborate paper has appeared on this form of paralysis from the pen of Dr. Webber 1 of Boston, who succeeded in collecting the records of 41 cases ; and more recently Dr. Poore, 2 physician to the New York Charity Hospital, collected the records of 85 cases, which furnish the material of his monograph. Weakness of the legs and a peculiar waddling gait are the first observ- able symptoms, and by them we are able to ascertain approximately the date of the commencement of the paralysis. In 27 of the cases collated by Dr. Poore the malady began so early in infancy that they were never able to walk like other children ; in 5 there is no record in regard to the time when the peculiar gait was first observed or whether they ever could walk ; 52. or about two-thirds of the cases, walked well at first, having no symptoms of the paralysis till after the age of two years. In 15 of these, weakness of the legs and the peculiar gait were first observed between the ages of two 1 Boston Med. and Surg. Jour., Xov. 17, 1870. 2 New York Medical Journal, for June, 1875. PSEVDO-HYPERTROPHIC PARALYSIS. 673 and a half and five years ; in 23, between the ages of five and ten years ; in 6, between the ages of ten and sixteen years ; and in 8, over the age of sixteen years. It is seen, therefore, that this malady is pre-eminently one of infancy and childhood. The gait, which is unsteady and waddling, has been compared to that of a duck. The child stands with the legs wide apart, and from the weakness of the limbs and unsteadiness of the gait frequently stumbles and falls. In many cases this muscular weakness and difficulty in walking occur before there is any perceptible enlargement of the muscles beyond the normal size. The hypertrophy occurs without tenderness, pain, or other nervous symp- toms, and without fever or constitutional disturbance. Occasionally the patient complains of stiffness or aching in the limbs, especially after exer- cise, even before the enlargement is observed, and exceptionally there is pain, even acute, in the legs. The hypertrophy is ordinarily observed first in the calf of one leg, and then in the opposite calf. In a case related by Nie- meyer the muscles of the gluteal region were first affected. In nearly all cases the gastrocnemii are hypertrophied. There were only 2 exceptions in the 85 cases collated by Dr. Poore, but almost any of the other muscles or groups of muscles may also be involved. The muscles which are most prominently affected and which produce the characteristic deformities are those of the extremities and posterior aspect of the trunk. Spinal curvature, which is attributed to the weakened state of the erector muscles of the spine, appears early and is seldom absent. The bending is such that a plumb-line, dropped from the most posterior of the spinal processes, falls behind the plane of the sacrum ; and this is a means of distinguishing this disease from certain other spinal affections. Figure 194 represents a case which came to the children's class at Bellevue in April, 1872. The boy was two years old. and the mother stated that the peculiar gait and the enlargements had only been observed from four to six weeks, and yet the curvature of the spine was quite marked. He did not return to the class, and his subsequent history is therefore unknown. Of the muscles in the upper extremities the deltoid and scapular are most frequently enlarged. Hypertrophy of the temporals has been observed in 3 cases, of the masseters in 2. of the tongue in 3, and of the heart in 4 (Poore). We shall see presently that atrophy occurs in the muscular element of the parts which are affected, and that the hypertrophy is due to hyperplasia of the connective tissue. Now, occasionally this hyperplasia does not occur or is tardy in occurring, while the atrophy has taken place. Therefore, certain muscles may have less than the normal volume, which, from contrast with those which are hypertro- phied, increases the deformed appearance. In ordinary cases the enlargement advances more rapidly and continues greater in the gastrocnemii, which are, as we have stated, the muscles first affected, than in other muscles, and therefore the prominence and hardness of the calves of the legs are greater than elsewhere. In advanced cases walking is 43 674 LOCAL DISEASES. impossible, and the patient is obliged to remain in a reclining posture. Some- times from the unequal muscular action the feet become extended and the toes flexed, so that the child in attempting to walk steps on the anterior part of the sole of the foot, as in talipes equinus. In the first stages of the disease the electric contractility of the muscles is nearly normal, but in advanced cases response to the galvanic current becomes more and more feeble according to the degree of atrophy of the muscular fibres. The skin retains its normal sensibility, with exceptional instances in which there is numbness either general or in places. Reddish or bluish mottling of the surface of the extremities is sometimes observed, which is attributed by some to obstructed venous circulation in the hypertro- phied muscles, and by others is supposed to be due to the peculiar neuro- pathic state. The bladder and rectum are not involved. The mental facul- ties are more or less blunted and feeble in certain cases, especially when the disease begins in early infancy, but in some patients they do not seem to be materially impaired. Anatomical Characters. — There have been so few post-mortem exam- inations of those who died having this disease that it is still uncertain whether there is any centric lesion. Cohnheim examined the spinal cord in one case, and could find nothing abnormal. Recently, Mr. Kesteven has examined the brain and spinal cord from a case, and found dilatation of the perivascular canals both in the brain and spinal cord, and also spots of granular degen- eration, chiefly in the white substance, " caused by loss of cerebral tissue replaced by morbid matter." l As this child was imbecile, it is not improba- ble that these lesions were connected with the mental state and not the mus- cular disease. Professor Charcot 2 reports a careful microscopic examination of the spinal cord and of the nerves in a case which had continued ten years. He could discover no deviation from the healthy state. More recently, Dr. J. Lockhart Clarke 3 examined a case and found the encephalon healthy, but in the spinal cord there was more or less disintegration of the gray substance in each lat- eral half, and in places dilatation of vessels and commencing sclerosis. It seems, therefore, that central lesions are not essential and are some- times absent. When they do occur it is probable that they are consecutive to the paralysis. The essential lesions in this malady are atrophy of muscular fibres and hyperplasia of the connective tissue which surrounds these fibres. The hyperplasia of the one element in the muscle is greater than the atrophy of the other, and hence the increase of volume above the normal size. The atrophy is probably a primary lesion, for muscular weakness ordinarily occurs for a considerable time before there is any evidence of the enlargement, and, as we have seen, certain muscles may undergo the atrophy without the hyper- plasia. Still, the mechanical effect of the newly-formed connective tissue doubtless increases the atrophy in those muscular fibres which this tissue surrounds, and the comparatively quiet state of muscles in consequence of paralysis not only tends to promote the atrophy and degeneration of these muscles, but also of contiguous healthy muscles. The muscles which are involved in this paralysis present a pale yellowish hue, resembling, says Niemeyer, the appearance of lipoma. Examining by the microscope, we find, in addition to a large increase in the fibrous tissue and atrophy, and in some places disappearance of the muscular element, more or less fatty matter, granular and globular, occupying the interstices. Mr. Kesteven describes as follows the appearance of the muscles in the case which 1 Jour, of Med. Sci., Jan., 1871. 2 Archiv. de Physiol, March, 1872. 3 Medico-Chir. Trans., 1874. PSETJDO-HYPERTROPHIC PARALYSIS. 675 he examined : " The muscular substance is pale, almost white, and very greasy. The superabundance of fat is evident to the naked eye. The mus- cular fibres present the ordinary striation, but less distinctly than usual. Fig. 195. 'h "^^D 2. Of Beginning changes in lipomatous pseudo-hypertrophy of the muscles after Ebstein and Man: increase and nuclear proliferation of the interstitial tissue and increase of the sarcolemma nuclei : 1 hf, two hypertrophic fibres; 2 af, atrophic fibres. (Enlarged 400 times.) The ultimate fibres are pale, and separated by a large increase of areolar and fibrous tissue." Causes. — Why there is this strange perversion of nutrition, so that there is an exaggerated development of the connective tissue of the muscles and atrophy of the muscular fibres, is unknown. Boys are more liable to be affected than girls. Of the 85 cases embraced in the statistics of Dr. Poore, 73 were boys, and there was a similar excess of males in the cases collated by Dr. Webber. There is in a considerable proportion of cases the record of hereditary transmission, and in almost all the instances the predisposition is acquired from the mother's side. Thus in 37 of Dr. Poore's cases " 2 or more belonged to the same family." In some instances three and even four maternal rela- tives had this form of paralysis. In one case observed by Duchenne, and in a few others subsequently observed, this malady seemed to be congenital, for the limbs at birth were unusually large, and the patients when they came under observation were unable to walk. No relation has been observed between this paralysis and syphilis, scrofula, or other diathetic diseases. Prognosis. — This disease is in most instances progressive, terminating fatally after a variable period. It is in its nature chronic, rarely ending in less than five or six years. A considerable proportion live longer, some even attaining adult age. The paralysis may be stationary for a time, but after- ward continue to increase. Duchenne has reported one case of recovery. In two or three other instances patients appeared to improve somewhat under treatment, but the writers admit they may have become worse afterward. Death usually occurs, not directly from the paralysis, but from some inter- current disease, especially of the lungs. Treatment. — The treatment thus far employed has been chiefly local, consisting in the use of electricity and kneading or shampooing over the 676 LOCAL DISEASES. affected muscles. Both the primary and induced electric currents have been employed, but. unfortunately, without any appreciable benefit in most cases. Benedikt. who claims a better result from electrization than any other observer, applied the copper pole over the lower cervical ganglion, and the zinc pole along the side of the lumbar vertebras by means of a broad metallic plate. CHAPTER XVI. DISEASES OF THE SPINAL COED AND ITS COVERINGS. The diseases of the spinal cord and of the parts which cover and protect it are important, but they are less understood than are those of any other portion of the body. This is partly due to the fact that in many cases the spinal disease coexists with a similar pathological state of the brain or its meninges, the symptoms of which predominate and mask those which pertain to the spine ; partly to the fact that the chief symptoms of spinal disease are often located in organs or parts which are at a distance from the spine ; and, lastly, to the fact that it is difficult, for obvious reasons, to determine the exact state of the spine at the bedside, while post-mortem inspection of the spine, which alone can give accurate pathological knowledge, is less frequently made than of any other organ. Certain spinal diseases occurring in childhood are the same as in adult life, presenting identical symptoms and lesions in the two periods, and there- fore they require no extended notice in this treatise. Others are common to childhood and maturity, but they present peculiarities in the former period which require to be pointed out, while others still are peculiar to childhood. The so-called spinal irritation or anaemic neuralgia is not infrequent in delicate and poorly-fed children. I have from time to time observed marked cases of it in the class in the Out-Door Department of Bellevue, the patients usually being above the age of three or four years and exhibiting evidences of cachexia. Most of them have been spare and pallid, some affected with a nervous cough or palpitation, and some with neuralgic pains in the chest, abdomen, or elsewhere, which pressure at a certain point upon the spine intensified. These cases recover by better feeding, out-door exercise, mild counter-irritation along the spine, and the use of tonics, especially of iron. Primary inflammation of the cord and its meninges is rare in children. Secondary inflammation of these parts is, on the other hand, more common in children than in adults. It is common in caries of the vertebras and in cerebro-spinal fever. The preponderance in functional activity of the spinal cord and the feeble controlling power of the brain render infancy and child- hood more liable to convulsions and reflex paralysis than any other period in life. Cases of true reflex paralysis occasionally occur in children, in regard to the etiology of which there can be no doubt. Prof. Sayre of this city has called attention to the fact that balanitis and preputial adhesions sometimes cause paraplegia, more or less pronounced, in young children, and which is relieved by dividing the adhesions and restoring the mucous surface of the glans and prepuce to its normal state. Such a case was brought to the chil- dren's class in the Out-door Department at Bellevue in April, 1875. The child could not walk or scarcely stand without support, but after the division of the adhesions and subsidence of the inflammation, locomotion rapidly CONGESTION OF THE SPINAL COBB AND ITS MEMBRANES. 677 improved. 1 In another instance a child could not walk properly, having a tottering gait and dragging one foot. The preputial and urethral orifices presented an irritated appearance. The prepuce was stretched and separated from the glans at a few sittings, the instrument used being an infant's catheter stiffened with a wire, so that it served as a probe. Large masses of smegma, nearly as far forward as the preputial orifice, were found underneath. These were removed, and the parts were smeared with sweet oil. The patient rap- idly recovered the full use of his limbs, and was soon entirely well. It is well known that masturbation sometimes causes a similar weakness of the lower extremities. Dr. West relates the case of a child " between two and three years old " who began to totter in his gait, and finally almost ceased walking. He was observed to practise masturbation. " This was put a stop to." and he soon recovered his health and his power of locomotion.' 2 CHAPTER XVII. CONGESTION OF THE SPINAL CORD AND ITS MEMBRANES. Congestion of the spinal cord and meninges occurs both as a primary and secondary malady, the latter being more frequent than the former. It may be active or passive. Active congestion, occurring independently of meningitis or myelitis, is in most instances transient and subordinate to some graver disease, in the course of which it arises. It is probably often over- looked. It is not fatal, and its symptoms are frequently masked by those which are referable to the brain or some other organ. It is believed to be common in the initial period of certain of the fevers of childhood. It is not improbable that the hypergesthesia observed upon the thoracic and abdominal surfaces and along the thighs in the commencement of remittent and certain other febrile diseases has its origin in a congested state of the spine. To this congestion writers attribute the lumbar pain and occasional paraplegia in the initial stage of variola. Active spinal congestion may also result from the sudden impression of cold, and, as we have stated above, this is apparently the most frequent cause of poliomyelitis acuta anterior. Certain anatomical circumstances favor the occurrence of passive con- gestion of the spinal cord and meninges — to wit, the tortuousness of their veins and the absence of valves, the lack of muscular support in them, of the vessels, and the inferior position of the spine in sickness as the patient lies quietly in bed. A common cause of passive congestion of these parts is some protracted and enfeebling disease which diminishes the contractile force of the heart (cardiac paresis), producing congestion of the spinal cord in the same manner as under similar circumstances hypostatic congestion of the lungs occurs. Severe convulsive diseases, as tetanus or eclampsia, when pro- tracted or occurring at short intervals, commonly produce spinal congestion. In tetanus this congestion is extreme, so that extravasation of blood is liable to occur from the engorged vessels, especially those of the pia mater. Anatomical Characters. — It is often impossible, at post-mortem exami. 1 Drs. Holgate and Bosley, formerly attending physicians in the children's class at Bellevue, made many examinations of the state of the prepuce in young children. They report that they found preputial adhesions almost daily, in most instances without symptoms, but sometimes with dysuria, and occasionally with more or less impairment of the use of the legs. rueonwe j Children, p. 146, 4th Amer. ed. 678 LOCAL DISEASES. nations, to determine how much of the congestion of the spine and its meninges is pathological and how much cadaveric, since, if the corpse be placed on its back at death, a very considerable engorgement of the spinal vessels occurs from gravitation of blood. If the body have been placed on the side or face, this cadaveric congestion is prevented. Since in active congestion the arterioles and capillaries are distended with arterial blood, the color is a brighter red than in passive congestion, in which venous blood predominates. Active con- gestion of the cord usually coexists with that of the meninges, but it may occur without it. In cases of considerable congestion the " puncta vascu- losa " appear upon the incised surface both of the white and gray substance. If the congestion be protracted or if it recur frequently, it may produce per- manent dilatation of the arterioles and capillaries in greater or less degree, and it may also lead to sclerosis of the cord. Passive congestion seldom, per- haps never, occurs in the cord without being equally and often to a greater extent present in the meninges. Continuing for a time, it gives rise to trans- udation of serum into the interspaces over the cord, and even softening of the cord may occur to a limited extent from imbibition of serum. In either form of congestion extravasations of blood are frequent. Symptoms. — Spinal congestion is announced by pain in the region of the spine, usually in the lumbar or dorsal and lumbar portions, and irradiations of pain and tingling in the legs. In addition, more or less paralysis of the bladder and legs may result. The paraplegia may occur early or not till the lapse of several days. In active congestion the symptoms are rapidly devel- oped, and they attain their maximum intensity sooner than in the passive form. In passive congestion the development of symptoms is not only more gradual, but they are ordinarily less pronounced, and are attended by more fluctuation, than in the active form. The paralysis, if present, comes on slowly after several days, and is incomplete. Spinal congestion, especially of the passive form, is sometimes associated with cerebral congestion — as, for example, in tetanus and severe eclampsia — and the spinal symptoms there- fore coexist with those which have a cerebral origin. The duration and the result of a hyperaemic state of the spinal cord and its meninges depend largely on the nature of the cause. If it be not relieved within a few days, there is strong probability that some other serious pathological state has supervened, as meningitis, myelitis, extravasation of blood, or serous trans- udation, with softening of the nervous substance. Treatment. — In the adult spinal congestion sometimes results from the sudden cessation of the hemorrhoidal or catamenial flow, and the application of leeches or wet cups along the spine is indicated. But in the child the abstraction of blood is seldom required. In the acute stage of active spinal congestion, with elevation of temperature, cold applications along the spine are often beneficial, as by an India-rubber bag. In active hyperasmia laxatives are useful, and rubefacient applications should be made along the spine, as by mustard or by friction with a stimu- lating liniment. In the inflammatory spinal congestion of cerebro-spinal fever I have employed with a very satisfactory result a liniment containing equal parts of camphorated oil and turpentine. In both active and passive hyper- asmia lateral decubitus should be prescribed rather than dorsal. The use of ergot in order to diminish the turgescence of the vessels of the spinal cord and meninges has been advocated by Brown-Sequard, and it is now one of the recognized remedies. Bromide of potassium is also a remedy of value, but it is more useful in some cases than in others. It is signally beneficial in those cases in which there is also cerebral congestion. When the conges- tion is increased or produced by clonic convulsions the bromide is one of the most reliable remedies which we possess for the removal of the cause. Thus, CONGESTION OF THE SPINAL CORD AND ITS MEMBRANES. 679 it should be employed in the treatment of the spinal and cerebral congestion in the commencement of variola, in which convulsions are so common, and in the convulsions of pertussis or pneumonia, which cause extreme passive con- gestion of the cerebro-spinal axis. Passive congestion of the spine, common in exhausting diseases and due to feebleness of the circulation, is best treated by stimulating and sustaining remedies and by the lateral decubitus. It is hypostatic, and may be associated with a similar congestion in the posterior part of the lungs. SECTION III. DISEASES OF THE DIGESTIVE APPARATUS. CHAPTER I. SIMPLE STOMATITIS, ULCEKOUS STOMATITIS, FOLLICULAR STOMATITIS. Diseases of the digestive system are very frequent in infancy and child- hood. They are for the most part readily recognized, and are more easily and quickly controlled by therapeutic agents, if rightly applied, than are the diseases of any other system. If misunderstood and improperly treated, they may, even when mild and very manageable in their commencement, become chronic and obstinate, or even fatal, or they may lead to other and more dangerous diseases. It is necessary, then, that the physician should understand thoroughly the pathology as well as the therapeutics of the digestive system, that he may make timely and correct use of the required remedies. The diseases of the buccal cavity in early life are for the most part in- flammatory, one of the most interesting of which — to wit, sprue or thrush — we have already treated of among the diseases of the newly-born. The mildest of these diseases is that known as Simple or catarrhal stomatitis, which is more common in infancy than in any other period of life ; it occurs over the whole buccal cavity or a portion of it, according to the nature of the cause. A common cause is the use of indigestible food or food not suitable for the age or development of the infant, and therefore irritating ; uncleanliness, personal and domiciliary ; in fine, all those agencies which impair the general health and enfeeble the digestive organs. Therefore stomatitis is more common among the city poor, who are often improperly fed, than in those in the better walks of life, and especially those who have the fresh air and properly prepared food of the country. Infants deprived of the mother's milk, and given a diet which, with all care of preparation, is a poor substitute for the natural aliment, are very liable to this disease. Beaumont ascertained from his experiments on St. Martin that irritative changes produced in the stomach by indigestible substances were soon followed by similar changes in the buccal mucous membrane. Since in young infants any kind of artificial food is less digestible than breast-milk, it is evident why those who are prematurely weaned or are carelessly fed are so liable to stomatitis. This inflammation is also sometimes due to irritating substances taken into the mouth, as drinks habitually too hot or too cold. Stomatitis is also present in measles and scarlet fever and the other eruptive fevers. It then corresponds with the cutaneous eruption, and disappears when that subsides. 680 SIMPLE STOMATITIS, ETC. 681 Stomatitis has long been ascribed to dentition. There is uniformly some tnrgescence of the gum over an advancing tooth, but in the normal state there is not, in my opinion, any decided inflammation from this cause, but inflammation may be produced by frequent rubbing of the gum or the chew- ing of an artificial nipple or other hard substance. Mercury, in whatever form introduced into the system, excreted by the salivary glands and flowing over the buccal surface, is an occasional cause. Symptoms ; Appearances. — Stomatitis, like other mucous inflammations, is characterized by increased redness and more or less thickening of the inflamed buccal membrane, by rapid proliferation and exfoliation of epi- thelial cells, and by an increased functional activity of the muciparous fol- licles. The heat of the mouth is sometimes augmented in an appreciable degree. The gums in severe cases are swollen and spongy, and bleed readily if rubbed or pressed. The tongue is usually covered with a light fur, and the salivary secretion is frequently augmented to such an extent as to dribble from the corners of the mouth. Often there is little suffering, but in other instances the patients are fretful, experience pain from the contact of solid food. and. if nursing, may even wean themselves from dread of pressure of the nipple. Simple stomatitis is not difficult of detection, provided that attention be directed to the mouth. Inspection informs us of its presence and extent. A favorable termination may be confidently predicted, unless there be a state of marked cachexia or a grave coexisting disease. If circumstances are unfavorable, simple stomatitis may terminate in a more severe form, as the ulcerous or diphtheritic. Treatment. — The physician should endeavor to ascertain the cause, and, if possible, should remove it by appropriate medicinal and hygienic measures. Sometimes no special treatment is required, as in measles or scarlet fever. When the primary affection terminates the stomatitis disappears of itself. If there be much fever and fretfulness, it has been the common practice to scarify the gums, but this operation is harmful instead of beneficial by in- creasing the tenderness. A few doses of bromide of potassium relieve the fretfulness. and mucilaginous and mild astringent lotions suffice for the catarrh. Borax is a good local remedy used either with honey or with gly- cerin and water — one part of borax to three of honey, or a drachm of borax to an ounce of water and two drachms of glycerin. A mixture of bismuth subnitrate and boracic acid is also a useful topical remedy. With either of these agents, in a favorable condition of system, and without any serious coexisting disease, the stomatitis is relieved. Ulcerous Stomatitis. In ulcerous stomatitis the anatomical characters are those of severe simple stomatitis, with the additional element which gives it the name by which it is designated. The inflammation usually begins upon the gums and extends along the buccal surface. Little white points soon appear upon the under surface of the mucous membrane, producing slight prominence of it. These points, which are inflammatory exudations, mainly fibrinous, gradually enlarge. Some unite and give rise to large irregular ulcerations ; others remain isolated, producing ulcers which are smaller and of more regular shape. There is. indeed, no uniformity as regards the size and form of the ulcers. In the folds of the buccal membrane they are usually elongated, while inside the lips or where the surface is smooth the circular or oval form predominates. It is a noteworthy fact that the exudation underlies the mucous membrane. 682 LOCAL DISEASES. obstructing its nutrient vessels, so that the ulcer which results causes destruc- tion of the mucous layer and cure is effected by cicatrization. Ulcerous stomatitis is usually confined to that part of the buccal surface which covers the gums or is in their immediate vicinity, but in some instances it aifects nearly every part of the cavity of the mouth. If the disease be severe, considerable swelling occurs around the ulcers, but the swollen part is soft and cushiony and not very tender on pressure. The soft and yielding nature of the swelling serves as a means of diagnosis between this disease and the premonitory stage of gangrene, since in the latter affection the swollen part is more indurated. If the disease grow worse, more ulcers appear, and those already present grow deeper and wider and their edges more vascular. If, on the other hand, there be improvement, the swelling subsides, the ulcers become more clean, their bases approach the level of the mucous mem- brane and present a granulating appearance. Finally, the mucous layer is reproduced. A considerable time after the ulcers are healed the new mem- brane which occupies their site has a redder hue than the adjacent surface. Causes. — Ulcerous, like simple, stomatitis is most frequent in the families of the poor. Personal uncleanliness, poor food, a residence in apartments dirty, humid, or in other respects insalubrious, favor its development. In fine, a cachectic condition, however produced, is a common predisposing cause. Ulcerous stomatitis frequently occurs when the system is reduced or enfeebled by acute diseases, as after the essential fevers and thoracic and intestinal inflammations. In protracted entero-colitis of infants it is some- times severe and obstinate, and a case in which this complication arises usually ends unfavorably. The abuse of mercury is an occasional cause of this form of stomatitis, as well as of simple catarrh. Jaccoud states that Bergeron established the fact that ulcerous stomatitis is propagated among soldiers by contagion, and he adds, " it is very probable that it is the same in infants." Symptoms. — The symptoms in ulcerous stomatitis are more severe than in the simple form. There are more pain, more salivation, and more fretful- ness. The ulcerated surface is sometimes very tender, so that there is but little sleep. Drinks, unless bland and lukewarm, are painful, and if the ulcers be on the lips or the front of the mouth, the infant nurses less eagerly than usual, and even with reluctance, sometimes weaning itself. Occasionally the submaxillary glands are tumefied, hard, and tender. The breath has an offensive odor. In mild cases, in which the stomatitis is of limited extent, this odor may scarcely be noticed, but in severe cases it is almost like that exhaled from putrid substances. The fever is in most instances, slight. Prognosis. — A favorable prognosis may be given unless the patient be in a decidedly cachectic condition or there be a serious coexisting disease, under which circumstances the case may be protracted. If death occur, it is due to the cachexia or to some pathological state quite distinct from the stomatitis, most frequently entero-colitis. Ulcerous stomatitis when the ulcers are small and the inflammation of limited extent, is of course more easily cured than when it is extensive and the ulcers are large. This disease is very liable to return unless the general health be good. Treatment. — The physician should endeavor to ascertain the cause of the stomatitis, and so far as possible should remove the patient from its influ- ence. It is often necessary, in order to ensure speedy recovery, to recommend a change in regimen, especially as regards diet and cleanliness. If the patient live in damp, dark, and dirty apartments, the family should seek a better residence, and he should be taken daily into the open air. Tonic remedies are generally required. The ferruginous preparations SIMPLE STOMATITIS, ETC. 683 may be advantageously given, or the vegetable tonics, or the two in combina- tion. In selecting the internal remedies we must regard the antecedent dis- ease, if there be any, which the buccal inflammation complicates and on which it depends. For that large proportion of cases in which there is in- testinal catarrh the treatment detailed elsewhere for this disease is indicated. Bismuth subnitrate, pepsin, and a careful selection of food appropriate for the age of the patient are needed. The following mouth-wash, applied with a camel's-hair pencil, has seemed to me more serviceable than the chlorate-of- potassium mixture which has been commonly employed : R. Bismuth subnitrate, 3y; Acidi borici, Sodii borat., da. £j ; Mellis, gss; Aquse destillat., q. s. ad :§iv. Aphthous stomatitis may occur at any age, but it is most frequent in childhood. It is sometimes designated follicular stomatitis, but the disease affects the contiguous mucous surface as well as the seat of the follicles. At first a vascular injection is observed, and within a few hours a whitish exuda- tion occurs immediately under the epithelium and upon the corium in small round or oval isolated spots. The smallest of these patches are not larger than a pin's head, but most of them have a diameter of one or two lines, and they cause slight prominence of the surface. In two or three days the exudation softens, and the epithelium which covers it is thrown off, producing an ulcer, superficial, without induration of its edges, but sensitive to the touch. It heals in one or two weeks, leaving only a reddish spot or stain, which soon fades. Sometimes two or more aphthae unite, forming a patch and an ulcer of correspondingly large size. The seat of aphthous stomatitis is usually the internal surface of the lips and cheeks, the gums, tongue, and occasionally the roof of the mouth. Causes. — Probably in most instances the exciting cause is some derange- ment of the digestive organs which may not be appreciable. We sometimes observe this form of stomatitis in cases of diarrhoea. Occasionally, espe- cially in spring and autumn, two children in a family are affected at the same time, or two or more in a school, so that the disease presents an epidemic character. Children surrounded by bad hygienic conditions, as in the tene- ment-houses of cities, are more liable to this, as well as other forms of stoma- titis, than are children who live in clean and airy localities and have nutri- tious and wholesome diet. Symptoms. — The constitutional symptoms in a large proportion of cases of aphthae are slight. In twelve children affected with the disease Billard found the pulse from sixty to eighty beats per minute. The ulcers are painful, as is indicated by the cries of the child when they are pressed, and its fretfulness. Solid food, and even drinks, unless bland and unirritating, are badly tolerated. The salivary secretion is also aug- mented. In those rare cases in which the ulcers become confluent or gangrenous the state of the patient is really serious. There is then often gastrointes- tinal disease. The symptoms indicate prostration. The pulse is feeble, the countenance pallid, and the body and limbs become wasted. Diagnosis. — This is easy. The only disease with which it is liable to be confounded is ulcerous stomatitis. In the ulcerous form there is antecedent and accompanying stomatitis affecting a considerable part, if not the entire buccal cavity, while in the follicular form the inflammation is ordinarily con- fined to the immediate vicinity of the ulcers. The character of the ulcers 684 LOCAL DISEASES. serves also as a means of distinction. In ulcerous stomatitis there is great variety as to size and form, while in aphthous stomatitis there is great uni- formity in both these respects. The small circular ulcers are characteristic of the follicular inflammation. Before the ulcerative stage the circumscribed character of the eruption serves to distinguish this form of stomatitis from other local diseases affecting the cavity of the mouth. Prognosis. — Aphthous stomatitis usually ends favorably, but if the ulcers became concrete or gangrenous the health is seriously affected, and a more cautious prognosis should be expressed. The unhealthy appearance of the mouth and the real danger are more often due to the depressing effect of some concomitant disease than to the stomatitis. Treatment. — In ordinary aphthous stomatitis, which is discrete and attended by little or no constitutional disturbance, local remedies suffice to cure the disease. Demulcent drinks or applications to the mouth should be used, as the mucilage from gum acacia, marshmallow, or flaxseed. Mild astringent lotions with the demulcent are also beneficial. The mel boracis is one of the best and most agreeable applications. It may be placed in the mouth with a spoon or applied with a camers-hair pencil. If there be much tenderness of the ulcers, with restlessness, a small quantity of some opiate should be added to the lotion or it may be administered separately. With this simple treatment the ulcers generally soon heal and the health of the patient is restored. If, however, the ulcers be painful and not dis- posed to heal, or be healing tardily, they may be touched lightly with a pencil of nitrate of silver, or, as Barrier recommends, hydrochloric acid in honey of roses. This diminishes the tenderness and expedites the healing process. A better remedy is iodoform, two drachms to one ounce of ether, and applied to the ulcers by a camefs-hair pencil. If, as may in rare cases occur, the ulcerations be numerous and accom- panied by considerable fever, there may be symptoms indicative of cerebral congestion or even premonitory of convulsions. In such cases laxatives and the soothing effect of one of the bromides, and sometimes of the warm foot- bath, are required. If there be an unhealthy appearance of the ulcers, if they gradually en- large or become concrete or gangrenous, indicating a cachectic state, tonics should be employed, with nutritious and easily-digested diet, and antihygienic influences should so far as possible be removed. CHAPTER II. GANGKENE OF THE MOUTH. The diseases of the mouth which we have been considering are attended by little danger, but the one which we are next to consider is among the most fatal of early life. It is gangrene of a portion of the cheek or gums, or of both. It is described by writers under various names, as cancrum oris, noma, necrosis infantilis, aqueous cancer of infants. Anatomical Characters. — Gangrene of the mouth is sometimes pre- ceded by ulceration of the mucous membrane at the point where it is about to commence, but in other cases this membrane is entire. The tissues at the point of attack, which is most frequently the inside of the cheek, become GANGEENE OF THE MOUTH. 685 inflamed, thickened, and indurated. The induration extends, and soon the purple hue of gangrene appears and increases. The next stage in the prog- ress of gangrene is sloughing of the portion the vitality of which is lost. The slough does not present the appearance of uniform decay. While the color is generally dark, there are in the mass, fibres of connective tissue, or even blood-vessels, which remain unchanged or are but partly decomposed. After separation or sloughing of the part where the vitality is first lost, the surface of the excavation, if the disease be not checked, has a dark, jagged, and unhealthy appearance. Commencing with the mucous membrane and the tissue immediately underlying it, the disease extends on the one side toward the skin and on the other toward the deeper-seated structures of the jaw. According to Billard, the swelling which precedes and surrounds the gangrene is in great part ©edematous. This disease is occasionally primary, but in a large proportion of cases it is secondary. Occurring secondarily, its symptoms are often masked by those of the antecedent and coexisting affection. Under such circumstances attention is sometimes first directed to the mouth by the loosening of one or more of the teeth or the appearance on the skin of a livid circular spot which indicates the approach of the disease to the cutaneous surface. The mucous membrane presents a dark-red appearance to the distance of a few lines beyond the point of gangrene. It covers tissues which are inflamed and indurated and about to become gangrenous. The tongue is usually more or less swollen, unless the disease be mild ; an offensive odor arises from the gangrene, due to the evolution of sulphur- etted hydrogen and other gases. There is great difference in the extent of the destruction and the gravity of the disease in different cases. It may sometimes be arrested by proper applications and a favorable change in the general health of the child at an early period, when there is little loss of substance. In other cases it extends till it perforates the cheek or even destroys a considerable part of the side of the face, and, extending inward, attacks the periosteum of the maxillary bone, destroying the gum and teeth and denuding the alveoli. Kecovery, if it take place at all under such cir- cumstances, is with the loss of a portion of the bone and with deformity. The duct of Steno is sometimes included in the. gangrenous portion, but it commonly resists the destructive process and remains pervious. Age. — The age at which gangrene of the mouth occurs is usually between two and six years. In 29 cases collated by Rilliet and Barthez, 21 were between the ages of two and six years, and the remaining 8 between six and twelve years. Of the cases which have fallen under my observation, most were between the ages of two and six years. It is seen that the period of greatest frequency of gangrene of the mouth is different from that in which the ordinary forms of stomatitis occur, Gangrene of the mouth may, however, occur under the age of one year. Billard reported 3 cases under the age of one month, but in 2 of these the disease does not appear to have been sufficiently marked to render it certain that they were genuine cases. Causes. — Gangrene of the mouth usually occurs in those whose systems are reduced or cachectic. It is therefore more frequent among the poor than those in comfortable circumstances — in the city than in the country. It is more frequently observed in asylums for children than in private practice. Most of the cases which I have seen have been in these institutions. If the constitution be good, it can only occur in those long deprived of pure air and wholesome nutriment or those enfeebled by disease. Among the diseases which have been known to terminate in or be followed by gangrene of the mouth are the pulmonary and intestinal inflammations. 686 LOCAL DISEASES. whooping cough, and the fevers, both eruptive and the non-eruptive. Rilliet and Barthez have published a table of 98 cases in which gangrene resulted from various diseases. In 49 of these the antecedent disease was measles, in 5 scarlet fever, 6 whooping cough, 9 intermittent fever, 9 typhoid fever, 7 mercurial salivation, and 5 enteritis. It is seen that the essential fevers were the most frequent cause of the gangrene. Of 46 cases collected by MM. Bouley and Caillaut, the antecedent disease was measles in all but 5. In this city also a larger number result from measles than from any other disease. One reason why so many cases of gangrene occur as a sequel of measles is probably because this disease is accompanied by stomatitis. Simple or ulcerous stomatitis often precedes gangrene. Diseases sometimes terminate in gangrene of the mouth in consequence of injudicious treatment which has lowered the vitality of the system. Ril- liet and Barthez mention the case of a child four years old in whom gangrene commenced at the twenty-ninth day of primitive pneumonia. The child had been reduced by the application of twelve leeches, three scarifications, a large blister, and by a poor diet. The misuse of mercury was once a much more frequent cause of gan- grene than at present, at least in this country, since this agent was formerly much more employed than now. In fact, most of the affections of infancy and childhood in which mercurials were formerly employed are now treated without it. Symptoms. — Gangrene of the mouth so often occurs in connection with other diseases that its symptoms are in a large proportion of cases blended with those which arise from a distinct pathological state. There is usually prostration, more and more pronounced as the gangrene extends. The features are ordinarily pallid, but occasionally their normal color is preserved for a time ; the expression of the face is melancholy, but composed. Sometimes the child is fretful if disturbed ; at other times it will quietly consent to an examination. The suffering is not proportionate to the gravity of the disease. There is less pain often than in some of the forms of stomatitis which are unattended with danger. As the disease advances the body and limbs gradually waste, the eyes are hollow, or, if the gangrene be near the orbit, the eyelids become oedematous ; the lips are infiltrated ; and both the lips and nostrils are often incrusted. If the cheek be perforated, alimentation is rendered difficult, and the appearance of the child is melancholy in the extreme. The tongue is usually moist ; it is occasionally swollen. The saliva flows from the mouth, either pure or mixed with offensive sanguinolent matter. Unless the disease be slight there is the peculiar gangrenous odor. The appetite is sometimes poor ; at other times it is preserved through the whole sickness. There is no vomiting or looseness of the bowels, unless from a complication. The thirst is usually great, and the pulse is accelerated and feeble except in mild cases. The skin in the commencement of gangrene is hot. When the vital force is much reduced, and especially as the disease approaches a fatal termination, the face and limbs become cold and the surface generally presents a waxen or ashy appearance. No derangement occurs of the respiratory system. Those cases which are attended by a cough or accelerated respiration are really cases of bronchitis or pneumonia coexisting with the gangrene. Diagnosis. — Gangrene of the mouth is easily diagnosticated. In those cases in which ulceration precedes the gangrene it may be mistaken in its first stage for that form of ulcerous stomatitis in which the ulcers assume an unhealthy appearance. The following are the distinguishing features of the GAXGREXE OF THE MOUTH. 687 two affections : Around the ulcer where gangrene is about to commence the tissues are greatly thickened and indurated or oedematous, while ulcerous stomatitis begins with a submucous deposit of fibrin, and is attended by little thickening of the surrounding parts and little or no induration or oedema. In ulcerous stomatitis the skin over the seat of the disease presents its normal Fig. 196. appearance, whereas in gangrene it presents a distended and shining appear- ance. The destructive process in ulcerous stomatitis is also more limited than in gangrene. Deep ulcerations do not occur or are rare. Ulcerous stomatitis is more readily healed, and it leaves no eschar, contraction, or deformity. The differential diagnosis of gangrene of the mouth from those cases of follicular stomatitis in which the ulcers occupying the seat of the follicles assume a gangrenous appearance must be made by a consideration of the same facts or particulars which serve to distinguish it from ulcerous stomatitis. Malignant pustule, of rare occurrence in the child, resembles this disease in some of its features. But the pustule always begins on the skin, while gangrene is a disease of the mucous surface primarily. In gangrene, there- fore, the chief destruction is of the mucous membrane and of the submucous tissue, while in malignant pustule the chief destruction is of the skin and the subcutaneous tissue. Prognosis. — This depends not only on the extent of the gangrene, but the nature of the disease, if there be one, which gave rise to it, and the degree of cachexia. If it occur in connection with or as a sequel to one of the less debilitating diseases, and there be considerable vigor of system, it may often be arrested when it has destroyed only the mucous and sub- cutaneous tissues, so that no deformity results. The friends may congratu- late themselves if the case terminate so favorably. In the graver cases, when the gangrene extends until it destroys the periosteum of the maxillary bone 688 LOCAL DISEASES. on the affected side, and perhaps perforates the cheek, if the child recover it is with the permanent loss of teeth, tedious separation of the necrosed bone, and a cicatrix which may interfere with the free use of the jaw. Death is, however, the more common termination of severe cases. Occasionally the gangrene destroys the continuity of a blood-vessel, causing abundant hem- orrhage and accelerating the fatal result. In most cases, however, there is little or no hemorrhage in consequence of coagulation in the vessels. Another serious complication sometimes arises — to wit, gangrene of other parts, as of the external genital organs. The English editor of Bouchut's treatise on diseases of children relates the following interesting case, from the Transactions of the Edinburgh Medico- Chir. Society: An infant eight months old became affected with gangrene of the face, head, and hands. " The right ear and the entire hairy scalp were of an intensely black color, and on both cheeks patches existed about the size of a half-crown piece. The right thumb and the backs of both hands were similarly affected. The child was noticed to have been restless and feverish on May 22d, and on the 23d a slightly darkened ring was found to have formed round the thumb, about the middle of the first phalanx ; in a few hours the whole thumb was gangrenous, and the dorsum of the hand became involved. On the ear the gangrene commenced with the appearance of a flea-bite, and subsequently extended rapidly to the scalp, assuming a remarkably regular form and giving to the child the appearance of wearing a black skull-cap. The pulse was observed to be very feeble. .... Death took place in twelve hours from the first appearance of gangrene on the thumb, the child being sensible and continuing to suck well up to a few minutes before death." Rilliet and Barthez state that pneumonitis frequently occurs in the course of gangrene of the mouth. Such a complication evidently diminishes materially the chance of recovery. Whether the result be favorable or unfavorable, it is evident from the nature of the disease that the duration is very different in different cases. The phy- sician's attendance may be required for a week or two or for several weeks. Treatment. — As gangrene of the mouth is eminently a disease of debility, all antihygienic influences should be removed and the most nourishing diet, together with tonics, be recommended. The ferruginous preparations or the bitter vegetables are required. As soon as the physician is called he should endeavor to arrest the gangrene, accelerate detachment of the slough, and produce a healthy and granulating state of the surrounding tissues. This is best effected by apply- ing a highly stimulating or even escharotic agent to the inflamed surface underneath and around the gangrene. For this purpose a great variety of substances have been used by different physicians, such as acetic, sulphuric, nitric, and hydrochloric acids, nitrate of silver, the acid nitrate of mercury, chloride of antimony, carbolic acid, and even the actual cautery. A safer, less painful, and in many cases successful treatment is that employed by many British and American physicians — to wit, the use of escharotic agents diluted, or, if applied in their full strength, such as are least active and penetrating. Some employ from the first topical treatment which is astringent and stimulating rather than escharotic, and they report satisfactory results. Dr. Gerhard believes " the best local applications are the nitrate of silver, if the slough be small in extent ; if much larger, the best escharotic is the muriated tincture of iron, applied in the undiluted state. After the progress of the disease is arrested the ulcer will improve rapidly under an astringent stimulant, such as the tincture of myrrh or the aromatic wine of the French Pharmacopoeia." GANGRENE OF THE MOUTH. 689 The local treatment recommended by Evan son and Maunsell differs from that advised by any of the writers from whom I have quoted. A knowledge of this treatment, from which I have myself seen good results, will be best imparted by quoting from these authors : l " The lotion which we have found by far the most successful is a solution of sulphate of copper as employed by Coates in the Children's Asylum. His formula is as follows : R. Cupri sulph., gij ; •Pulv. cinchona?, 5ss ; Aquae, 5iv. — Misce. This is to be applied twice a day very carefully to the full extent of the ulcerations and excoriations. The addition of the cinchona is only useful by retaining the sulphate of copper longer in contact with the edge of the gums. A solution of the sulphate of zinc, gj to an ounce of water, by itself or com- bined with tincture of myrrh, Dr. Coates found to be also useful in some cases." A moment's reflection will show us that the above treatment is preferable, provided that it is equally effectual in arresting the gangrene, to the treat- ment by the strong acids which are in common use, and the efficiency of which cannot be questioned. The purpose in applying the acid is to establish a healthier state of the tissues. It cauterizes and destroys whatever soft tissues it comes in contact with ; besides, it produces a strong corrosive action on the teeth and bone. Therefore in gangrene affecting the jaw there is great danger that it will destroy the periosteum, and consequently increase the necrosis. Dr. West, 2 who advocates the use of the acid, says : " In one of the cases that I saw recover the arrest of the disease appeared to be entirely owing to this agent, though the alveolar processes of the left side of the lower jaw, from the first molar tooth backward, died and exfoliated, apparently from having been destroyed by the acid." No such result follows the use of the solution of sulphate of copper. In one of these severe cases in which the disease resulted from scarlet fever, and in which there was so much debility that an unfavorable prog- nosis was made, I succeeded in arresting the disease by the use of Dr. Coates's prescription. The child recovered with the loss of two teeth and the corresponding portion of the maxillary bone. From the good effects which I have observed from iodoform as an application for gangrenous vul- vitis following measles, it has occurred to me that it may also be useful in gangrene of the mouth. If, after employing the milder treatment for two or three days, the gan- grene continue to spread, the strong muriatic acid should be cautiously applied by a camel's-hair pencil or small swab in such a way that it comes in contact only with the diseased surface. Its use should be immediately fol- lowed by an alkaline wash, as a solution of sodium bicarbonate. In 1881 an epidemic of measles occurred in the New York Foundling Asylum during the attendance of Drs. O'Dwyer and Lee. The number of children affected with it was 165, and, since many of them were cachectic. we were not surprised that gangrene appeared as a complication or sequel in 7 cases. In a girl of three and a half years it appeared upon the upper jaw at the base of the teeth; in two girls of four years it appeared upon the inside of the cheek and upon the vulva, and not upon the gums ; in a boy of three years it attacked the lower jaw, destroying four teeth with their sockets, and the upper jaw, destroying five teeth, with the correspond- 1 Diseases of Children, 2d Amer. ed., p. 188. 2 Ibid. y 4th Amer. ed. 44 690 LOCAL DISEASES. ing portion of the maxillary bone, so that all the incisors and one canine were lost, as well as the cartilaginous portion of the nasal septum. Gan- grene also occurred in the groin in this case. Another boy of three and a half years lost two incisors from gangrene of the jaw. The treatment by muriatic acid was employed, and, according to the house physician, Dr. Kort- right, there was no further extension of the gangrene after the first applica-' tion in any of the cases. All lived except the first, Who had broncho-pneu- monia. The remaining two patients, aged respectively four years, died of diphtheria and pneumonia before treatment could be tested. One of them had commencing gangrene of the lower jaw, the other of the soft palate. Recently, in the Foundling Asylum carbolic acid has been used as an eschar- otic in one or two cases, instead of the strong acid, and with such a result as to encourage its further use. The gases arising from the gangrenous mass are not only highly offensive to others, but they are doubtless injurious to the patient, who is constantly inhaling them. To remove the fetor, chlorine or carbolic acid, properly dilu- ted, should be occasionally used between the applications of the sulphate of copper. Labarraque ; s solution, one part to eight or ten parts of water, is an eligible form for its use. When the gangrene is removed and the granula- tions present a healthy appearance, all danger is usually past and convales- cence is fully established. Then no energetic topical treatment is required. A mild stimulating lotion, like the tincture of myrrh, as recommended by Dr. Gerhard, suffices, with the aid of tonics and nutritious diet. Efflorescence, Furring, and Eruptions upon the Tongue. From time immemorial the physician has inspected the tongue of the patient in order to determine his or her physical condition and obtain aid in diagnosis. Elevation of temperature, whatever the cause, persisting a few hours, indigestion, as Beaumont has shown, and many maladies, not only those located in the digestive system, but in organs distantly connected with this system, cause a fur to collect on the tongue. Hence from the infancy of medicine until the present time the tongue has been inspected by the physician before he announced the diagnosis. The fur occurs on the dorsum of the tongue, and not on its under surface, and scantily or not at all on its borders. It consists of epithelial cells of varying thickness, brown and dry in severe and malignant diseases, and of a light-yellow color and moist from the secretion of mucus in diseases of a milder type. An occasional " circinate eruption " upon the dorsum of the tongue has attracted the attention of various observers from the time of Gubler (article " Bouche," 1869) until the present time. It begins as a light-colored patch and enlarges peripherally. It forms a ring or series of rings resembling the ringworm, the interior of which presents a reddish appearance, contrasting with the thickened epithelium which forms the rings. In some instances, from intersection of the rings, arches are formed. As the circles extend the epithelial layer is restored in their centres and the disease gradually disap- pears. Most cases occur in infants, and the disease is of little clinical im- portance. Cases which I have observed are without pain or other symptom, and the patients recovered without treatment. This malady has the appear- ance of being microbic, but its origin is uncertain. It is probably best treated by antiseptic washes and gargles, as a wash of listerine or Seller's tablet. DENTITION. 691 CHAPTER III. DENTITION. The opinion formerly entertained in the profession, and now prevalent in the community, that many infantile maladies arise directly or indirectly from dentition is erroneous. Still, there are physicians of experience who believe that teething is a common cause of certain maladies, especially of functional derangements, even of organs remote from the mouth. On the other hand, equally good observers — and the number is increasing — almost wholly ignore the pathological results of dentition. They say that as it is strictly a phys- iological process, it should, like other such processes, be excluded from the domain of pathology. A moment's reflection will show how important it is to understand the exact relation of dentition to infantile diseases. Every physician is called now and then to cases of serious disease, inflammatory and non-inflammatory, which have been allowed to run on without treatment, in the belief that the symp- toms were the result of dentition. I have known acute meningitis, pneumo- nia, and entero-colitis, even with medical attendance, to be overlooked, and the symptoms attributed to teething during the very time when appropriate treatment was most urgently demanded. Many lives are lost from neglected entero-colitis, the friends believing the diarrhoea to be symptomatic of denti- tion, a relief to it, and therefore not to be treated. Such mistakes are trace- able to the erroneous doctrine, once inculcated in the schools, and still held by many of the laity, that dentition is directly or indirectly a common cause of infantile diseases and derangements. I shall endeavor to point out what is really ascertained in regard to the pathological relations of dentition. The first dentition commences at the age of about six months and termi- nates at the age of two and a half years. The corresponding teeth of the two sides pierce the gum at about the same time. The two inferior central incisors first appear at about the age of six or seven months, followed, in the order in which they are mentioned, by the upper central incisors, upper lat- eral incisors, lower lateral incisors, the four anterior molars, the four canines, and, lastly, the four posterior molars. The incisors usually appear in rapid succession, so that all are in sight by the age of one year. From the age of one year to eighteen months the anterior molars appear, and from the age of sixteen to twenty-four months the canines, and from twenty-four to thirty months the posterior molars. This order is not always preserved. Sometimes the upper central incisors appear before the lower, and sometimes the lower lateral before the upper lateral. In rare cases there have been teeth at birth. I have seen but one or two infants with such premature dentition. Retarded dentition is much more common. Those who have rickets or are feeble either constitutionally or by disease often have no teeth till considerably after the usual period. In such the first incisors may not appear till the age of twelve months, or even later. Pathological Results of Dentition. — The evolution of the teeth is commonly attended by more or less turgescence around the dental bulbs. This is greater with some of the teeth than with others. Thus the superior incisors cause more swelling than do their congeners of the inferior jaw. The turgescence, although attended by more or less congestion, is physiological within certain limits, and not a disease. 692 LOCAL DISEASES. But exceptionally there is an unusual amount of swelling around the dental follicles ; the afflux of blood to them is greatly augmented ; they are the seat of such a degree of tenderness and pain that the infant is fretful. It carries the finger often to the mouth, indicating the seat of its suffering. The surface over the follicles presents greater redness than in ordinary den- tition, and the salivary secretion is considerably increased. There may now be actual gingivitis, but such cases are rare. Occasionally the turgescence affects a greater extent of the buccal sur- face than that lying directly over the follicles, so that most writers speak of stomatitis as one of the results of dentition. In a few cases I have known such a degree of inflammation over the advancing tooth that a small abscess formed, producing pain and restlessness till it was opened by the lancet. The pathological results of dentition which I have mentioned, though they may interfere more or less with nursing or feeding, are not dangerous. They are easily detected. They result directly from the rapid growth and aug- mented sensitiveness of the dental follicles. There are other supposed accidents of dentition occurring in distant parts of the system in consequence of the relation and interdependence of organs which exist through the system of nerves. Some children prior to the eruption of the teeth are affected with diar- rhoea, occasionally accompanied by irritability of the stomach. Certain writers have supposed that gastro-intestinal catarrh is present in these cases ; others that there is simply a hypersecretion, an increased activity of the intestinal follicular apparatus — that it is, in other words, one of the forms of non- inflammatory diarrhoea. Barrier believes that the diarrhoea of dentition depends usually on what he calls a " subinflammatory turgescence limited to the gastro-intestinal follicular apparatus." He believes that in occasional cases it is due to defective or altered innervation. It would then be analogous or similar to that form of diarrhoea which occurs in the adult from the emotions. Bouchut calls the diarrhoea of dentition nervous diarrhoea. It is certain, however, that in most cases of diarrhoea which are attributable to dentition there are other causes, such as unsuitable food or residence in an insalubrious locality. It is certain, as regards city infants, that the chief causes of diar- rhoea during the period of dentition are strictly antihygienic, dentition being quite subordinate as a cause, and probably ordinarily not operating at all as such. But when, as sometimes happens, at each period of dental evolution the infant is affected with diarrhoea, the influence of teething is apparent. Such cases give rise to the belief that teething may really sustain a causal relation to certain diseases not located in the buccal cavity. Among the more common pathological results of difficult dentition are certain affections referable to the cerebro-spinal system. Eclampsia is one of the admitted results. Barrier attributes convulsions in the teething infant to excitement of the nervous system arising from the pain which is felt in the gums, and to a determination of blood to the dental apparatus, in which afflux the whole vascular system of the head participates. In most cases of convulsions, occurring during the period of dental evolu- tion, a careful examination discloses other causes in addition to the state of the gums. Difficult dentition must then be considered not so frequently a direct as perhaps a co-operating or predisposing cause, producing a sensitive state of the nervous system, or possibly an afflux of blood to the head, of which Barrier speaks, and which by an additional stimulus, perhaps trivial in itself, ends in convulsions. The belief is not unreasonable that convulsions may result when several teeth penetrate the gum at or about the same time. In- fants who are burned or scalded are very liable to clonic convulsions. This is, in fact, the chief danger as regards life from such accidents. So the DENTITION. 693 swollen and tender gmn, if several teeth are about emerging, may possibly affect the cerebro-spinal system like tlie burn or scald and produce the same nervous phenomena. Thus in a case already alluded to in the chapter on Convulsions, live incisors pierced the gum within about two weeks, and in this period there were two attacks of eclampsia with an interval of a few days. The attacks were not severe, and the most careful examination could reveal no other cause than the simultaneous development of so many den- tal follicles. Previously and since the infant has been well. Dentition sometimes, though rarely, occasions also tonic contraction of certain muscles. The following case occurred in the practice of the late Dr. A. S. Church of this city, the history of which he communicated, as follows : Case. — " H , seven months old, was first visited April 3, 1863. The patient had been fretful for several days, but about daylight on the morning of my first visit it commenced crying, and had not ceased for a moment at the time of my visit, 9 a. m. The bowels were somewhat constipated and tympanitic ; abdominal mus- cles very tense. The pain was supposed to be in the abdomen, and a brisk cathar- tic, to be followed by an anodyne, was ordered. Some relief followed, but on the ensuing and for several consecutive mornings the pain returned, each day lasting longer, until the child only ceased crying while under the influence of a full ano- dyne. The gum over the upper incisors was considerably swollen, hot, and dry, but the parents would not consent to have it scarified. For the first week there was no fever, no vomiting, and not the least indication that the nervous system was suffering. About the 10th the thumbs were noticed to be flexed during the attack of pain, and about the 15th the flexors of the toes were contracted and the hands were turned backward and outward, but only while the child was awake. About the 20th there was constant contraction of the flexors of both extremities, with opisthotonos, and constant rolling of the head, loss of appetite, progressive emacia- tion, coated tongue, and highly-inflamed gums. Consent was finally obtained to relieve the inflamed gum, and free incisions were made, and the following night the child slept comfortably for three hours without opiates. In three days the gums were freely cut again, and the teeth soon made their appearance. All symptoms of disease had now ceased, the child became playful, and on the 30th the patient was discharged." More recently a child of about eighteen months, seen by me in consulta- tion, had tonic contraction of the flexors of the left thigh and leg, continuing nearly a month, so that the thigh was flexed on the body and the leg on the thigh. The infant was cutting five teeth at the time, and the gums were considerably swollen over them. The normal state of the affected limb returned after these teeth had penetrated the gum. The opinion has been prevalent in the profession that painful and dif- ficult dentition is one of the chief causes of infantile paralysis, but it is now admitted that it is only a subordinate or remote cause, if indeed it is proper to consider it a cause at all. (See art. Paralysis.) The older writers sometimes expressed the opinion that acute meningitis occasionally results from teething. The facts, however, that are relied upon to prove this are uncertain. The occurrence of meningitis during dentition is probably in most instances merely a coincidence. Teething does not often disturb the respiratory system. A cough occurs in some infants at each period of dental evolution. It is attended by little expectoration, but is sometimes associated with an inflammatory turgescence of the bronchial mucous membrane. Eczema and certain other cutaneous diseases, as well as acceleration of pulse and more or less fever, are common during dentition, but their depend- ence on it as a cause has not been demonstrated. Diagnosis. — The accidents of dentition which are located in the mouth are easily diagnosticated, except the odontalgia which writers describe, and 694 LOCAL DISEASES. which is not necessarily attended by any perceptible anatomical alteration of the gums. Those accidents which pertain to remote and concealed organs are usually detected with ease, though it is often difficult to determine with certainty their relation to dentition. It is certain, as the nature of diseases becomes better understood, dentition becomes less and less important as an etiological factor. Treatment. — It is obvious that remedial measures in cases of difficult dentition must be twofold — namely, those directed to the state of the gums, and those designed to relieve the derangements or diseases to which denti- tion has given rise. If there be diarrhoea, this should be controlled by proper remedies, so as to reduce the number of evacuations to two or three daily. It is well to state to the friends of the child who believe that diarrhoea is salutary during the period of teething that this number is quite sufficient, and that more frequent evacuations endanger the safety of the child. The nervous affections, as convulsions, require such soothing and deriva- tive measures as are recommended in our remarks on Diseases of the Nervous System. The bromide of potassium I have found especially useful and safe in cases of fretfulness and nervous excitement during the period of dentition and perhaps having dentition as the cause. Demulcent and soothing lotions are sometimes useful in cases of painful dentition, and the infant may be allowed to hold in its mouth an India-rubber ring, which seems to give con- siderable relief. Mothers often attempt to c: rub through a tooth," as they term it, by means of a ring or thimble. This should be forbidden. So great friction cannot fail to have an injurious effect by increasing the swelling and inflam- mation, unless the tooth have already reached the mucous membrane. We come now to a subject which has engaged the attention of many physicians of ample experience, and in reference to which there is still a dif- ference of opinion among the highest authorities in medicine. I refer to scarification of the gums. The gum-lancet is much less frequently employed than formerly. It is used more by the ignorant practitioner, who is deficient in the ability to diagnosticate obscure diseases, than by one of intelligence, who can discern more clearly the true pathological state. Its use is more frequent in some countries, as England, under the teaching of great names, than in others, as France, where the highest authorities, as Rilliet and Barthez, dis- countenance it. It is well to bear in mind, as aiding in the elucidation of this subject, the remark made by Trousseau, that the tooth is not released by lancing the gum over the advancing crown. The gum is not rendered tense by pressure of the tooth, as many seem to think, for if so the incision would not remain linear, and the edges of the wound would not unite, as they ordinarily do by first intention within a day or two. This speedy healing of the incision unless the tooth be on the point of protruding is an important fact, for it shows that the effect of the scarification can last only one or two days. The early repair of the dental follicle is probably conservative, so far as the development of the tooth is concerned. It may help us to understand how active, how powerful, the process of absorption is, if we reflect that the roots of the deciduous teeth are more or less absorbed by the advancing second set, without much pain or suffering from the pressure. If the calcareous particles of the teeth are so readily absorbed, what is the foundation for the belief that the fleshy substance of the gum is absorbed with such difficulty ? Too much importance has evidently been attached to the supposed tension and resistance of the gum in the process of dentition. DENTITION. 695 Follicles in the period of development are especially liable to inflamma- tion. We see this in the follicular stomatitis and enteritis so common when the buccal and intestinal follicles are in a state of most rapid growth. Does not this law in reference to the follicles hold true of those by which the teeth are formed, so that the period of their enlargement and greatest activity, which corresponds with the growth and protrusion of the teeth, is also the period when they are most liable to congestion and inflammation ? It seems probable that the dental follicles are most liable to become inflamed, and therefore tender, from various causes apart from dentition at the time of their greatest functional activity. If there be no symptoms except such as occur directly from the swelling and congestion of the gum, the lancet should seldom be used. The patho- logical state of the gum which would, without doubt, require its use is an abscess over the tooth. As to the symptoms which are general or referable to other organs, as fever and diarrhoea, the lancet should not be used, because the symptoms can be controlled by other safe measures. All co-operating causes should first be removed, when in a large proportion of cases the patient will experience such relief that scarification can be deferred. If the state of the infant be one of immediate danger, as in eclampsia, and it be not quickly relieved by the ordinary remedies, scarification may not only be proper, but required to ensure safety. For in such cases all measures, provided that they are safe and simple, which can possibly give relief, should be employed without delay. But I can recall to mind only three accidents of dentition which would be likely to be benefited by scarification — namel} T , suppurative inflammation in the dental follicle, extreme fretfulness continuing day after day, and convulsions. But since the bromide of potas- sium and hydrate of chloral have come into use as nervous sedatives and as efficient remedies for clonic convulsions, scarification of the gums is much less frequently required, for even severe eclampsia commonly yields to these medi- cines if the condition of the bowels be attended to. In some instances I have found that the elixir anisi (aniseed cordial) of the National Formulary, containing as it does anethol and the oils of fennel and bitter almond, administered in doses of ten drops to an infant of one year, is apparently more quieting in cases of restlessness than the bromide. It may be given with the bromide. Second Dentition. — Rilliet and Barthez mention particularly neuralgic pains, rebellious cough, and diarrhoea as effects which they have observed of the second dentition. Rilliet relates the case of a girl eleven years old who had a very obstinate and protracted cough, the paroxysms lasting often half an hour to one hour. This cough immediately and permanently disappeared when the molars pierced the gums. Dr. James Jackson x says : u I have seen persons between twenty and thirty years of age much affected by a wisdom tooth not yet protruded, and distinctly relieved by cutting the gum. But I think the most common period of suffering from the second dentition is from the tenth to the thirteenth year. The most characteristic affections are wasting of flesh and nervous diseases. The boy loses his comeliness and his complexion is less clear, while emaciation takes place in every part, though mostly perhaps in the face. The nervous symptoms are various, but the most common are a change in the temper and a loss of spirits. With these there is some loss of strength. The patient is unwilling to engage in play, and soon becomes tired when he does so. Among the distinct symp- toms which are not uncommon I may mention pain in the head and in the eyes. The headache is not commonly severe, but it is such as inclines the patient to keep still. The eyes are not only painful, but are often affected with the morbid sensibility to which these organs are subject. I have known boys truly 1 Letters to a Young PJu/sician. 696 LOCAL DISEASES. anxious to pursue their studies, obliged to give them up on this account ; and these, not having the disposition to play, will of choice pass the day with their mothers and increase their troubles for the want of air and exercise. Nervous affections of a more severe character are sometimes manifested. 7 ' Whether the symptoms which have been attributed to second dentition have always been due to this cause is questionable. Practically, however, it matters little whether we recognize dentition as the cause or assign some- thing else. Hygienic and medicinal measures to improve the general health will usually suffice to relieve the patient. Elsewhere I have related the case of a boy of nervous temperament, about seven years old, who recovered immediately from a cough which had lasted for several weeks by taking a mixture of iron and nitric acid. Many do well without medicine, simply by hygienic measures. Dr. Jackson says : " The remedies which I have found most useful are as follows : First, a relief from study or from regular tasks, yet using books so far as they afford agreeable occupation or amusement. Second, exercise in the open air, preferring the mode most agreeable to the patient, and in more grave cases the removal from town to country." Ranula. Ranula is a cyst beneath the tongue, usually intimately related to the salivary ducts. The ducts becoming closed, the epidermic lining is deposited in the interior, and the secretion accumulates until a large tumor is formed which presses the tongue upward and backward, greatly interfering with the functions of that organ. These cysts are readily recognized on inspec- tion of the under surface of the tongue. The treatment may at first be the passing of a seton (Fig. 197) to secure drainage of the sac and adhesion of Fig. 19- Ranula : introduction of seton. its walls. If this fail, resort to free incision, and keep the wound open ; or excision of a portion of the walls may be necessary. If the disease per- sists, open the cyst and cauterize with nitrate of silver, or even nitric acid. If the cyst project in the neck, open it in the middle line below the hyoid bone, and keep it open till the cavity is obliterated. DENTITION. 697 Fig Alveola. Hypertrophy of the alveola appears as a congenital affection, and con- sists of an expanded and prolonged development of the alveolar borders of the maxillae, immense thickening of the fibrous tissue of the gum, and exu- berant growth of the papillary surface. When fully developed the patient presents an extraordinary appearance — a large mass, dense, inelastic, insensitive, pink, and smooth, protrudes from the mouth (Fig. 198). Excision should be performed. Vascular growths, nsevi, and aneurysms by anastomosis form in the tissues about the necks of the teeth, especially between the incisors or canines and lateral incisors of the upper jaw ; they have a purplish color ; are smooth and streaked, with many vessels; are easily compressed and become pale and re- duced, but are elastic and resume their pre- vious aspect on removal of pressure. The whole gum is red, turgid, and swollen, and the little tongues of gum between the necks of the teeth are enlarged and spongy ; troublesome hemorrhage occurs later in the disease. These growths are now more readily destroyed by the galvano-cautery needles. If this treatment fail, excision should be performed with a scalpel, the bleed- ing being controlled by pressure and ice. Dentigerous cysts are collections of serum in the maxillary bones depend- ent upon impacted misplaced teeth ; they arise only when the tooth or teeth associated with them are imbedded in the substance of the jaw-bone, and do not occur after the tooth has pierced the gum ; they occur in connection Front view of tumor of alveolus, due to hypertrophy and dilatation of tooth-fang (Bryant). Fig. 199. Fig. 200. Dentigerous tumor of jaw (Bryant). with the permanent teeth, which may fail to pierce the gum, either from the great depth of the sac or growth in an oblique direction, or from arrest of development. The symp- toms are expansion of the jaw-bone, weight, and tension, and disfigurement of the fea- tures (Fig. 199). The diagnosis depends on pressure, which reveals fluid, expansion of bone, and crepitation like stiff parchment, and absence of a tooth or of teeth which have never appeared. The treatment consists in opening the cyst freely with knife, gouge, or trephine, extraction of the imbedded tooth, and, if the expansion is large, removal of the dilated bone (Fig. 200). The result is always satisfactory. Canine tooth as seen in a ease of den- tigerous cyst. Expanded lower jaw with tooth : b, natural size ; a, bone removed by the trephine (Bryant). 698 LOCAL DISEASES. Tonsil. Abscess of the tonsil is a frequent result of acute inflammation. It should be punctured as soon as pus is detected, care being taken to avoid wounding the internal carotid artery. Select a broad spatula and a sharp-pointed straight bistoury, wrapped to within about half an inch of its extremity ; place the patient in a chair in front of a good light, the head firmly supported by an assistant ; lay the spatula slightly on the tongue until the abscess is brought into view ; pass the knife backward, avoiding wounding the tongue, and incline the point, when it penetrates the tonsil, toward the median line of the fauces, thus protecting the internal carotid from all danger ; if the abscess cannot be sufficiently exposed, it may be necessary to direct the point of the knife by the index finger of the left hand ; if the abscess contain a large amount of pus, the patient's head should be thrown forward immediately after the puncture to avoid the flow into the pharynx or larynx. Chronic inflammation of the tonsil is caused by repeated acute conges- tions of the pharyngeal mucous membrane, and consists of an equable and uniform overgrowth of all the histological elements of the follicles ; the size and shape of the entire tonsil undergo an alteration. It forms a globular and often pedunculated tumor which may project so far as to interfere with breathing ; or. it may grow vertically, extending below into the pharynx and upward toward the posterior nares. The symptoms depend upon the peculiarties of the hypertrophy. When large and protruding it interferes with natural sleep, affects the voice, and often the general health is impaired. There is " a vacuous, heavy look from obstruction to breathing and consequent imperfect aeration of the blood ; also imperfect development, and often stunting of the growth ; the mouth is kept open, the breathing is stertorous, and during sleep snoring ; there is usually chronic nasal, and often aural, catarrh, from the extension of irritation from the tonsils to the neighboring mucous surfaces ; the speech is nasal and indis- tinct or dead ; the chest is often ill-developed, pigeon-breasted, or has the diaphragmatic constriction." l The treatment should be the application of iodine in the early stages. In advanced cases the only proper treatment is removal. Various methods Fig. 201. have been employed to destroy the tonsil — compression, massage, electrol- ysis, galvano-cautery puncture, ignipuncture, and the snare. But excision with the tonsillotome has proved the most useful, especially when the tonsil projects. The danger from hemorrhage is comparatively slight ; the opera- 1 Ashby and Wright, Diseases of Children, p. 54. DENTITION. 699 tion is quickly performed and does not require a specially skilled hand. The Mackenzie instrument is the more simple (Fig. 201). An anaesthetic should be given to the child to the extent of slight narcosis, but not so as to abolish the reflexes. The patient is placed on the back, the mouth-gag is introduced, and the tonsils removed. The child is then turned on its face to facilitate the flow of blood from the mouth. Knight states that there should be no hesitation in adopting this method in children under ten years of age and in older children of nervous tempera- ment. He advises to remove as much of the tonsil as possible, for the stump does not shrink and may prove a source of irritation, and the farther out the section is made the more nearly we approach healthy tissue. In the absence of a tonsillotome the tonsils may be partially removed with curved hook-teeth forceps, and a straight probe-pointed or curved scissors. If the patient is a child, give chloroform, and when sufficiently under its influence to open the mouth, seize the tonsil, draw it out from between the pillars, and, having the knife-blade wrapped to within an inch of the point, cut away from below upward the proper amount. Recurrent tonsillitis is a term used by Leland 1 of Boston in describing that form of tonsillitis which recurs with such violent symptoms, often with- out an\ T premonition. He says: "The onset of the exacerbation maybe sudden, ushered in by a chill more or less marked, with high fever, followed by more or less formidable swelling, with exudation, white or yellow patches, etc., to subside after a week or two ; or it may go on to abscess, intratonsillar or peritonsillar, with great distress, forced starvation, restless days, sleepless nights, extreme prostration and anxiety (both for patient and physician), requiring weeks or months for recovery. The mental state of the attendant is not an enviable one when he knows that he may have a sudden fatal ter- mination from extreme faucial swelling, oedema glottidis, suffocation from sudden discharge of pus or by involvement of the great vessels — the carotid and internal jugular — by extension of inflammation." He describes two varieties of tonsils which are subject to such recurrence : First is the tonsil which in an inflammatory attack simply rounds out an increase in size — smooth, red, shiny, the parenchymatous variety. The crypts or lacunae are not markedly developed, but the lymphoid elements are increased in size and in number. If the capsule is broken and the finger introduced, a soft, friable feeling is communicated to it, something like that of the normal spleen. After several inflammatory attacks these tonsils are adherent to the pillars of the fauces, and especially when this adhesion has taken place are they apt to be permanently enlarged, and even to close the faucial passage, pushing forward the uvula, with every slight cold or disturbance of the digestion, or from some other ill-defined cause, so that the voice and respiration of the sufferer are much affected. The other variety is the chronic tonsil, which has a hard, rubbery feel, whose surface is full of crypts or lacunas which run into its depth from one- quarter of an inch to one inch or more, which crypts usually contain inspis- sated secretion of a cheesy consistency and of a most offensive odor. This is the ' lacunal' tonsillitis of Wagner or Brown. It may be large enough to just project beyond the pillars or it may reach even to the uvula. Because of the diseased condition of the interior of the crypts it is especiall} T liable to fre- quent inflammatory attacks from even the slightest cause. It acts as a foreign body in the fauces, producing a tickling, hacking cough, giving a malodorous breath, and doubtless keeps the general health of the patient down from the absorption of these decomposing cheesy masses through the tonsil itself or 1 Boston Med. and Surg. Joum., Oct. 12 and 19, 1893. 700 LOCAL DISEASES. from their being swallowed. It is said that attacks of indigestion light up inflammatory conditions in the tonsil. It is probably also true that the con- tents of the crypts excite or keep up fermentative indigestion. This variety of tonsil is doubtless the result of repeated attacks of the first variety. The treatment recommended by Leland is the removal of the inspissated secretion of the crypts on which the inflammation depends, and " the tearing away of the partitions between the crypts so as to connect the many small contracted mouths into a few large wide-open ones.' 1 For this purpose he has devised a knife (Fig. 202), which he uses as follows : The olive-shaped tip of the knife is introduced into a crypt in the upper part of the tonsil, and then turned downward and inward and made to come out by another in the lower part. The substance of the organ between these two holes is then cut through. This can be repeated from three to ten times at a sitting until the surface of the tonsil presents the appearance of being full of slits. There Fig. 202. duced oftentimes to its fullest extent without danger. As soon as the bleeding has ceased the slits are painted with Monsel's solution or with a mixture of glycerin and tincture of iodine in equal parts. These solutions may be put upon the end of the cotton-wrapped bent applicator and crowded down to the bottom of the tonsil. This is done for antisepsis and to prevent the wounds from uniting immediately, as they tend to do, thus rendering the operation futile. The patient is advised to gargle with hot water very frequently for three or four days, and to return in a week for another operation, if necessary. Dobell's or Seller's solution or a little borax may be added to the hot water. It usually requires from four to eight sittings to cause a large tonsil to recede from the median line to a position almost out of sight behind the pillars of the fauces. If the tonsil is very fibrous and hard, there will be left small projections upon the surface. These can be readily nipped off with adenoidal forceps or can be seized by long dressing forceps and removed with a blunt-pointed bistoury. The patient is then instructed to return on the slightest symp- tom of the old trouble, that any crypt which has escaped treat- ment may be attended to. In adults this method can be carried out with the greatest facility and ease, and often in children as young as ten years of age. I have also been able to operate with satisfaction, although with a little more necessary per- suasion, in children as young as five or six ; and recurrent tonsillitis is not apt to occur younger than that, at least in my experience. The first variety of tonsillitis, in which the crypts are not so much developed or so fully diseased, is much benefited by this method if the capsule is torn or cut and the solution applied to its interior, and perhaps even if only adhesions between the tonsil and the pillars of the fauces are cut away by this method. Adenoid vegetations consist of nodules of lymphoid tissue which form masses of soft tissue or ridges or lobules on the upper and lateral surfaces of the posterior nares. They often exist in connection with hypertrophy of the tonsils, and they have been called the pharyngeal tonsil. They may be seen with the laryngeal mirror, and may be felt with the index finger, well protected by a shield of celluloid, passed behind the soft palate. They may be suspected to exist in a child who snores, has a mucous discharge from the nose, and a thick speech. According to Power, 1 the facial expression is characteristic in the later stages ; there is a dull and heavy look, a sallow complexion, thick and prominent lips ; 1 Power, Surg. Dis. Children, p. 281. CATARRHAL PHARYNGITIS, ETC. 701 mouth open: nostrils narrow; alas indented at junction of superior and inferior lateral cartilages ; bridge of nose broad and often crossed by a large vein ; eyes appear unduly far apart ; often dulness of hearing. The treatment is removal. Various instruments have been devised for this purpose, as curettes, forceps, and artificial nails, but a Volkmann's spoon, passed through the anterior nares, guided by a finger in the pharynx, effects the purpose. The child should be brought partially under the anaes- thetic and a gag employed. Power has the head of the patient hang over the table, so as to prevent the escape of blood into the air-passages. The nasal cavity should be swabbed out during the operation with absorbent cotton. On removing the gag the bleeding ceases. Recovery is usually rapid. CHAPTER IV. CATAEEHAL PHARYNGITIS, PEBIPHAEYNGEAL ABSCESS, OESOPHAGITIS. Catarrhal Pharyngitis. Children of all ages are liable to inflammation of the pharynx. In its mildest form it often, doubtless, escapes detection in the young infant. In older patients it is revealed by pain in swallowing solid food and more or less tumefaction below the ears, apparent to the sight. It is said to be less fre- quent in infancy than in childhood. In the adult and in children over the age of four or five years inflammation of the pharyngeal surface is often con- fined to the portion of membrane which covers or immediately surrounds the tonsils. It occurs in connection with inflammation of these glands. But in infancy and early childhood this limitation is comparatively rare. Catarrhal inflammation of the fauces at this age is ordinarily general, the tonsils par- ticipating in the morbid state. Pharyngitis is primary or secondary. The secondary form occurs in mea- sles, scarlet fever, bronchitis, croup, pneumonia, and occasionally in other affections. As these diseases are common, physicians are oftener called to treat patients who have the secondary form than the primary. Rilliet and Barthez met 83 secondary to 16 primary cases. Anatomical Characters. — The pathological anatomy of pharyngitis is ascertained by depressing the tongue and inspecting the fauces. The faucial surface is seen to be redder than in health, with more or less swelling accord- ing to the intensity of the inflammation. In the primary inflammation the color is commonly bright red, almost like that of arterial blood. If, on the other hand, the inflammation occur in connection with a constitutional malady, the hue is often darker. In grave cases of scarlet fever or measles it is some- times even livid, indicating a vitiated state of the blood — a condition of real danger. The tonsils are tumefied so as to project, though not to the extent which we observe in the adult. They are less firm than in the normal state. The follicles of the throat are enlarged and active, pouring out a muco-purulent secretion. This is sometimes seen in a layer over the tonsil or the posterior portion of the fauces. In a case of primary pharyngitis 702 LOCAL DISEASES. examined after death by Rilliet and Barthez the tonsils were softened, infil- trated with pus, and slightly enlarged. A layer of bloody mucus lay on the pharyngeal surface, which was dark red and thickened. The submaxillary glands were also swollen and somewhat softened. If the inflammation be intense, the deep-seated portions of the tonsils become involved, and even sometimes the adjacent connective tissue. In such cases by applying the fingers in the hollows below the ears the tonsils can be felt. Causes. — The usual cause of primary pharyngitis is exposure to cold. It also occasionally occurs from the use of drinks too hot or containing some irritating substance. I have met it in the most intense form caused by swal- lowing boiling water, and in one case from acetic acid taken through mis- take. When it occurs in the eruptive fevers it is usually part of a more extensive phlegmasia, in which the buccal and perhaps laryngeal and nasal surfaces participate. Symptoms. — Fever, with thirst and loss of appetite, is common, and is usually proportionate in intensity to the extent and severity of the inflamma- tion. At first there is dryness of the faucial surface, and this is succeeded by a more or less abundant viscid secretion. Swallowing is painful, except in mild cases. The muscles of the anterior half-arches, which by their con- traction close the opening from the pharyngeal to the buccal cavity, and those of the posterior arches, which close the opening to the nasal cavity, both which sets lie a little under the mucous membrane, are often so infiltrated with serum that their contractile power is diminished, and if the same happen with the constrictor muscles, which carry downward the food, swallowing becomes difficult, and in the attempt more or less of the ingesta is liable to return into the mouth or enter the nostril. During health the air passes through the nostrils in the pronunciation of two letters only — namely, n and m — but in severe pharyngitis, in consequence of the swelling and the impair- ment of the action of the muscles concerned in speech, the air passes through the nostrils with the utterance of many words, producing the nasal tone of voice. Sometimes the inflammation traverses the Eustachian tube to the middle ear, causing earache, which may be relieved by the escape of pus down the tube or by perforation of the drum into the external ear. The breath is foul, but not fetid ; the respiration normal or but slightly accelerated ; there is commonly no cough, but it is sometimes present, due to the extension of the inflammation to the upper part of the larynx or to the collection of mucus around the aperture of the glottis. In most cases of pharyngitis a light fur covers the tongue, and stomatitis of a mild grade is present, as shown by redness of the buccal surface and increased mucous secretion. Chronic pharyngitis, which is so common in adults, and which is produced in some by gastric derangements, and in others by excessive smoking or the prolonged use of intoxicating drinks, and in others still by the syphilitic or mercurial cachexia, is comparatively rare in children. Prognosis. — In mild cases of pharyngitis convalescence commences within a week. If the inflammation be dependent on a constitutional malady, it may continue considerably longer, especially if the glands of the neck and the connective tissue be much involved. The prognosis in secondary pharyn- gitis is less favorable than in that of the primary form. In fatal cases there is usually a vitiated state of the blood, either from the coexisting constitu- tional disease or from previous cachexia. Pharyngitis may, however, become dangerous from complications to which it gives rise. The proximity of the inflammation to the brain or its effect upon the cerebro-spinal axis through the medium of the nerves sometimes CATARRHAL PHARYNGITIS, ETC. 703 oives rise to clonic convulsions. In a recent case of primary pharyngitis in iny practice repeated and violent convulsions occurred in an infant about one year old from this cause. They commenced at the inception of the inflamma- tion, and constituted the only real danger. Pharyngitis may interfere mate- rially with nutrition in consequence of the dysphagia, but in most cases of primary pharyngitis this symptom does not continue sufficiently long to endanger the life of the patient. In grave constitutional affections, as scarlet fever, the difficulty of swallowing and the consequent innutrition augment the danger. As regards, therefore, the prognosis in catarrhal pharyngitis, whether primary or secondary, it may be stated as a rule that it is not, per se, a fatal disease, but is only so from complications or from aggravating the primary malady with which it is associated. Diagnosis. — This is not difficult, provided that attention be directed to the throat ; but the physician often fails to discover it at his first visit from neglecting to examine this part. In many cases the local symptoms are not well-marked, and in the absence of these the febrile reaction may at first be referred to some other cause than the true one. Inspection not only reveals the presence of inflammation, but enables us to determine the form with the aid of the microscope. This instrument, now in common use, enables us to differentiate simple catarrhal inflammation from diphtheritic, pseudo-diph- theritic, and other forms of pharyngitis. Treatment. — Mild cases of simple pharyngitis require little treatment. With moderate counter-irritation around the neck, as by one of the following prescriptions, and by appropriate remedies the patient recovers : R. Olei caryophylli, ^ij ; Olei camphorati, £iv. — Misce. For external use. R . Olei terebinthinse, ,^ss ; Olei camphorati, t ^iij. — Misce. For external use. Sometimes warm-water applications, or, if the temperature exceeds 103° F., applications containing ice. give most relief. In severe forms of the disease occurring independently of any other malady more active measures are sometimes required. Carl Seller's tablet, which, according to the published formula, contains several sodium combina- tions with aromatics and antiseptics, will be found very useful for this and other forms of pharyngitis, sprayed frequently over the fauces according to the following formula : R. Creasoti (Morson's beechwood), gtt. ij ; Seiler' s tablet for the fauces, No. j ; Aquae destillat., J;iij. — Misce. Spray fauces, and if necessary nares, every hour. If there be stupor or restlessness, with unusual heat of head, and start- ing or twitching of the limbs which threatens convulsions, two to five grains of the bromide of potassium given every two or three hours produce a calm- ative effect. Diaphoretic and sometimes cardiac sedatives are also indicated, such as liquor ammonias acetatis, spiritus setheris nitrosi, ipecacuanha, and aconite. Medicines of this kind may be variously combined according to the age and condition of the patient and the severity of the disease. As the symptoms abate the intervals between the doses may be in- creased. 704 LOCAL DISEASES. In cases attended by much tenderness and dysphagia great relief is often obtained by hot poultices frequently applied over the neck. The treatment of secondary pharyngitis will be described in connection with the treatment of the diseases which it complicates. Suffice it here to say that this form of inflammation must not be treated by those depressing remedies which may be useful in cases of idiopathic pharyngitis. Peripharyngeal Abscess. An abscess occasionally forms between the pharynx and vertebral column (retropharyngeal) or upon the side of the pharynx in the submucous connec- tive tissue. This constitutes a disease which may be fatal, but which can ordinarily be promptly relieved by the surgeon. Yet if we look over the records of peripharyngeal abscess we shall see that in a large proportion of fatal cases the disease was supposed to be some- thing else, and so treated until its nature was revealed by post-mortem exam- ination. This abscess may occur at any age, but is most common in infancy and childhood. It is more frequent in the first two years of life than at any other period. Of the cases collated by Allen in which the age is stated, 20 were under ten years and 21 over this age. The abscess occurs in some patients from caries of the vertebral column, and in others from inflamma- tion developed in the connective or small lymphatic glands lying immediately outside the pharynx, or from a catarrhal pharyngitis. The patient is usually scrofulous or in a reduced state of system. Writers describe two kinds of peripharyngeal abscess, the primary and secondary. This distinction is based on the fact whether or not the inflam- mation which leads to the abscess be dependent on an antecedent pathological state. In the primary form the cause is usually some irritating substance which has been swallowed, and which, lodging in the pharynx, produces phlegmonous pharyngitis. The cause is mentioned in 20 cases of the primary form, collated by Allen, as follows : exposure to cold, 10 cases ; lodgement of bone in pharynx, 8 cases ; blow with a fencing-foil, 1 case. In the last case the button of a fencing-foil passed through the right nostril into the pharynx. The secondary form occasionally occurs after measles and scarlet fever. The inflammation of the pharynx common in those diseases extends to the subjacent connective tissue, and, aided by the dyscrasia of the patient, becomes suppurative. The most common cause of the second form is, however, caries occurring in the cervical vertebrae, and it is similar, both as regards cause and nature, to lumbar abscess. It would follow the same chronic course were it not for its proximity to the air-passages, which renders the symptoms urgent and dangerous. In a few recorded cases the abscess was a sequel of erysipelas. In 19 cases of secondary abscess in Allen's collection the cause is assigned as follows : erysipelas of face, 2 ; inflammation following a fall upon the inferior maxilla, 1 ; after cerebritis, 1 ; syphilis, 4 ; caries of the cervical vertebras, 6 ; scrofula, 5. The opinion is expressed by Mr. Fleming l that the suppuration of peri- pharyngeal abscesses begins in a large proportion of cases in the small lymphatic glands which lie in the connective tissue external to the pharynx. The late Prof. George T. Elliott 2 has recorded the case of an infant of seven months in whom abscess immediately followed and was apparently due to parotiditis. 1 Lublin Journ. of Med. Sci., vol. xviii. 2 Obst. Clinic, X. Y. CATARRHAL PHARYNGITIS, ETC. 705 In rare instances, the abscess, or the local disease which leads to it, appears to exist from birth. Thus Dr. E. 0. Hocken relates 1 the history of an infant which died at the age of nine weeks. It had always, when taking the breast, thrown back its head as if nearly suffocated. The walls of the abscess were thick and firm, described by the writer as cartilaginous. Occasionally there is no apparent cause of the abscess except the strumous or cachectic state. Anatomical Characters. — The seat of the abscess is not the same in all cases. The swelling can ordinarily be seen on examining the fauces, but occasionally it is so low as to be really periesophageal, and therefore invisible. The size of the abscess varies : sometimes it is large, pressing inward the wall of the pharynx even against the velum palati, and into the posterior nares if the abscess have a high location, or if lower against the larynx, so as to embarrass respiration. Sometimes the abscess is so large or has such lateral extension that there is external swelling along the side of the neck. In a few cases on record the pus, instead of being discharged into the pharynx, made its way down the neck between the muscles and the connective tissue to the pleural cavity, which it entered, producing fatal pleuritis. The walls of the abscess have been found in a different state in different cases. Sometimes the sac at the projecting point is so thin that it seems as if there might have been a spontaneous cure could life have been preserved a few hours longer. In other cases the sac is so thick and firm that its rup- ture for many days would be impossible, Symptoms. — The precursory symptoms differ in different cases according to the nature of the cause, whether it be phlegmonous pharyngitis or simply adenitis or vertebral caries. If the abscess proceed from caries, it is preceded by deep-seated pain, greatly increased by movements of the head, and prob- ably preceded also by induration along the sides of the vertebrae. The patient with this disease is restless, his mouth hot and dry, tongue furred, deglutition more or less difficult. Sometimes after suppuration has occurred there are alternations of rigors and fever. The symptoms indicate approximately the seat of the inflammation, but on examination we do not find that degree of redness of the mucous surface which we had been led to expect. The tissues which are chiefly involved in the inflammation, being submucous, are hidden from view. We observe redness of the pharynx, but it is disproportionate to the intensity of the symptoms. Some patients fre- quently experience a chilly sensation through the entire period of the abscess, though greater at one time than at another, and occasionally convulsions occur, especially in young infants. In ordinary cases embarrassment of res- piration begins early, and is the cause of the chief danger. It becomes more and more marked as the abscess increases. It is noticed both during inspi- ration and expiration. The dysphagia also increases, sometimes to such a degree that drinks are taken with difficulty and solid foods refused. The respiratory symptoms bear considerable resemblance to those in protracted laryngitis, for which this disease has been mistaken. While the respiration becomes impeded or whistling, the voice is also feeble or indistinct from the pressure of the tumor. But the symptoms described above are not all present in every ease. They vary according to the size and location of the abscess, whether it be high or low, posterior or lateral. I have met the disease in a child old enough to make known the subjective symptoms, in whom there was little or no dys- phagia ; and others report similar cases. When the tumor has attained such a size that it produces well-marked symptoms and jeopardizes the life of the patient, it or a part of it can ordinarily be seen on depressing the tongue. but usually its location and condition can be better ascertained by exploration 1 Prov. Med. and Surg. Joum., 1842. 45 706 LOCAL DISEASES. with the finger. The dyspnoea increases as the abscess enlarges, and after a time, unless it burst spontaneously or be opened by the surgeon, imperfect oxygenation of the blood results. In some patients paroxysms of dyspnoea occur, so as to threaten immediate suffocation ; coughing or attempts to swal- low induce these paroxysms, and the patient is forced to remain in an erect or semi-erect posture ; the tongue is protruded, the head thrown back, the pulse is frequent and rapid, the limbs become livid and cool, and finally death results from dyspnoea. Occasionally, when death seems inevitable, the abscess breaks during the struggles of the child and the patient is restored to health. In rare cases the result is different. The trachea and bronchial tubes are deluged by the purulent discharge and immediate suffocation occurs. The following was an example : In May, 1871, a boy two years and five months old, who had the symptoms of an abscess for three months, was brought to the class at Bellevue. The head was carried on one side, its rotation caused pain, and a laryngeal rale accompanied respiration. The upper part of the tumor could be detected by the finger, but on account of its low location it was impossible to open it with a bistoury. The temperature was 103°, pulse 156. The case remained under observation, but in a few days the dyspnoea suddenly became so urgent that death was imminent, when the attending physician of the class, Dr. Swezey, broke the abscess with his finger and pus was ejected on the floor; death, however, occurred almost immediately. A correct appreciation of the symptoms and nature of peripharyngeal abscess will be best obtained by relating a case. I select the following from the Trans, of the Lond. Pathol. Soc, Oct. 20, 1846: A female infant died at the age of seven months, having had difficult breathing three weeks and extreme dyspnoea during the last days of life. The dyspnoea was constant, and was aggravated by mental excitement, by movements of the body, and by exposure to cold. During the par- oxysms a peculiar croupy sound accompanied inspiration. There was no dysphagia through the entire sickness, and death occurred from apnoea. The sac of the abscess was of the size of a pigeon's egg, and was situated between the upper cervical ver- tebrae and the back of the pharynx. The abscess was flattened in front, so as not to cause any decided prominence of the wall of the pharynx. From the sac a sec- ond small cyst extended forward, forming a nipple-like swelling in the pharynx which completely closed the orifice of the glottis. Its aperture of communication with the body of the abscess admitted the point of the little finger, and the whole swelling was freely movable and perfectly translucent at its extremities and sides. The abscess might have been easily punctured, with probably the preservation of life. The duration of this malady is very different, according to the inflam- mation, the rapidity with which the abscess enlarges, and the direction which it points. A lateral or downward extension is not so immediately dangerous to life as the anterior. The time when the abscess begins to form cannot be precisely ascertained, and most writers in determining its duration compute from the first appear- ance of symptoms which are referable to the pharynx. Dr. J. Byrne l relates a fatal case in which the disease had apparently continued only about one week. The patient was an infant one year old, and its death was from apnoea. The abscess was large, extending from the base of the skull to the thorax and pressing both on the larynx and trachea. M. Besserer 2 gives the his- tory of an infant four months old who died in the same way after thirteen days. An infant nine months old, whose case was published by Dr. W. C. Worthington, 3 lived nine days. The abscess occurred from exposure to cold ; the patient was treated for croup and died from suffocation. The anterior wall of the abscess was very thin. In two cases treated by me the symptoms indicated a continuance of the disease from two to four weeks, and in a third case four months. A fourth case is interesting on account of the short duration of the severe symptoms. The fol- 1 Amer. Journ. of Med. Sci., 1838. 2 Arch. gen. de Med., 1840. 3 Prov. Med. and Surg. Journ. , 1842. CATARRHAL PHARYNGITIS, ETC. 707 lowing is the record of it: M. E , aged seven months, female, nursing, inmate of the^ New York Foundling Asylum, was observed to have difficult breathing for the first time on March 28, 1875. Since about March 8th some swelling had been noticed along the side of the neck, but it gave rise to no marked symptoms, and she had not seemed ill till the obstruction in the respiration commenced. At my visit on the evening of the 28th the infant was pointed out to me as in a dying condition. She was lying in a state of stupor, pallid and gasping for breath, with a tempera- ture of 10*3°. and very feeble pulse, numbering about 200 per minute. On carrying the linger into the throat an abscess could be readily detected situated in the walls of the pharynx, on the left side posteriorly. This was easily opened by a curved bistoury, around which adhesive plaster was wound to within half an inch of the point. The breathing immediately began to improve. On the following day the infant was playing in the mother's lap, with a pulse of 140, but a normal tempera- ture. With the use of cod-liver oil and the syrup of the iodide of iron its health was soon fully restored. In the fifth case the abscess was ruptured by the finger, and in a sixth it was opened by the lancet. All these patients recovered. "When the abscess grows slowly and presses lightly on the air-passages the case may continue for months. Such a one was observed by the late Professor Willard Parker (Allin). This infant was one year old ; it suffered from pharyngeal symp- toms nine months, was treated for tonsillitis, and death occurred as usual from apncea. The abscess was two inches long, and there was no disease of the vertebrae. The same surgeon saved the life of another patient four years old, in whom the disease was protracted, by puncturing the abscess ; the late Professor Post also treated successfully a case which had continued three months (Allin). Diagnosis. — The diagnosis of retropharyngeal abscess is ordinarily easy, provided that the physician examine carefully and bear in mind the occasional occurrence of such an abscess. In a large proportion, however, of the recorded fatal cases the true nature of the disease was not recognized during life. Especially is the diagnosis difficult when the cerebro-spinal system is early implicated and symptoms arise which divert attention from the throat to the brain. The maladies for which peripharyngeal abscess is most frequently mis- taken are laryngitis and simple but severe pharyngitis, From laryngitis, for which it has been most frequently mistaken, it may be distinguished by the dysphagia and by the character of the initial symptoms. In laryngitis there is usually the peculiar cough from the first or very early, while in abscess there is an initial period of several days, or even weeks, before respiration is materially affected. This is the period of inflammation which precedes sup- puration. In abscess, pressure of the larynx backward is badly tolerated, greatly increasing the dyspnoea, while in pharyngitis and croup this effect is not so marked. In abscess the horizontal position aggravates the dyspnoea, but not in pharyngitis and croup. The character of the voice also aids in diagnosti- cating an abscess from laryngitis, since in the former it is usually nasal, and in the latter hoarse and whispering. But the decisive test is afforded by inspection and digital exploration. The tumor is seen — or, if situated too low to be seen is felt — upon the walls of the pharynx. If the symptoms of abscess are masked by those arising from the cerebro- spinal system, as by convulsions, the priority of the pharyngeal symptoms aids in determining the true disease. In a case of suspected abscess the physician should not only carefully inspect the fauces, but should also employ digital examination. The finger will often detect fluctuation before the abscess is apparent to the eye. Prognosis. — With proper treatment the result is usually favorable, but if the disease be not recognized, many die. In Dr. Allin's cases, of those under the age of twelve years, 9 died, while 10 recovered by the opening of the abscess by the lancet, trocar, or finger, and 1 by its spontaneous rupture. 708 LOCAL DISEASES. If the abscess be due to disease of the spinal column, death may occur immediately after the sac is opened, the caries of the intervertebral cartilages producing, according to Dr. Allin, dislocation of the vertebrae. Death may also occur, though rarely, from pleuritis, in consequence of the bursting of the abscess into the pleural cavity. Even in caries, if the sac be properly opened, and if need be reopened, and the head supported by suitable appara- tus, recovery is possible, as in a case treated by Prof. Post. Treatment. — The proper treatment of peripharyngeal abscess is simple, consisting in breaking or puncturing the sac by the finger, the lancet, bis- toury, or pharyngotome. Each method has been successfully employed. In the majority of cases the proper way to open the abscess is by the ordinary curved scalpel or bistoury, which should be covered by a strip of adhesive plaster to within half an inch of the point. If the abscess be postpharyngeal, it should be opened in the median line. A single incision suffices to evacuate the pus. If the abscess point or be elastic, there is little danger of wound- ing any important vessel or producing dangerous hemorrhage if the operation be properly performed, It may be necessary to open the abscess more than once, as in a case reported by Dr. Post and another which I saw with Dr. Livingston of this city. In certain cases, when the knife cannot be readily employed, the abscess may be opened by pressure with the finger-nail or the edge of a teaspoon. At the moment of puncture the child's head should be thrown forward, so as to give free escape to the pus externally. When, as in caries of the cervical vertebrae, the abscess is deep-seated and causes external prominence, it may be more successfully and safely opened by an external incision in the following manner (Chiene) : Commence the incision one inch below the mastoid process, and immediately behind the posterior border of the sterno-mastoid muscle, and extend it about one inch in length, down to and dividing the deep fascia ; with a blunt direc- tor the dissection is continued and the abscess opened, one finger pressing on the wall of the pharynx through the mouth. The pus may be evacuated by pressure on the pharynx. The cavity should be thoroughly cleansed by the douche, using the bichloride solution (1 : 5000). The cavity should not be scraped, but the drain- age-tube should be inserted so as to reach the most dependent place. Recovery is usually entirely satisfactory. Patients with this disease ordinarily require constitutional treatment, especially the use of tonics, ferruginous and vegetable. The citrate of iron and quinine, the citrate of iron and ammonium, and in strumous cases the syrup of the iodide of iron with cod-liver oil, are eligible preparations. Nutri- tious diet and often alcoholic stimulants are required. Swallowing Foreign Substances. The child is very liable to swallow such articles as buttons and pennies which have been given it. Parents are often greatly alarmed, but usually these small round bodies are harmless. It is well to advise giving a large supply of soft food, as bread and potatoes, and after a few days add a dose of castor oil. If the foreign body is thin and pointed, as a pin, needle, fish-bone, bristle, it most frequently sticks between one or other of the pillars of the fauces and the tonsil, or in the mucous folds connecting the base of the tongue with the epiglottis ; if more bulky, it is arrested at or about the junction of the pharynx and the oesophagus. The symptoms of a small pointed body in any of these positions are — local pain, with a pricking, increased on pressure, behind the angle of the jaw ; sometimes there is difficulty or pain in swal- lowing, with a disposition to vomit ; when it is at the upper orifice of the CATARRHAL PHARYNGITIS, ETC. 709 larynx, there may be cough and dyspnoea ; if the body is large, it usually causes death. In every case, instead of wiping the parts roughly with a sponge, make the most careful attempts to discover and remove the body ; if it is small and not detected by the sight or finger, use a laryngeal mirror, requiring the patient to inspire deeply while the tonge is depressed ; when found, seize it with properly curved forceps (Fig. 203). Or, employ the bristle probang (Fig. 204), which must be introduced, closed, below the for- eign body, then spread out and slowly withdrawn. If the obstructing body is food, dislodge it with the finger, or by inverting the trunk, as of a child, and giving to the back in that region a smart blow, or by forcing it down- ward with a probang (Fig. 205). If asphyxia is threatened, perform trach- Fig. 203. Fig. 204. Fig. 205. Pharyngeal forceps. Bristle probang. 19 Probands. eotomy or laryngotomy. If the body is irregular and too firmly impacted to be removed without dangerous violence, open the pharynx, even though severe symptoms are present. Pharyngotomy and cesophagotomy have the same details. If the body passes beyond the pharynx, it is most liable to lodge oppo- Fig. 206. Fig. 207. G.TIEMANN-CO. Probang forceps. Irregular curved forceps. site the cricoid cartilage, or just above the diaphragm, where the tube is most constricted ; if small in bulk, but pointed, as a needle, it may stick in the mucous membrane a long time, or loosen easily by ulceration, or pone- 710 LOCAL DISEASES. trate the walls ; if large, hard, and irregular, deglutition is generally difficult and serious results are early threatened. The diagnosis depends upon the Fig. 208. Right-angled forceps. history. External palpation rarely gives any assistance in ascertaining the presence of a foreign body lodged in the oesophagus ; the tube lies so deep behind the trachea and below all of the muscles of the neck that the hardest and most irregular substances lodged in it can very rarely be appreciated by external examination. Attempt prompt removal ; if the substance be digestible, endeavor to force it onward into the stomach by the probang ; if indigestible, attempt to with- draw it by means of forceps having a suitable curve (Figs. 206, 207, 208). Introduce them, well oiled, with the blades closed, using them as a probe, until the object is reached, when they should be opened and an attempt be made to seize the foreign body ; if successful, the most careful manipulation is necessary in withdrawing it to avoid lacerating the mucous membrane ; if the body is small, use a probang to which a dry sponge is fastened, or a sound to which a skein of silk is attached, so as to form a snare with a great number of loops, or the bristle probang (Fig. 204). These instruments should be passed beyond the obstruction and gently rotated during its withdrawal. Coins and such bodies may often be extracted with a flat blunt hook con- nected by a thin strip of steel to the end of a long whalebone probang (Fig. 209). Vomiting induced by titillating the Fig. 209. fauces or injecting apomorphia into the arm will sometimes dislodge a small body, but if the obstruction is firm, excessive vomit- ing may fix it more firmly or rupture the oesophagus. If respiration is dangerously embarrassed, tracheotomy must be per- formed, and if the obstruction is below the point of operation, a tube must be Hooks for extracting coins. carried down the trachea sufficiently to admit the air to the lungs. When, how- ever, a solid substance, though only of moderate size and irregular shape, has become fixed at the commencement of the oesophagus or low down in the pharynx, and has resisted a fair trial for its extraction or displacement, its removal should at once be eifected by incision into that tube, though no urgent symptoms are present. (Esophagotomy for the removal of a foreign body is not difficult, especially when the body can be located by external pressure : Place the patient, fully anaesthetized, on the back, the head and shoulders slightly elevated and face turned to the opposite side. If the foreign body pro- ject, make the operation at that point ; if not, operate on the left side, to which the oesophagus inclines. Make an incision in the course of the depression between the sterno-mastoid and the trachea, extending from about opposite the upper bor- der of the thyroid cartilage nearly to the sterno-clavicular articulation, through the integument (Fig. 210) ; divide the platysma myoides muscles and the cervical fascia; separate the edges of the wound and draw the omo-hyoid muscle out- CATARRHAL PHARYNGITIS, ETC. 711 Fig. 210. ward or cut it ; divide the outermost fibres of the sterno-hyoid and thyroid to a sufficient extent, 3 ; the carotid sheath, 2, is now fully exposed, and should be drawn outward with the sterno-mastoid and retained ; separate the thyroid body as far as it may be necessary with the handle of the' knife and draw it inward ; now draw the larynx some- what forward, turn it slightly upon its long axis, and pass the finger behind it to discover the position of the foreign body. If it is not found, pass a pair of long curved forceps well down into the pharynx through the mouth, open them so as to press the walls of the tube well toward the wound as a guide, care- fully avoiding the recurrent laryngeal nerve 5 open the tube, 1, sufficiently to admit the finger, and extend the cut upward into the pharynx, 4, or downward along the oesophagus, as may be necessary to reach the object sought; search for the foreign body with the finger, and when found extract it by means of suitable forceps. The wound should not be closed with su- (Esophagotomy. tures. For the first few r days the patient should be fed by the rectum, but later through a tube passed by the mouth below the wound. Stricture of the oesophagus in children is generally due to cicatrices caused by attempts to swallow hot or corrosive fluids. It occurs chiefly on a level with the cricoid cartilage or the bifurcation of the trachea. It may be linear, annular, or tubular, or the cicatrix may embrace only part of the circumference of the tube and thus form a rigid valve-like projection. The leading symptom of organic stricture is gradually increasing difficulty of deglutition, with its concomitant distress and pain. If the patient is thin and the stricture high, it may sometimes be felt externally. To determine its presence and peculiarities, place the patient in a sitting posture, with the head thrown back, and pass an olive-pointed oesophageal bougie along the posterior wall of the pharynx down the tube to the seat of obstruction : the extent and condition of the stricture can thus be made out. The diagnosis in the early period depends upon the history. The treatment of the cicatricial form is by dilatation, cesophagotomy, or oesophagostomy. Dilators are made of different graduated sizes, of hard rubber, cylindrical, tapering at both ends alike, and securely fastened to a whalebone stem (Fig. 211) ; they may be held in the stricture for a Fig. 211. short time at each introduction, giving the benefit of pressure ; the tolerance of these bougies by the oesophagus gradually increases, though their pressure against the larynx may interfere with respira- tion and prevent their long retention within the stricture. Place the patient in a chair with the head thrown back. Now depress the tongue with the finger or a spatula, and, holding the bougie as a pen, pass it along the posterior wall of the pharynx down to the obstruction, and gently insinuate the conical extremity into the contracted passage. Apply the gag to keep the mouth open. The force used should be slight, lest the wall of the tube be per- forated, as has been done. The object is to open the stricture laterally and not push it downward : repeat the operation every second or third day, gradually increasing the size of the bougie as the stricture is enlarged. If the stricture is unyielding and deglutition impossible, gastrostomy must be performed. Sands says : " Gradual dilatation is usually the safest and best mode of treat- ment whenever it is practicable ; it should always be resorted to as a preventive measure in the incipient stage of the disease before cicatrization has occurred : as (Esophageal dilators. 712 LOCAL DISEASES. a rule, treatment should be commenced within a week or ten days of the injury and continued indefinitely." (Esophag ostomy is the establishment of a fistulous opening in the neck for the relief of stricture of the oesophagus. It should never be performed unless there is reason to believe that it will be possible to introduce a tube into the gullet below the seat of stricture. The advantages are that it is attended with little shock and facilitates the subsequent dilatation of the stricture ; the disadvantages are — the doubt whether the opening will be below the stricture, the adhesion of diseased parts to surrounding structures, and the difficulty of operating in the vicinity of large vessels, nerves, and the thyroid gland. The operation is as follows : Place the patient on his back with his shoulders somewhat raised and his head turned toward the right side ; an anaesthetic having been given, standing behind the patient's head, make an incision through the skin oil the left side from just above the sterno-clavicular articulation to about the level of the hyoid bone ; cut the platysma, and if a vein of any size, such as the external or anterior jugular, is met with, divide it between two ligatures and turn aside ; slit the superficial fascia on a grooved director along the line of the original incision, and lay bare the anterior edge of the sterno-mastoid ; the patient's head should then be slightly raised, so as to relax the tissues of the neck, and an assistant should draw aside the sterno-mastoid with a retractor ; the omo-hyoid (which can be recognized by its direction inward and upward) is now brought into view, and should be divided as near to its hyoid insertion as possible ; the carotid sheath is next to be held aside, together with the sterno-mastoid, whilst the trachea is drawn inward by a second assistant ; the connective tissue being torn through with the handle of the knife, the left lobe of the thyroid body should be raised and pushed toward the middle line, when the trachea will be fully exposed, together with the oesophagus behind it. When the tube has been opened, a silk ligature should be passed through each edge of the oesophageal wound, and again through the corresponding lip of the cutaneous incision, and the gullet should be gently drawn toward the surface and loosely attached to the outer wound. A curved tube measuring about three inches in length below and one above the bend, with a suitable shield at its upper extremity, should be introduced into the oesophagus through the wound and fixed in position by means of tapes round the neck. Sutures may be used to bring the edges of the skin-wound together above and below the feeding-tube should this appear desirable. (Esophagitis. Disease of the oesophagus in infancy and childhood is comparatively rare, inflammation being the most frequent affection of this portion of the diges- tive tube in these periods, and, indeed, the only one which claims attention. It is most common in infants under the age of three or four months who are deprived of the breast-milk and are given a diet which is with difficulty digested, and perhaps taken too hot or too cold. It is therefore most com- mon in foundling hospitals. I have frequently observed it in the Infants' Hospital and the Nursery and Child's Hospital of this city, chiefly at the autopsies of bottle-fed infants under the age of six months whose symptoms had indicated disease or derangement of the digestive function. Many of them had diarrhoea and died in a state of emaciation. Oesophagitis in these cases was associated with simple or gangrenous stomatitis, thrush, or with gastritis or entero-colitis. Sometimes all these inflammations coexisted. In a few cases the confervoid growth of thrush had extended from the mouth to the oesophagus. It occurred in small hemispherical masses scarcely as large as a pin's head. Swallowing corrosive or strongly irritating substances, as the acids or alkalies, is an occasional cause of oesophagitis, the irritant at the same time producing stomatitis and gastritis. CATARRHAL PHARYNGITIS, ETC. 713 Anatomical Characters. — The inflamed surface sometimes presents a uniformly injected appearance. Usually, however, there is greater intensity of the inflammation in streaks or patches than over the surface generally. I have frequently observed at autopsies a greater degree of inflammation in the lower than in the upper half of the oesophagus, even when the infant had stomatitis at the time of death. (Esophagitis occurring from faulty regimen or antihygienic conditions is not accompanied by as much thickening of the walls of the tube as often occurs in some other portions of the digestive canal ; as, for example, in the colon. Diphtheritic inflammation of the oesophagus is accompanied by so great infiltration of the mucous membrane and underlying connective tissue that I have seen the oesophageal walls three or four times the normal thickness. Occasionally ulcerations of the oesophageal mucous membrane are observed in the lower part of the tube, and Billard describes the ulcerative form of oesophagitis. At the first autopsies at which I observed these ulcers I sup- posed that they were pathological and indicated a severe grade of inflamma- tion : but a more extended observation has convinced me that they are usually post-mortem, and are not at all dependent on inflammation of the oesophagus. The solvent power of the gastric juice not only causes ulcera- tion in the stomach, but, entering the oesophagus, may and not infrequently does produce a solvent action on the mucous tissue there in the cadaver. At the meeting of the London Pathological Society, March 4, 1852, Dr. Graily Hewitt presented a specimen in which the gastric juice had not only eaten entirely through the coats of the oesophagus an inch above the stomach, but had even attacked the left lung. Over the age of six months inflammation of the oesophagus is rare. The symptoms of oesophagitis in young and emaciated infants, in whom it ordinarily occurs, are not well pronounced, Pain in deglutition or tender- ness on pressure over the oesophagus, if present in these infants, is ordinarily not appreciable, nor have they seemed to me to vomit oftener than other infants of this class who suffered from indigestion and gastro-enteritis with- out oesophagitis. It is therefore difficult to diagnosticate oesophagitis in them. It is, according to my observation, oftener present than absent in spoon-fed infants of three months or under who have persistent stomatitis and entero- colitis. Treatment. — In the oesophagitis of foundlings and ill-nourished infants, which arises, as has been stated, from faulty regimen, no treatment is required apart from that designed to relieve the stomatitis or entero-colitis with which it occurs. Attention must be directed mainly to the diet and hygienic man- agement. The remedial measures proper for such patients are more fully detailed in our remarks on entero-colitis. (Esophagitis produced by swallow- ing corrosive or highly irritating substances requires the same treatment as in the adult — to wit, poultices, demulcent drinks, etc. 714 LOCAL DISEASES. CHAPTER Y. INDIGESTION, CONGESTION OF STOMACH, GASTEITIS, FOLLICULAK GASTKITIS, DIPHTHEKITIC GASTEITIS. Indigestion. Indigestion is more common during infancy than in any other period of life. While the digestive organs in the adult readily assimilate a great variety of food, it is necessary for the well-being of the infant that its diet be simple and carefully prepared. Departure from this rule leads to indiges- tion and ulterior diseases. After the age of two years a mixed diet is readily assimilated, the digestive function is less frequently disordered, and indigestion presents few peculiarities to distinguish it from that of the adult. Indigestion in some children is habitual ; in others the digestive process is ordinarily well performed, but from some temporary derangement of system or error of diet an acute attack of indigestion occurs. Hence, two forms of this ailment may be described ; first, acute, referring to temporary attacks ; secondly, chronic, referring to the habitual state. The subject of the diges- tion in infancy and childhood is treated of in other chapters of this book, to which the reader is referred. In the majority of cases of indigestion the fault does not exist in the child. It is fed too often or irregularly or upon a diet that is unwholesome or indigestible. It is well known that the milk of the mother or the wet- nurse is liable to changes which render it for the time unsuitable for the infant. Her food may be of such a quality, or her mind so excited, or some function of her system so disordered, as to effect a temporary change in the constitution of her milk. The occurrence of the catamenia or of gestation in mothers who are suckling not infrequently produces this unfavorable result. The most common cause of indigestion in the infant is artificial feeding. This, in the cities, is productive of a great amount of gastric and intestinal derangement and disease. The younger the infant the less frequently does it thrive if brought up by hand. Whatever care may be bestowed in the preparation of its food, whether cow's or goat's milk or farinaceous substances be used, there is seldom that healthy nutrition which is observed in infants who receive the breast-milk. The " swill-milk " in common use among the poor families of this city is totally unfit for the feeding of infants, and is apt to cause flatulence, acidity, and indigestion. Acute indigestion occurs in children of any age from food unsuitable in quality or quantity, which produces gastralgia and other symp- toms to be detailed hereafter. Those who suffer habitually from malassimila- tion are especially liable to such acute attacks. In the period of childhood, chronic indigestion is much less frequent than in infancy, but children are perhaps more subject than infants to the acute form. This is induced by ingesta taken in too large quantity or of a kind which is with difficulty digested. Cherries, currants, raisins, and the paren- chyma of oranges and lemons, dried fruits, and confectionery, which are so often heedlessly given to children, are common causes of acute attacks of indigestion. These substances, being but partially digested or not at all, and sometimes accumulating for days in the stomach or intestines, may lead to a very serious and dangerous condition. IXDIGESTIOX, ETC. 715 Symptoms. — Vomiting is a symptom that should always arrest attention and its cause be ascertained. If the child cease to grow and lose its vivacity, the vomiting has pathological significance. Frequent vomiting, without other marked symptoms referable to the digestive apparatus, and with evident loss of flesh and strength, is in most cases a symptom of gastric indigestion or of incipient meningitis. The presence of mucus in the ejected matter, eructation of gas, and the apparent absence of headache and of other menin- geal symptoms apart from the vomiting, aid in establishing the diagnosis of gastric indigestion. The nursing infant, if the milk continually disagree with it, is fretful. It has a discontented aspect ; it seldom smiles, and is not amused by playthings or is only amused for a short time. Its features are pallid and bear the appear- ance of faulty nutrition. Its body and limbs are more or less wasted or are soft and flabby. Vomiting is frequently present, and sometimes a large mass or masses of casein are ejected which have evidently lain a considerable time in the stomach. The bowels may be constipated or loose and the evacuations are unhealthy. This state of the infant, continuing, prevents the necessary rest of the mother, and may affect unfavorably her health, so as to reduce the quantity of her milk or render it still more unwholesome. In habitual indigestion of young children fermentation of the food occurs to a great extent, instead of normal digestion, and the fermentation results in the production of acids. Whatever irritates the gastro-intestinal surface causes an increased secretion of mucus, and it is believed that the mucus, since it is alkaline, prevents to a great extent the digestive action of the pepsin, which requires an acid medium, so that lactic, butyric, and the fatty acids result. This acid fermentation, beginning in the stomach, extends to the intestines as the food is carried downward. Hence the acid breath, sour-smelling ejecta, fetid stools, flatulence, and colicky pains, indicating both gastric and intestinal dyspepsia, so common in young, improperly-fed infants. Habitual indigestion is, as might be expected, more common and severe in artificially fed infants than in those at the breast, and it is more likely to result in gastro-intestinal catarrh. In rural localities, where children are much of the time in the open air, have good constitutions, active digestion, and fresh food, dyspepsia is comparatively rare, but in large cities, in which the conditions of life are so different, its occurrence is common. Gross care- lessness in the feeding, and ignorance on the part of mothers of the dietetic requirements of young children contribute greatly to its frequency. Attacks of acute indigestion not infrequently occur from careless and improper feeding in children who are habitually dyspeptic, as well as in those whose digestive function is usually well performed. In these acute attacks young children, especially infants, often suffer much from colicky pains, gastralgia, or enteralgia. Their countenances indicate suffering ; they utter sharp cries ; their thighs are flexed over the abdomen and moved from side to side. Warm spirituous lotions, friction or gentle pressure upon the abdomen, give some relief, especially if they be attended by the expulsion of flatus. Vomiting or an evacuation of the bowels commonly removes the offen ding- substance, and the pain subsides. Attacks of acute indigestion come on suddenly, and occasionally are so severe that they produce dangerous symptoms, as eclampsia. Apart from pain or a sensation of weight or fulness in the abdomen, symptoms of a reflex character frequently occur, such as headache, drowsiness or languor, sudden twitching of the limbs premonitory of convulsions, and even severe or repeated convulsions. One of the most severe attacks of eclampsia which I have seen occurred in a boy of eight or ten years, induced by swallowing the pulp of 716 LOCAL DISEASES. oranges which he had been in the habit of eating, and which had accumulated in the stomach and intestines. The expulsion of the offending substance gave immediate relief. In some children with acute indigestion the pulse is notably accelerated, the face flushed, the surface hot, and the temperature elevated two or three degrees above normal. As the child advances in years and becomes stronger its digestive func- tion is more active, a greater variety of food can be assimilated, and indi- gestion, whether temporary or habitual, is less frequent than in the first years of life. Prognosis. — Indigestion in the adult, when not due to organic disease, involves little danger to life, but in infancy its consequences are often serious. Habitual indigestion in the infant, whether due to the bad quality of the breast-milk or to artificial feeding, is liable to cause inflammation of the buc- cal, oesophageal, gastric, or intestinal mucous membrane, and in some patients of two or more of these divisions of the intestinal tract. Thus, especially in the warm months, the fermenting products of indigestion often cause dangerous catarrhal inflammation, accompanied by vomiting and frequent stools. Many cases of atrophy in infants, characterized by arrested growth and gradual loss of flesh and strength, till perhaps the features have a sunken and senile appearance from the waste and the skin lies in wrinkles, originate in habitual indigestion. Henoch points out the frequency of gastro-malacia in infants who have suffered from severe dyspepsia accompanied by the abun- dant production of acids. The softening of the stomach is believed to be largely, if not entirely, cadaveric, the result of post-mortem digestion from the presence of pepsin and the acids of fermentation. The gastric mucous membrane can be readily scraped away by the nail, and it presents a gelatini- form appearance. Sometimes even the stomach is perforated and the adjacent organs are acted on by the corrosive liquids. If the dyspepsia have not continued so long as to cause inflammatory complications, prompt recovery is probable by the use of suitable food and corrective medicines. If such complications be present, recovery can only be gradual. Diagnosis. — Habitual indigestion does not usually continue long without the occurrence of more or less gastro-intestinal catarrh. The poor nutrition and appetite, the unhealthy, flatulent stools containing mucus, the vomiting and occasional colicky pains, are symptoms which plainly indicate a dyspeptic origin. Attacks of acute indigestion are also easily diagnosticated, in most instances by the sudden occurrence of the symptoms, such as vomiting, pain in the abdomen or a sensation of fulness, eructation of gas, etc., and the speedy subsidence of symptoms when the cause is removed. But sometimes, especially in children over the age of two or three years, the symptoms may so closely resemble those of other acute diseases that a careful examination is required in order to make a clear and correct discrimination. Thus I have related above the history of a case in which the high temperature and expira- tory moan closely resembled those of pneumonia, but the symptoms quickly abated on the expulsion of a considerable quantity of orange-pulp. An attack of acute indigestion, attended by vomiting, rapid pulse, elevated temperature, with perhaps some erythema, may be mistaken for the com- mencement of one of the febrile diseases to which children are so liable. If on examination of the fauces no redness of the throat be observed, scarlet fever and diphtheria can be excluded. By a free evacuation of the bowels the symptoms abate and the attack ends, so that if there were any doubt in the diagnosis it is soon dispelled. When eclampsia results from an attack of acute indigestion, the physi- INDIGESTION, ETC. 717 cian is often compelled to act promptly without a clear diagnosis, but the result of treatment soon renders the nature of the attack apparent. Treatment. — The first indication in treatment is obviously the removal of the cause. In acute indigestion, when there is reason to believe that there is some offending substance in the stomach or intestines, if the symptoms occur soon after the substance is taken an emetic may be administered, and ipecacuanha, in syrup or powder, is a safe and usually efficient remedy. If several hours have elapsed a purgative should be given, as castor oil, either alone or in combination with syrup of rhubarb, or an enema of glycerin and water may be employed. If the symptoms be urgent, especially if convulsions be threatened, we should not wait for the slow action of a purgative, but should resort at once to an enema to open the bowels. Sometimes the pain in acute indigestion is such as to require immediate treatment. I have found in such cases five to ten drops, according to the age, of the spiritus anisi, a very useful remedy. The following mixture will be found useful in such cases : R. Bismuth subnitrat., ^ij ; Wveth' s elixir of digestive ferments, Jjj ; Aquae anisi, ^iij. — Misce. Shake bottle. Give one teaspoonful every two to three hours if in pain from indigestion. If in the acute indigestion of infants diarrhoea occur, the camphorated tincture of opium, in combination with bismuth and pepsin, may be given. Infants, whose diet consists largely of cow's or goat's milk, digest with most difficulty the casein, which often passes the bowels in an imperfectly digested state, or it collects in a large and firm mass in the stomach, causing gas- tralgia and rendering the child fretful till it is vomited. I have elsewhere recommended, as important to prevent these attacks of acute dyspepsia, the use of the upper third of the milk, which contains less than the average casein. The addition of a little farinaceous food, as barley-water, to the nursing-bottle will sometimes produce the same effect by mechanically sepa- rating the particles of casein. Peptonized milk, as recommended in our re- marks elsewhere, will also be found useful in certain cases, and also the em- ployment of a good preparation of pepsin at each feeding. In chronic indigestion the means of relief are different. They are two- fold : first, as regards change of diet ; secondly, measures to improve the digestive function. Spoon-fed infants, suffering from habitual indigestion, require the utmost care as regards the character of their food, its preparation, and the times of feeding. Often it is best, if practicable, to procure a wet- nurse, and sometimes removal to a more salubrious locality is followed at once by improvement in the digestive function. If the infant be already wet-nursed, the milk should be examined microscopically and otherwise, and inquiry should be instituted in reference to the health and diet of the wet- nurse. Sometimes a change of wet-nurse is advisable. (For facts and con- siderations bearing on this point the reader is referred to the chapters relating to regimen.) Children with chronic indigestion are occasionally much benefited by the moderate and judicious use of alcoholic stimulants. These should be given sparingly with their food, and should be discontinued as soon as the digestive function is fully restored. M. Donne and some other French writers recom- mended the habitual use of wine for infants even in a state of health, but there are reasons, moral as well as physical, why alcoholic stimulants should only be used as medicines and not in a state of health. If the case be one of simple or uncomplicated indigestion, one of the 718 LOCAL DISEASES. pepsin preparations of the shops, and tonics may be employed. In many instances, however, especially in infancy, gastro-intestinal inflammation has supervened, and in such cases those remedies should be employed which exert a favorable — or at least not an unfavorable — effect on the inflamed sur- face over which they pass. In habitual indigestion remedies are obviously required which increase the quantity of the digestive ferments. The following will be found a use- ful prescription in cases of indigestion in which gastro-intestinal catarrh has supervened : R. Acidi hydrochloride dilut., gtt. xvj-xxxij ; Pepsini puri, in lamellis, 3J ; Bismuth, subnitrat., gij ; Syr. simplic, J;ss '■> Aquse destill at. , ^ iij . — Misce. Shake bottle, and give one teaspoonful before each feeding. The lactopeptin of the shops is also useful, and when diarrhoea accom- panies the indigestion the following may be prescribed : R. Bismuth, subnitrat., giij ; Lactopeptin, ,5ij ; Pepsini puri, in lamellis, Jj. Give as much as goes on a five-cent-piece to a child of ten months before each feeding. If the stools continue frothy and offensive on account of the fermenta- tion the following will be found beneficial : R. Salol or resorcin, gr. iv ; Syr. simplic., ^ss ; Aquae destill at., giss. — Misce. Dose : One teaspoonful every two hours to a child of one year. In children over the age of three or four years the vegetable tonics are often useful, as quinine in half-grain or one-grain doses. Iron may also be given, especially the milder preparations, as the citrate, in anaemic cases. Among the useful vegetable stomachics and tonics may also be men- tioned the compound tincture of cinchona, the compound tincture of gen- tian, the infusion of columbo, the fluid extract of columbo, and the fluid extract of cinchona. If chronic indigestion be complicated with gastro-intestinal inflammation, subacute or chronic, for this is the form which is usually present, there are still certain tonics which may be advantageously administered. Columbo and the compound tincture of cinchona are often useful in these cases, and of the chalybeates wine of iron or the citrate of iron and ammonium or the liquor ferri nitratis may be safely administered. In most cases, however, change in the diet properly made will be found more useful than tonic and corrective medicines. Infants affected with diarrhoea from indigestion often improve under the use of powders consisting of equal parts of subnitrate of bismuth and lacto- peptin. An infant of three months can take three grains of each every three hours or before each feeding, or it may take three or four grains of the sub- nitrate of bismuth with half a grain of pure pepsin in scales. Dyspepsia often rapidly disappears by hygienic measures without the use IXDIGESTIOX, ETC. 719 of medicines, as by removal from the city to the country, out-door exercise. In infants also marked improvement is often observed on the approach of the cool and bracing weather of autumn and winter. Congestion of the Stomach. Passive congestion of the stomach is described among the diseases of this organ by Billard, but it is a pathological state of little importance in itself. It occurs in new-born infants asphyxiated at birth and with difficulty resusci- tated. In these cases there is generally intense capillary congestion through- out the system. The mucous membrane of the stomach is injected, but not more than that of the mouth or intestines. If circulation and respiration be fully established, the injection of the capillaries subsides. No treatment is required, except measures to promote the circulatory and respiratory func- tions. In cyanosis and atelectasis there is often general congestion of the capillaries of the systemic circulatory system on account of the obstruction to the flow of blood through the heart in the one disease and through the lungs in the other. There is in these cases passive congestion of the stomach, but not more than of other organs. Gastritis. Inflammation of the stomach, except when produced by the direct con- tact of some irritant, is rare in infancy and childhood independently of dis- ease in some other portion of the intestinal tract. Cases have, however, been reported in which it was not known that any irritating ingesta had been taken, and in which a careful examination revealed a healthy or nearly healthy state of other portions of the digestive tube. The subjects were for the most part young infants. The following is an example related by Billard : An infant, four days old, remarkable for the color of its face and firm- ness of flesh, refused the breast and vomited yellow, acid matter. On the following day the vomiting had increased, the legs were oedematous, face pallid and pinched, respiration difficult, skin cold, pulse slow and irregular, and pressure on the epigastric region produced cries indicative of pain. Third day : general sinking ; face thin and expressive of great pain ; stools natural. Fourth and fifth days : condition the same. Death occurred on the sixth day, and the autopsy was made on the day following. With the exception of slight pneumonia no disease was discovered in any part of the system besides the stomach. The mucous membrane of this organ was intensely vascular near the cardiac orifice and along the lesser curvature. This part was also tumefied, and could be easily raised with the finger-nail. The remainder of the gastric surface was hyperaemic, but to a less extent. This case is interesting as showing what may happen, though rarely. A nursing infant is seized with gastritis without apparently having taken any irritating ingesta and without other diseases of the digestive apparatus. It is probable, however, that in cases like the above the cause, if ascertained, would be found in the ingesta ; perhaps drinks too hot, perhaps elements of colostrum or pathological elements in the milk, which might produce gastritis in young infants, in whom the mucous membrane is delicate and sensitive. Gastritis is not uncommon in infancy in connection with inflammation of the intestines. The latter inflammation is sometimes apparently subordinate to the former, and if such patients die the fatal result is due mainly to the gastric disease. The reverse is, however, the rule. The gastritis is ordinarily subordinate to the intestinal catarrh. 720 LOCAL DISEASES. Cause. — Gastritis, as I have observed it in infants, has been in most cases due in great part to the continued use of improper food — of food not suitable to the age of the child, and which was therefore with difficulty digested. Milk, acid or otherwise unwholesome, farinaceous substances, stale or of an inferior quality and not properly prepared, drinks too hot or too cold, may be specified among the causes. Therefore this disease is most common in bottle- fed infants, and is comparatively rare in those who receive abundant and wholesome breast-milk. Antihygienic agencies, apart from the diet, no doubt exert some influence in the production of gastritis, as they do of stomatitis. Uncleanliness and residence in damp and dark apartments or in an atmosphere loaded with noxious gases produce a condition of system which strongly pre- disposes to these inflammations, if indeed, they may not be enumerated among the direct causes. Eilliet and Barthez have called attention to the fact that certain medicinal substances given to children occasionally cause gastritis. They have observed this effect from the use of tartar emetic, kernies mineral, and croton oil. Gastritis occurring in this way may or may not be associated with inflamma- tion in contiguous portions of the digestive tube. Elsewhere I have related a case in which gastro-enteritis occurred in a child nine years old after having taken a considerable quantity of kerosene oil for spasmodic croup. Inflammation of the stomach is thought by some to accompany measles and scarlet fever during the eruptive period, but this opinion is probably incorrect. If it occur, it corresponds with the stomatitis and dermatitis of these diseases, and disappears as they subside. It is mild and accompanied by few symptoms. I have, as stated in the remarks on Scarlet Fever, exam- ined in certain instances the stomachs of those who have died during the eruptive periods of these diseases, and found them free from any appreciable inflammatory lesion. Age. — From the records of about seventy cases of inflammatory disease of the digestive mucous membrane which I have preserved it appears that gastritis is not common over the age of six months. On the other hand, it is common in infants under the age of three months who are deprived of breast-milk. I have met it chiefly in foundlings fed with the bottle, and hav- ing at the same time entero-colitis, and often also stomatitis and oesophagitis. In these cases there is sometimes continuous or almost continuous injection and thickening of the mucous membrane from the lip to near the pyloric orifice of the stomach, and even beyond this orifice in the intestines. The following is an example of gastritis as it frequently occurs in found- ling institutions : Case. — R. "W , female, two weeks old, was admitted into the New York Infant Asylum, August 24, 1865, anaemic and somewhat emaciated. She was in part wet-nursed and in part bottle-fed. The emaciation increased, and nearly the entire buccal cavity became covered with the confervoid growth of sprue. On September 4th diarrhoea commenced. Borax was used for the mouth and alkalies and astringents to check the diarrhoea, but without material improvement. The following was the record for September 7th : " Cries almost constantly, with feeble or whining voice ; still has thrush ; nurses and does not vomit ; stools five or six daily, and green ; pulse 130, feeble." Death occurred Septem- ber 8th. Autopsy, September 9th. — Mouth and fauces not examined ; mucous membrane of oesophagus vascular in its whole extent, with slight thickening, but without ulceration ; mucous membrane of stomach hyperaeniic, like that of the oesophagus, and somewhat thickened, except in its pyloric extremity, where the appearance was natural or nearly so ; the color in the central part of the inflamed gastric membrane was deep red ; no thrush was noticed except on the buccal surface during life ; along the great curvature of the stomach were white flakes resembling those of thrush, but which were found by the microscope to consist mainly of oil-globules INDIGESTION, ETC. 721 and epithelial cells, -without the cryptogamic formation ; mucous membrane of small intestines healthy in its whole extent, except slightly increased vascularity in a few places in the ileum ; mucous membrane of colon much injected throughout, except near the ileo-caecal valve, where the vascularity was slight; in the trans- verse and descending colon the redness was pretty uniform, and the membrane was thickened, but not ulcerated ; solitary glands and Peyers patches moderately elevated. The observations of Valleix show how frequently gastritis is associated with severe attacks of thrush. In 23 of his cases of the latter disease in which the condition of the stomach was noted after death this organ pre- sented inflammatory lesions in 17, and in 3 others appearances which may or may not have been due to inflammation. Symptoms. — A difficulty exists in isolating and defining the symptoms of gastritis, from the fact that it commonly coexists with other inflammations of the digestive tube. Though we may never be able to diagnosticate this catarrh as certainly as we can croup or pneumonia, still there are symptoms which arise directly from the gastritis, and with care we may be able to dis- tinguish them from those symptoms which are due to other pathological states. If gastritis be acute, pain is present. In the above case from Billard, as well as in a case observed by myself and related under the head of Gelat- inous Softening, there were frequent cries, and the countenance indicated much suffering until the stage of collapse. If there be less intensity of inflammation and the disease be more protracted, as is ordinarily the case, the pain is not so severe, and it may be so slight as not to attract attention. Sometimes there is tenderness, so that pressure upon the epigastric region is badly tolerated. Vomiting is regarded as one of the most constant symp- toms. The infant after nursing seems in distress till the milk is vomited, but it nurses with avidity in consequence of the thirst if it be not too exhausted or feeble. The dejections may be quite regular throughout the disease, as in the case from Billard. There is ordinarily, however, diarrhoea from the presence of entero-colitis. The pulse is sometimes accelerated and sometimes nearly natural. The emaciation in gastritis is rapid, since not only the nutri- ment is in great measure vomited, but the digestive function, so far as the stomach is concerned, is seriously impaired. The features become wrinkled and senile, the eyes hollow, the limbs attenuated, and the cranial bones uneven. Death occurs from exhaustion. Anatomical Characters. — Simple gastritis may affect the entire mucous surface of the stomach or be limited to a certain part. The part which is most likely to escape is that toward the pyloric orifice. This portion of the organ is sometimes found in nearly or quite the normal state, while the cardiac half or two-thirds is inflamed. The vascularity of the diseased surface is not uni- form. In one place there is simple arborescence ; in another intense continu- ous redness ; and between these two extremes are different grades of vascu- larity. The mucous membrane is somewhat thickened, softened, and the secretion of mucus increased. Extravasation of blood is not infrequent under the mucous membrane, usually in points, and the mucus may be mixed with more or less blood. Small shreds or portions of coagulated milk are often found with the mucus attached to the gastric surface. I have observed, though rarely, small superficial ulcers at the point where the inflammation had been most intense. Dr. A. Jacobi says : ' ; Indeed, the boundary-line between a simple dys- pepsia and a gastric catarrh is perhaps never made out clearly. The epithelium of the mucous membrane does not belong to it exclusively, but spreads in the contiguity of the tissues into the muciparous and the peptic glands. Thus 46 722 LOCAL DISEASES. the inflammatory condition of the surface becomes at once a parenchymatous affection, though it be possible that an uncomplicated catarrh and an uncom- plicated inflammation may have an occasional existence Unless a gastric catarrh or a dyspepsia .... be relieved at once, the merely func- tional or superficial disorder becomes organic and deep-seated. These changes may refer either to the tissue or the secretion. Inflammatory thickening, erosions, ulcerations, or (Moncorvo) dilatation of the stomach will be observed in a great many instances. The secretions become abnormal ; the normal hydrochloric acid of the gastric juice is almost invariably diminished Lactic acid, however, is produced in much larger quantities than the first stage of digestion requires, and with it acetic, butyric, and the rest of the fatty acids." Diagnosis. — In protracted cases, when entero-colitis is present, it is dif- ficult to make a positive diagnosis. Our opinion must then be little more than a plausible conjecture. In the acute attacks we can diagnosticate the gastritis with more certainty. If a young infant affected with sprue be seized with pain, and vomits often ; if emaciation be rapid and there be no diarrhoea, or diarrhoea not sufficient to account for the prostration ; if the buccal mucous membrane, dotted with the points of thrush, presents a dry appearance and the deep-red color of severe stomatitis, — there can be little doubt of the presence of gastritis. The diagnosis is rendered more certain by signs of tenderness when pressure is made upon the epigastric region. Prognosis. — like other inflammations, gastritis is probably sometimes so mild that it does not materially increase the suffering or danger of the child. This mild form of the disease under favorable circumstances soon subsides. In other cases, by the continuance or increase of the cause, the inflammatory process becomes more severe and extensive, resulting even in disintegration of the mucous membrane. Those cases are especially severe and likely to end fatally which are protracted and accompanied by severe thrush, with a desiccated appearance of the buccal surface or with entero- colitis. Pain, vomiting, and rapid emaciation in such children indicate the speedy approach of death. Improvement in the stomatitis or entero-colitis is a favorable indication, but these inflammations may improve without cor- responding improvement in the gastritis. Treatment. — All food or drinks except those of a bland and unirritating nature should be forbidden. If practicable, the young infant should have the mother's milk or that of a wet-nurse. If this be impossible, the reader is referred to the chapter on Infantile Alimentation for advice in relation to the feeding. Death occurs from exhaustion, and it is therefore important that the vital powers be not reduced. To relieve the thirst, and at the same time sustain the child, I have found half a teacupful of carbonic-acid water, Vichy water, or plain water, mixed with one teaspoonful of the liquid peptonoids of the Arlington Chemical Works or of Fairchild's panopepton, agreeable and useful to the patient. Follicular Gastritis; Diphtheritic Gastritis. The pathological character of follicular gastritis is similar to that of fol- licular stomatitis. It is an inflammation affecting the gastric follicles and ending in their ulceration. It is not a frequent disease ; it occurs in young infants. Billard observed fifteen cases. The symptoms in these patients were similar to those in simple gastritis of a severe form. The emaciation and prostration were rapid, and death occurred early. We can only diagnos- ticate the gastritis without determining its follicular character. How many recover it is impossible to ascertain, but the disease is likely to be fatal on GASTRO-IXTESTINAL BACTERIA. 723 account of the intensity of the inflammation, not only of the follicles, but of the intervening mucous membrane. The treatment is that of gastritis. Diphtheritic gastritis is infrequent. It occasionally occurs during epi- demics of diphtheria. Allusion is elsewhere made to a case treated in the Nursery and Child's Hospital of this city in December, 1859. The patient, eighteen months old, had had previously protracted entero-colitis, and died exhausted after a brief attack of diphtheria. There were lesions referable to the entero-colitis, and the body was much emaciated. The diphtheritic exudation was found covering the fauces, epiglottis, glottis to the rim a glot- tidis. the entire oesophagus, and almost the entire stomach. The mucous surface underneath was injected; that of the oesophagus and stomach espe- cially was very vascular, softened, and thickened, and the submucous connec- tive tissue was infiltrated. The pseudo-membrane taken from the epiglottis and examined under the microscope presented an amorphous appearance ; no cells were noticed in it, and fibrillation was not distinct ; that from the stomach was found to consist almost entirely of cells. The digestive process, so far as the stomach was concerned, had evidently been almost if not entirely suspended, and hence in part the sudden prostration. Diphtheritic gastritis probably does not occur without general infection of the system with the diphtheritic virus. The proper treatment is the use of one of the solvents of pseudo-membranes which do not irritate the mucous membrane, while the constitutional treat- ment proper for diphtheria is employed. Dilatation of Stomach. The stomach may undergo abnormal dilatation, according to Dr. A. Jacobi, from overfeeding with bulky, especially amylaceous, food ; from diminished contractility in its muscular coat consequent on debility ; from imperfect digestion and flatulence ; from catarrhal gastritis and peritoneal adhesions. In its treatment he recommends medicines (as bismuth) which diminish fermentation, the avoidance of fats and starches and of large quan- tities of fluid ingesta. Milk may be given in small quantities and often. Raw beef, beef peptones, and peptonized milk are useful, as is also an abdominal binder. Faradic and galvanic currents have been used with some advantage, and the tincture of nux vomica or strychnia, gr. T l^ to T -l~g-, three times daily, will increase the contractility of the muscular coat of the stomach. 1 CHAPTER VI. GASTRO-INTESTINAL BACTEEIA. Recent investigations have demonstrated that these organisms sustain an important causal relation to the indigestion, malassimilation, and diarrhceal diseases of infancy. They are minute unicellular bodies, and are classified as follows : first, the micrococci, or globular bacteria ; secondly, the bacilli, or rod-shaped bacteria ; and thirdly, the spirilla, or spiral bacteria. The pathogenic character of these bodies has been to a considerable ex- tent elucidated by the microscopic examinations and experiments of several European scientists, prominent among whom is Escherich, and by the inves- tigations of Booker and Vaughn in America. 1 Arch, of Pediatrics, Aug., 1889. 724 LOCAL DISEASES. Bacteria are not present in the stomach and intestines in the foetus, nor in the meconium at birth. They are conveyed to the digestive tract of the newly-born through the air and saliva and the liquid ingesta. and it is believed that they sometimes obtain entrance through the anus, for they have been found in the meconium three to seven hours after birth (Esch- erich). When the meconium is expelled the bacteria which it contains disappear, and other species subsequently take their place in the milk-feces. The feces of healthy nurslings contain a larger number of bacteria, of which the bacterium lactis aerogenes and bacterium coli commune are uniformly present. According to Booker, in the healthy suckling the stomach contains few bacteria, chiefly bacilli ; the duodenum also contains but few ; but they increase in number on tracing the intestine downward. On reaching the lower end of the upper third of the small intestine, we find a considerable number of bacteria, including diplococci, bacteria lactis aerogenes, and colon bacteria. The bacteria lactis aerogenes undergo no farther increase in the lower part of the small intestines and in the colon, but the colon bacteria (bacterium coli commune) undergo a great increase in number in the lower part of the ileum and in the colon. They exist in large numbers in the entire length of the colon, and of larger size than in the small intestine. The bacterium lactis aerogenes occurs in the form of " short, thick rods, with rounded ends." Injected into the blood of guinea-pigs and rabbits, it causes death, preceded by the phenomena of intestinal catarrh. The bacterium coli commune is believed to be always present in feces, whatever the diet. It is also rod-shaped, and it varies in size and length, the largest and longest specimens attaining the length of five micro-millimetres. According to Booker, both these microbes promote fermentation in the intestines. Many other forms of bacteria have been discovered in the milk-feces of infants, in addition to the two which we have described. Escherich discovered twelve varieties^ micrococci and bacilli. To the physician the gastro-intestinal bacteria are mainly interesting on account of the supposed causal relation which they sustain to certain abnor- mal conditions of the digestive tract, especially to the diarrhoeal affections. It is important in investigating this subject to ascertain what bacteria are present in normal feces, and whether they exert pathogenic action under cer- tain circumstances. This has been, in a measure, ascertained, as we have seen, but another interesting and important inquiry relates to new forms of bacteria that appear in the feces in diseased conditions of the stomach and intestines, and the causal relation which they bear to these conditions. New forms of bacteria may appear in the feces in gastro-intestinal disease without sustaining a causal relation to it or influencing it. Again, although not causing the disease, they may influence its course and duration, or they may cause gastro-intestinal disease by lodging in the food, especially in milk, and producing by their agency poisonous chemical substances in it before it is employed in the nursery. The well-known poisoning by the tyrotoxicon in the hotels at Long Branch, this poison being produced in milk probably by microbic action six or eight hours after the milking, was an instance of this kind. Again, a species of bacteria not occurring in the stools in health, but appearing in disease, as in indigestion, inanition, or diarrhoea, may be the chief factor in causing this morbid state. According to Booker, none of the gastro-intestinal secretions have an inju- rious effect on bacteria, except the gastric juice, but certain bacteria are antagonistic to others, so that their presence prevents the full development of the latter. Bacteria, which in the normal state of the gastro-intestinal tract do not find a soil suitable for their development in the stomach or GASTRO-ISTESTINAL BACTERIA. 725 intestines, obtain the conditions favorable for their growth and propagation in diseased states, as when indigestion or catarrh is present. The pathogenic action of bacteria in the digestive tract can be most suc- cessfully investigated by experimenting with them when they have been iso- lated from other substances by repeated cultivations. Hay em and Lesage have isolated a bacillus which they have discovered in green stools of infants, and which they believe produce by its disturbing action the green color and abnormal state of the stools. The green color in the feces of infantile diar- rhoea they believe to be sometimes due to an excess of the bile-pigment, but in other instances is produced by the action of a bacillus, which occurs especially in the upper two-thirds of the small intestine, where it attains the length of two (o three micro-millimetres. Injected into the blood of sucking animals, this bacillus appeared in the duodenum ten or twelve hours subsequently, and, increasing in number, caused green discoloration of the intestinal contents. The same result was produced when this microbe was administered in the ingesta. In its dry state it floats in the air, so that when an infant having green stools produced by its action enters a ward, others are liable to be attacked with the green diarrhaea if its soiled diapers are allowed to dry in the room. Baginsky has investigated the stools in the acid diarrhoea of infants, and has isolated two forms of bacteria which liquefy gelatin. One of these pro- duces green coloring matter, and is probably the same as that described above ; the other was constantly present in the acid diarrhoeal feces, was poisonous to animals, and it is probably impotent in the pathogenic role. Baginsky believes from his observations that the bacterium lactis aerogenes present in the normal stools of the suckling is under favorable circumstances antagonistic to the development of pathogenic organisms. Dr. Booker has isolated forty bacteria from the stools of 30 infants, all seriously sick with diarrhoeal diseases, 11 having cholera infantum, 14 catarrhal enteritis, and 5 dysentery. The largest number of these organisms occurred in cases of cholera infantum, and the next largest number in cases of catarrhal entero-colitis. According to Booker, the bacteria of the normal milk-feces still appear in the diarrhoeal stools. The bacterium coli commune was found by him in all the diarrhoeal cases, but its number appeared to diminish according to the severity of the attack. On the other hand, the bacterium lactis aerogenes occurred in larger number in the diarrhoeal stools than in healthy milk-feces. Booker discovered bacteria of the proteus group in 7 of the 11 cases of cholera infantum ; which is a matter of significance, inasmuch as Escherich did not find any bacterium of this group in normal milk-feces. In a very interesting and instructive paper read before the American Pediatric Society in June, 1890, Dr. Victor C. Vaughan detailed his experi- ments, which showed that " three micro-organisms, differing sufficiently to be recognized as different species, produce poisons, all of which cause vomit- ing and purging, and, when used in sufficient quantity, death" in cats and dogs experimented on. Dr. Vaughan concludes his paper with the following aphorisms : " 1. There are many germs, any one of which, when introduced into the intestine of the infant under certain favorable circumstances, may produce diarrhoea. 2. Many of these germs are probably truly saprophytic. 3. The only digestive secretion which is known to have any decided germici- dal effect is the gastric juice. Therefore, if this secretion be impaired, there is at least the possibility that the living germ will pass on to the intestine, will there multiply, and will, if it be capable of so doing, elaborate a chemical poison, which may be absorbed. 4. Any germ which is capable of growing and producing an absorbable poison in the intestine is a pathogenic germ. 726 LOCAL DISEASES. 5. The proper classification of germs in regard to their relation to disease cannot be made from their morphology alone, but must depend largely upon the products of their growth." CHAPTER VII. SIMPLE DIARRHOEA. Diarrhcea is frequent during the whole period of infancy. French writers describe several varieties, according to the character of the evacuations, as acescent, mucous, and serous. M. Rostan even describes fourteen distinct kinds. But the tendency of medical science in modern times is to simplify the nomenclature of diseases — to describe under a single name those affections which are essentially the same, though differing somewhat in their features. Now, all the forms of diarrhoea in the infant may be so grouped as to reduce the number to not more than three or four. In this way repetition and prolixity are avoided, as well as an unnecessary refinement. The most common form of diarrhoea is that enunciated in our heading. But often a diarrhcea which is non-inflammatory at first becomes a catarrh. Thus the simple diarrhoea of infancy may become an entero-colitis from the continued use of improper diet. Causes. — These are various. Conditions or agencies which have no appreciable effect in the adult often increase the number of evacuations in young children. Food which imperfectly digests, and some of which perhaps ferments, stimulates the intestinal follicles to excessive secretion, and increases the peristaltic movements by its irritating action, thus causing diarrhoea. Too frequent and abundant feeding is another cause, especially in young infants, some of whom may vomit the surplus food and remain well, but others do not. Food which cannot be assimilated becomes an irritant in consequence of fermentative change, and produces frequent and unhealthy evacuations. In the light of our present knowledge we assign to the agency of intestinal bacteria an important causal relation to those forms of diarrhoea which are attended by fermenting, imperfectly-digested, and unhealthy stools. By the investigations of Booker and others it is now known that many forms of bacteria exist in the stools, and when abundant excite the vermicular and peristaltic movements so as to excite more abundant evacuations. The mother's milk or the milk of the wet-nurse may disagree, either from some temporary derangement of her system or continued ill-health, or from causes which are not understood. Diarrhoea in the nursling is the result. Fright or strong mental impressions will also in some children increase the number of evacuations. This cause being transient, the diarrhoea soon subsides. Another cause is exposure to cold. Children who are insufficiently clothed in the winter season, who are taken from a heated room into a cool one with- out sufficient protection, or who lie uncovered at night are very subject to diarrhoeal attacks from the impression of cold on the system. The cause of simple diarrhoea may exist in the child itself. In some children the evolution of the teeth is attended by a relaxed state of the bowels, which ceases when the gum is pierced, but whether it is a cause of the diarrhoea we are not prepared to state. Worms in the intestines may SIMPLE DIARRHCEA. 727 also operate as a cause. Diarrhoea is occasionally salutary within certain limits, and of course it is not strictly correct to call it a disease when it is a means of relief. If occurring from excessive or irritating ingesta, it is obviously conservative. Symptoms. — Diarrhoea may come on suddenly ; at other times there are precursory symptoms continuing for some days. Whether or not there be antecedent symptoms depends chiefly on the cause. If this be exposure to cold or the use of improper aliment, it commonly occurs immediately. Among the prodromic symptoms sometimes present are restlessness, dis- turbed sleep, transient abdominal pains, nausea or vomiting, and other symp- toms of indigestion. The stools in simple diarrhoea differ much in color and consistence in different cases, and perhaps at different periods in the same case. In infants they are often green. This color, which is a source of anxiety to the inexperienced, and especially to the parents, is often produced by trivial causes. Slight indigestion will produce it, and so will excess of food, even when bland and unirritating. We have already stated that a cer- tain microbe has the power to produce the green color. The stools in infantile diarrhoea often contain particles of coagulated casein, but in children advanced beyond the period of first dentition they do not differ materially in appearance from the evacuations of the adult. They are usually passed easily, but if they be acid or in any way irritating there may be more or less tenesmus, especially in infants. Sometimes before the evacuations there is a sensation of fulness in the abdomen. In that form of diarrhoea which has been desig- nated acescent not only are the stools acid, but matters vomited have an acid odor and give an acid reaction. During the quiet hours of sleep, when no foods and drinks are taken, the diarrhoea diminishes. If the complaint be slight, there is little thirst ; but if the stools be frequent and thin, especially if they approach the watery character, the patient is thirsty. The appetite varies, the tongue is moist and covered with a light fur, and there is often more or less meteorism, but no abdominal tenderness. The features in this disease are pallid. In a few days, if the evacuations continue, there is evident loss of weight and flesh. The rotundity of the limbs is gradually lost and the tissues become soft and flabby. But in most cases when the malady has reached this stage its original character is lost, and it has become inflammatory. Certain epiphenomena, as Barrier terms them, occur at times in non- inflammatory as well as in inflammatory diarrhoea ; as, for example, a sym- pathetic cough or, which is more serious, cerebral complications. Convul- sions or stupor, indicating the supervention of spurious hydrocephalus, may occur in either form of diarrhoea. This disease is described elsewhere. More or less fever may occur in simple diarrhoea, but it is not constant and the pulse may or may not be accelerated. Anatomical Characters. — It is obvious from the nature of simple diarrhoea that it is attended by little or no perceptible anatomical change. In cases supposed to be simple or non-inflammatory, which have ended fatally either from the diarrhoea or an intercurrent disease, the most marked lesions observed have been more or less tumefaction of the intestinal glands, with perhaps diminished firmness and resistance of the mucous membrane. Cases like the following, which have usually been regarded as non-inflammatory, are not infrequent, but it seems probable that in at least a certain proportion of such cases the intestinal follicular apparatus has passed beyond the physiological state of an exaggerated functional activity, and that the dis- ease should be designated a catarrh or inflammation. Inasmuch as non- inflammatory diarrhoea, if protracted, is very liable to become inflammatory, 728 LOCAL DISEASES. it is often difficult to determine whether the malady has undergone this change, even with the aid of post-mortem inspection. On the 7th of July, 1865, a foundling one month old died at the Infant Asylum. It was much emaciated, with eyes sunken and features pinched, at the time of its death. It was wet-nursed to the close of its life, but the nurse's milk was insufficient. It did not vomit, did not have any marked acceleration of pulse (128 per minute), and its evacuations were about four daily, and thin. The stomach and intestines were pale throughout. The solitary glands, particularly those in the colon, and the patches of Peyer were tumefied so as to be visible and somewhat raised above the surround- ing surface. But no lesions being observed which are characteristic of inflammation, the disease was regarded as non-inflammatory. Niemeyer, with others, describes even the mildest forms of diarrhoea under the term catarrhal inflammation, and he appears to consider the transient effects of a purgative as an incipient catarrh. But it seems to me prefer- able, in the present state of pathological knowledge, to regard all those diar- rhoeas which immediately abate with the removal of the cause, and which are attended by no marked anatomical change, as non-inflammatory or simple. They are characterized by increased secretion of the intestinal follicles and increased peristalsis. Prognosis. — In a large proportion of cases simple diarrhoea is not dan- gerous. With the adoption of suitable measures to remove the cause and the use of medicines to control the discharges the patient recovers. The remark already made may be repeated here, that occasionally diarrhoea is salutary within certain limits, as when there is a foreign substance in the intestines either irritating mechanically or by its chemical properties, and which the diarrhoea serves to remove. The danger arises from complications, as spurious hydrocephalus, or from the emaciation and exhaustion, or from its eventuating in inflammation. If the rotundity of the figure and firmness of the tissues be preserved, showing that alimentation is still sufficient, and no complication arise, the diar- rhoea is not as a rule dangerous. In infants that over-nurse and do not vomit the surplus milk, the evacuations are sometimes green and frequent, and yet fulness of figure is preserved and the development of the body proceeds as usual. On the other hand, diarrhoea attended by emaciation or softness or flabbiness of the flesh involves danger and requires immediate treatment. Treatment. — It is necessary, in order to treat diarrhoea in infancy and childhood successfully, to ascertain the cause, and, as far as possible, to remove it. It is not till the cause ceases to operate that we can expect a satisfactory result from medication. The disease may be temporarily relieved by medicine, but it usually returns at once when treatment is omitted, unless the patient be removed from the influence of the agencies which produce it. These remarks are especially applicable to the diarrhoea of infants. With them very generally, when affected with this complaint, there is some fault as regards the quantity or quality of food. Attention to this matter will show the need of a change of wet-nurse, or, if the infant be spoon-fed, a change in the character of its food or in the mode of preparation, or even in the quantity given. Sometimes by change in the diet and the adoption of hygienic measures the complaint ceases, so as to require no medication. Sometimes the temporary abstinence from milk-food, and the employment of barley gruel in its place or the use of barley gruel and peptonized milk, or, better, barley gruel mixed with the white of an egg, added to a little cold water and beaten in a saucer five minutes, suffice to cure the diarrhoea, If medicines be needed and the symptoms are not urgent, it is occasionally advantageous to commence treatment by the use of one of the milder purga- SIMPLE DIARRHCEA. 729 tives in a small dose. In the in/ant, in whom the dejections are so generally acid, an alkaline laxative or a laxative conjoined with an alkali often has a good effect as preliminary treatment. Half a teaspoonful to one teaspoonful of castor oil or a proportionate dose of calcined magnesia removes any acid or irritating snbstance from the intestines, and is followed by a diminution in the number of stools. The improvement, however, without subsequent treat- ment is usually only for a day or two. A purgative dose of castor oil is often given as a domestic remedy in infantile diarrhcea, the beneficial effect from it having popularized its use for this purpose. Trousseau usually gave Eochelle salts, but this medicine is too severe and dangerous for the treat- ment of infantile diarrhcea, especially in warm months. If there have been previous constipation and the diarrhcea have just com- menced, a purgative is obviously indicated. West says : " Provided there be neither much pain nor much tenesmus, and the evacuations, though watery, are fecal and contain little mucus and no blood, very small doses of the sulphate of magnesia and tincture of rhubarb have seemed to me more useful than any other remedy : R. Magnesiae sulphatis, £j ; Tinct. rhei, 3j ; Syr. zingiberis, 3J 5 Aquae carui, gix. — Misce. Dose, 3J three times daily for a child one year old. I seldom fail to observe from it a speedy diminution in the frequency of the action of the bowels and a return of the natural character of the evacuations." Since many cases of simple diarrhcea are due to the use of food which does not readily digest, but undergoes in part fermentation, the food should be carefully selected and prepared according to the directions given in the chapters relating to artificial feeding. In cases of fermentation, due often to microbic agency, the digestion is very imperfect, and the diarrhcea which results is often best treated, so far as medicines are concerned, by the use of pepsin and bismuth subnitrate, as ten or fifteen grains of pepsinum sac- charatse and bismuth subnitrate given at each feeding. In the simple diarrhcea of infants the compound powder of chalk and opium is sometimes a good remedy, combining as it does an astringent with the opiate and alkali. It may be given in doses of three grains to a child one year old every three hours midway between the feedings. The follow- ing is a convenient formula for administering substantially the same medi- cines in the liquid form : R. Tinct. opii deodorat., gtt. xvj ; Bismuth, subnitrat., gij ; Wyeth's elix. of digestive ferments or Fairchild's essence of pepsin, ^ss ; Aquae, ^iss. — Misce. Shake well, and give one teaspoonful every three hours between the feedings. If the patient be not relieved by the opiate, digestive ferment, and bis- muth, and by proper regimen, in all probability inflammation of the intes- tinal mucous membrane is present. In patients over the age of two or three years simple diarrhcea approaches in character that of the adult, and the treatment appropriate for the adult is proper in these cases, allowance being- made for the difference in age. In infants, in whom this disease, if pro- tracted, very soon becomes an undoubted entero-colitis, attended if it be pro- 730 LOCAL DISEASES. tracted by emaciation and weak heart, stimulating digestive agents are often required at an early period on account of the prostration and feeble power of endurance. CHAPTER VIII. INTESTINAL CATAKKH OF INFANCY (ENTEKO-COLITIS). It is customary with writers to treat of inflammation of the small and large intestines in infancy as a single disease, for the following reasons: First, the symptoms of colitis at this period of life do not ordinarily differ,, in any marked degree, from those of enteritis. The tormina, tenesmus, and abdominal tenderness which characterize colitis in childhood and adult life are ordinarily lacking or are not appreciable by the observer, and the niuco- sanguineous evacuations are oftener absent than present. On account of this absence of symptoms Bouchut says : " Dysentery is a very rare disease among young children. Its existence might even be denied if it had not been observed at the period of some severe epidemics of dysentery." If Bouchut refers by the term " dysentery " to the ordinary phenomena of that disease, his remark is correct ; but as regards the lesions it is erroneous, for colitis is a common infantile malady. Billard, after analyzing eighty cases of intestinal inflammation in infants, says : " From this calculation it is evidently very difficult to make a correct diagnosis of inflammation of the intestinal tube in suckling infants, yet it would seem as if the proper signs of enteritis or ileitis were the rapid tympanitis of the abdomen, the diar- rhoea, accompanied with vomiting ; while in colitis, diarrhoea alone, without tympanitis, is the most frequent." And again : " In consequence of the impossibility we have found to exist of tracing with exactitude the series of symptoms proper to inflammation of the different portions of the digestive tube, we shall content ourselves with presenting an analytical sketch of the causes, symptoms, and ordinary course of inflammation of the mucous mem- brane of the intestines in general." The frequent absence of any pathognomonic symptom or sign by which to determine the exact seat of intestinal inflammation in the infant is admitted by recent observers as well as Billard. The second reason why intestinal inflammation in the infant is described as a single disease is, that enteritis and colitis in the majority of cases coexist. This will be seen when we come to speak of the anatomical characters. In rural districts infantile diarrhoea is not so prevalent and fatal as in cities. In the farming sections it does not materially increase the death-rate,, and it is therefore not so important a malady as in cities. In cities it largely increases the aggregate of deaths. Especially fatal is that form of it which is known as the summer epidemic, as is seen by the mortuary records of any large city. Thus, in New York City during 1882 the deaths from diar- rhoea reported to the Health Board, tabulated in months, were as follows : Jan. Feb. Mar. Apr. May. June. July. Aug. Sept. Oct. Nov. Dec. Under five vears . .34 32 50 50 72 231 1533 817 362 195 68 35 Over five years. . . 14 15 14 20 15 19 131 149 84 55 31 24 It is seen that in 1882 in New York City the deaths from diarrhoea under the age of five years were greatly in excess of the number during the whole period of life subsequently to that age. INTESTINAL CATARRH OF INFANCY. 731 The following statistics show how great a destruction of life this malady causes even under the surveillance of an energetic Health Board ; and before this Board was established it was much greater, as I had abundant opportuni- ties to observe. The last annual report of the New York Board of Health was made in 1875, since which time weekly bulletins have been issued. The deaths from diarrhoea at all ages in the last three years in which annual reports were issued were as follows : 1873. 1874. 1875. January - - 94 43 46 February 84 34 52 March * 93 40 58 April 114 47 45 May 95 61 89 June 220 144 157 July 1514 1205 1387 August 967 1007 1012 September 424 587 608 October 213 255 185 November 87 105 57 December 53 56 50 In its annual report for 1870 the Board states : ." The mortality from the diarrhceal affections amounted to 2789, or 33 per cent, of the total number of deaths ; and of these deaths, 95 per cent, occurred in children less than five years old, 92 per cent, in children less than two years old, and 67 per cent, in those less than a year old." Every year the reports of the Health Board furnish similar statistics, but enough have been given to show how great a sacrifice of life infantile diarrhoea produces annually in that city. What we observe in New York in reference to this disease is true also, to a greater or less extent, in other cities of this country and Europe, so far as we have reports. Not in every city is there the same proportionate mortality from this cause as in New York, but the frequency of infantile diarrhoea and the mortality which attends it render it an important disease in, I believe, most cities of both continents. In country towns, whether in villages or farm-houses, this disease is comparatively unimportant, inasmuch as few cases occur in them, and the few that do occur are of mild type, and consequently much less fatal than in cities. The comparative immunity of rural districts has an important relation, as we will see, to the hygienic management of these cases. Etiology. — The intestinal catarrh of infants is occasionally produced by taking cold. Infants insufficiently protected by clothing and exposed to sudden changes of temperature or to currents of air in the apartments where they reside, or heedlessly exposed out-doors by careless nurses, some- times become affected with diarrhoea, even of a fatal character. They con- tract an intestinal inflammation from taking cold, just as other infants may contract coryza or bronchitis from the same cause. But the most common causes of infantile diarrhoea are, first, the use of food which is unsuitable for infantile digestion, and which therefore acts as an irritant ; and, secondly, residence in a foul atmosphere, to which we will soon call attention, and which largely increases the percentage of deaths in our cities during the hot months. Diarrhoea due to taking cold occurs in all localities and climates, but it is obviously most common in time of change- able weather. That due to the use of unsuitable food and foul air occurs for the most part in cities, and much more frequently in the summer season than in the cool months, as the above statistics show. Infantile intestinal catarrh, however produced, presents nearly the same anatomical characters, 732 LOCAL DISEASES. so that, whatever its etiology, it is proper to describe it as one disease ; but that form of it which requires most elucidation, and the causes of which we will consider in the following pages, is that produced by impure air and improper diet. The prevalence and severity of infantile diarrhoea in cities correspond closely with the degree of atmospheric heat, as may be inferred from the foregoing statistics. In New York this disease begins in the month of May — earlier in some years than in others — in a few scattered cases, commonly of a mild type. Cases become more and more numerous and severe as the weather grows warmer, until July and August, when the diarrhoea attains its maximum prevalence and severity. In these two months it is by far the most frequent and fatal of all the diseases in the cities. In the middle of Sep- tember new patients begin to be less common, and in the latter part of this month and subsequently new cases do not occur, unless under unusual cir- cumstances which favor the development of this malady. In New York a con- siderable number of deaths of infants occur from diarrhoea in October. October is not a hot month in our latitude — its average temperature is lower than that of May — and yet the mortality from this disease is considerably larger in the former than in the latter month. This fact, which seems to show that the prevalence of the summer diarrhoea does not correspond with the degree of atmospheric heat, is readily explained. The mortality in October, and indeed in the latter part of September, is not that of new cases, but is mainly of infants, as I have observed every year, who contract the disease in July or August or earlier, and linger in a state of emaciation and increasing weak- ness till they finally succumb, some even in cool weather. The fact is therefore undisputed, and is universally admitted, that the summer season, stated in a general way, is the cause of this annually recur- ring diarrhoea! epidemic. That atmospheric heat does not in itself cause the diarrhoea is evident from the fact that in rural districts there is the same intensity of heat as in cities, and yet the summer complaint does not occur. The cause must be looked for in the state of the atmosphere engendered by heat where unsanitary conditions exist, as in large cities. Moreover, obser- vations show that the noxious effluvia with which the air becomes polluted under such circumstances constitute or contain the morbific agent. Thus, in one of the institutions of this city a few years since, on May 10th, which happened to be an unusually warm day for this month, an offensive odor was noticed in the wards, which was traced to a large manure heap that was being upturned in an adjacent garden. On this day four young children were severely attacked by diarrhoea, and one died. Many other examples might be cited showing how the foul air of the city during the hot months, when animal and vegetable decomposition is most active, causes diarrhoea. Several years since, while serving as sanitary inspector for the Citizens' Association in one of the city districts, my attention was particularly called to one of the streets, in which a house-to-house visitation disclosed the fact that nearly every infant between two avenues had diarrhoea, and usually in a severe form, not a few dying. The street was compactly built with wooden tenement- houses on each side, and contained a dense population, mainly foreigners, poor, ignorant, and filthy in their habits. It had no sewer, and the refuse of the kitchens and bed-chambers was thrown into the street, where it accumulated in heaps. Water trickled down over the sidewalks from the houses into the gutters or was thrown out as slops, so that it kept up a constant moisture of the refuse matter which covered the street, and promoted the decay of the animal and vegetable substances which it contained. The air in the domiciles and street under such conditions of impurity was necessarily foul in the extreme, and stifling during the hot days and nights of July and August ; INTESTINAL CATARRH OF INFANCY. 733 and it was evidently the important factor in producing the numerous and severe diarrhoeal cases which were in these domiciles. In another locality, occupied by tripe-dealers and a low class of butchers who carried on fat- and bone-boiling at night, the air was so foul after dark that the peculiar impurity which tainted it could be distinctly noticed in the mouth for a considerable time after a night visit. In the street where these nuisances existed and in adjacent streets the summer diarrhoea was very prevalent and destructive to human life. Murchison states that 20 out of 25 boys were affected with purging and vomiting from inhaling the effluvia from the contents of an old drain near their school-room. Physicians are familiar with a similar fact showing this purgative effect of impure air — that the atmosphere of a dissecting-room often causes diarrhoea in those otherwise healthy. The impurities in the air of a large city are very numerous. Among those of a gaseous nature are sulphurous acid, sulphuric acid, sulphuretted hydro- gen; various gases of the carbon group, as carbonic acid, carburetted hydrogen, and carbonic oxide ; gases of the nitrogen group, as the acetate, sulphide, and carbonate of ammonium, nitrous and nitric acids; and at times com- pounds of phosphorus and chlorine (Parkes). A theory deserving consider- ation is that certain gaseous impurities found in the air form purgative com- binations. D. F. Lincoln, in his interesting paper on the atmosphere, in the Cyclopaedia of Medicine, writes in regard to sulphuretted hydrogen : '* When in the air, freely exposed to the contact of oxygen, it becomes sulphuric acid. Sulphide of ammonium in the same circumstances becomes a sulphate, which, encountering common salt (chloride of sodium), produces sulphate of sodium and chloride of ammonium. The sulphates form a characteristic ingredient of the air in manufacturing districts." The sulphates, we know, are for the most part purgatives, but whether they or other chemical agents exist in the respired air in sufficient quantity to disturb the action of the intestines, even where atmospheric impurities are most abundant, is problematical and uncertain. Again, the solid impurities in the air of a large city are very numerous, as any one may observe by viewing in a darkened room a sunbeam which is made visible by the numerous particles floating in it. These particles consist largely of organic matter, which sometimes has been carried a long distance by the wind. The remarkable statement has been made that in the air of Berlin organic forms have been found of African production. Ehrenberg discovered fragments of insects of various kinds — rhizopods, tardigrades, polygastrics, etc. — which, existing in considerable quantity and inhaled in hot weather when decomposition and fermentation are most active, may be deleterious to the system. Monads, bacteria, vibriones, amorphous dust con- taining spores which retain their vitality for months, are among the substances found in the air of cities. The well-known hazy appearance, when viewed from a distance, of the atmosphere resting over a large city like New York is due to the gaseous and solid impurities with which the air is so abundantly sup- plied — impurities which assume importance in pathological studies, since minute organisms are now believed to cause so many diseases the etiology of which has heretofore been obscure. There can be no reasonable doubt, from recent investigations, that the deleterious agents which cause the form of diarrhoea which we are considering are to a great extent bacteria, which find a soil most favorable for their propagation where the air as well as ingesta con- tains impurities. In foul air, as in the summer season in the crowded parts of the city, and especially where decomposing animal and vegetable matter exists, the number of micro-organisms is vastly greater, as different observers have remarked, than in salubrious localities. Foul air and unwholesome food 734 LOCAL DISEASES. — food that has begun to undergo decomposition or that digests with difficulty, so that part of it ferments — afford the conditions which are eminently favor- able for the development of pathogenic as well as non-pathogenic germs. We have seen that Booker and Vaughn have found bacteria in diarrhceal stools which when isolated by cultivation either kill the animals experimented on or cause intestinal catarrh in them, or the toxins produced by the bacteria have this effect. The evidence, therefore, is strong that bacteria are the chief causal agents of those forms of diarrhoea which originate from foul air and unwholesome and indigestible food. In those portions of our cities which are occupied by the poor more than anywhere else those conditions prevail which render the atmosphere foul and unwholesome. One accustomed to the pure air of the country would scarcely believe how stifling and poisonous the atmosphere becomes during the hot summer days and close summer nights in and around the domiciles in the poor quarters of the city. Among the causes of this foul air may be men- tioned too dense a population, the occupancy of small rooms by large families, rigid economy, and ceaseless endeavor to make ends meet, so that in the absorbing interest sanitary requirements are sadly neglected. Adults of such families, and children of both sexes as soon as they are old enough, engage in laborious and often filthy occupations. Many of them seldom bathe, and they often wear for days the same under-garments, foul with perspiration and dirt. The intemperate, vicious, and indolent, who always abound in the quar- ters of the city poor, are notoriously filthy in their habits and add to the insa- lubrity by their presence. Children old enough to be in the streets and adults away at their occupations escape to a great extent the evil effects of impure air, but the infantile population always suffers severely. Every physician who has witnessed the summer diarrhoea of infants is aware of the fact that the mode of feeding has much to do with its occur- rence. A large proportion of those who each summer fall victims to it would doubtless escape if the feeding were exactly proper. In New York City facts like the following are of common occurrence in the practice of all physicians : Infants under the age of eight months, if bottle-fed, nearly always contract diarrhoea, and usually of an obstinate character, during the summer months. The younger the infant, the less able is it to digest any other food than breast-milk, and the more liable is it therefore to suffer from diarrhoea if bottle-fed. In the institutions nearly every bottle-fed infant under the age of four or even six months suffers in the hot months from symp- toms of indigestion and intestinal catarrh, while the wet-nursed of the same ages remain well. Sudden weaning, the sudden substitution of cow's milk or an artificially prepared food in place of breast-milk in hot weather, almost always produces diarrhoea, often of a severe and fatal nature. Feeding an infant in the hot months with indigestible and improper food, as fruits with seeds or the ordinary table food prepared in such a way that it overtaxes the digestive function of the infant, causes diarrhoea, and sometimes that severe form of it which will be described under the term cholera infantum. Many obstinate cases of the summer complaint begin to improve under change of diet, as by the substitution of one kind of milk for another or the return of the infant to the breast after it has been temporarily withdrawn from it. It is a common remark in the families of the city poor that the second summer is the period of greatest danger to infants. This increased liability of infants to contract diarrhoea in the second summer is due to the fact that most infants in their second year are table-fed, while in the first year they are wet-nursed. Such facts, with which all physicians are familiar, show how important the diet is as a factor in causing indigestion and diarrhoea. Occasionally, from continued ill-health, the milk of the mother or wet- INTESTINAL CATARRH OF INFANCY. 735 nurse does not agree with the nursling. Examined with the microscope. it is found to contain colostrum. Under such circumstances if a healthy wet-nurse be employed the diarrhoea ceases. It is very important that any woman furnishing breast-milk to an infant should lead a quiet and regular life, with regular meals and sleep. R. B. Gilbert l relates striking cases in which venereal excesses on the part of wet-nurses were immediately followed by fatal diarrhoea in the infants whom they suckled. One not a resident would scarcely be able to appreciate the difficulty which is experienced in a large city in obtaining proper diet for young chil- dren, especially those of such an age that they require milk as the basis of their food. Milk from cows stabled in the city or having a limited pastur- age near the city, and fed upon a mixture of hay with garden and distillery products, the latter often largely predominating, is unsuitable. It is defici- ent in nutritive properties, prone to fermentation, and from microscopical and chemical examinations which have been made it appears that it often con- tains deleterious ingredients. If milk be obtained from distant farms, where pasturage is fresh and abundant — and in New York City this is the usual source of the supply — considerable time elapses before it is served to cus- tomers, so that, particularly in the hot months of July and August, it fre- quently has begun to undergo lactic-acid fermentation when the infants receive it. That dispensed to families in the morning is the milking of the previous morning and evening. The use of this milk in midsummer by infants under the age of ten months frequently gives rise to more or less diarrhoea. The ill-success of feeding with cow's milk has led to the preparation of various kinds of food which the shops contain, but no dietetic preparation has yet appeared which agrees so well with the digestive function of the infant, and is at the same time sufficiently nutritive, as the breast-milk of healthy mothers or wet-nurses. In New York City improper diet, unaided by the conditions which hot weather produces, is a common cause of diarrhoea in young infants, for at all seasons we meet with this diarrhoea in infants who are bottle-fed ; but when the atmospheric conditions of hot weather and the use of food unsuitable for the age of the infant are both present and operative, this diarrhoea so increases in frequency and severity that it is proper to designate it the summer epidemic of the cities. Several years since, before the New York Foundling Asylum was established, the foundlings of New York, more than a thousand annually, were taken to the almshouse on Blackwell's Island and consigned to the care of pauper-women, who were mostly old, infirm, and filthy in their habits and apparel. Their beds, in which the foundlings were also placed alongside of them, were seldom clean, not properly aired and washed, and under the beds were various garments and utensils which these pauper-women had brought with them as their sole property from their miserable abodes in the city. With such surroundings the air which these infants breathed day and night manifestly contained poisonous emanations, while their diet was equally improper, for it was prepared by these women from such milk and farinaceous food as were furnished to the almshouse. When assigned to duty in the alms- house, this service being at that time a branch of Charity Hospital, I was informed that all the foundlings died before the age of two months ; one only was pointed out as a curiosity which had been an exception to the rule. The disease of which they perished was diarrhoea, and this malady in the summer months was especially severe and rapidly fatal. The unpleasant experiences in this institution furnished additional evidence, were any wanting, that foul air and improper diet are the two important factors in causing the summer 1 Louisville Med. Journal, Aug. 19, 1882. 736 LOCAL DISEASES. diarrhoea of infants. Since that beneficent charity, the New York Foundling Asylum, in East Sixty-eighth street, came into existence, providing pure air and, for a considerable proportion of the foundlings, breast-milk, many of these waifs have been rescued from death. Age. — Age is a predisposing cause of intestinal catarrh, since most cases occur under the age of three years. A large majority of the summer diar- rhoeas of the cities occur under the age of two years. The following table embraces all the cases that came to one of the city dispensaries during my service between the months of May and October, inclusive: Age. Cases. 5 months or under 58 5 months to 12 months 212 12 months to 18 months 174 18 months to 24 months . 93 24 months to 36 months 36 Total 573 Dentition. — Statistics show that by far the largest number of cases occur during the period of first dentition ; hence the prevalent opinion among fam- ilies that dentition causes the diarrhoea. It is the common belief among the poor of New York that diarrhoea occurring during dentition is conservative, and should not be checked. They believe that an infant cutting its teeth suf- fers less, and may be saved from serious illness, if it have frequent stools. Every summer I see infants reduced to a state of imminent danger through the continuance of diarrhoea during several weeks, nothing having been done to check it in consequence of this absurd belief. The progressive loss of flesh and strength and wasting of the features do not excite alarm, under the blind- ing influence of this theory, till the diarrhoea has continued so long and become so severe that it is with difliculty controlled, and the patient is in a state of real danger when the physician is first summoned. The following statistics, which comprise cases occurring during my service in one of the city dispensaries, show the preponderance of cases during the age when dental evolution is occurring : Cases. No teeth and no marked turgescence of gums 47 Cutting incisors - 106 Cutting anterior molars 41 Cutting canines 40 Cutting last molars , 20 All the teeth cut 28 Total 282 It so happens that the period of dental evolution corresponds with that of the most rapid development and the greatest functional activity of the gastric and intestinal follicles, and the predisposition which exists to diarrhoeal mala- dies at this age must be attributed to this cause rather than to dentition. Symptoms. — The intestinal catarrh of infancy commonly begins gradually with languor, fretfulness, and slight rise of temperature. The diarrhoea at first usually attracts little attention from its mildness. The stools, while they are thinner than natural, vary in appearance, being yellow, brown, or green. Infants with milk diet usually pass green and acid stools containing particles of undigested casein. The tongue in the commencement of the attack is moist and covered with a slight fur. At a more advanced stage it may be moist, but is often dry, and in dangerous forms of the malady, accompanied by pros- tration, the buccal surface is red and the gums more or less swollen and some- INTESTINAL CATARRH OF INFANCY. 737 times ulcerated. Vomiting is common. It may commence simultaneously with the diarrhoea, especially when food that is indigestible and irritating to the stomach has been given, but more frequently this symptom does not appear until the diarrhoea has continued a few days. I preserved memoranda of the date when vomiting began in the cases treated in two consecutive years, and found that ordinarily it was toward the close of the first week. When it is an early and prominent symptom it appears to be due to the presence in the stomach of imperfectly digested or fermented and acid food, which, when ejected, gives a decidedly acid reaction with appropriate tests. It contains coagulated casein and undigested particles of whatever food has been given. In many patients the progressive loss of flesh and strength is largely due to the indigestion and vomiting, by which the food, which is so much required for proper nourishment, is lost. Emesis occurring at a late stage of infantile diarrhoea is often due to commencing spurious hydrocephalus, which is not an infrequent complica- tion, as we will see, of protracted cases. Perhaps when a late symptom it may sometimes have an ursemic origin, for the urine is usually quite scanty in advanced cases. It seems probable, however, that deleterious effects from non-elimination of urea are to a considerable extent prevented by the diarrhoea. The fecal evacuations may remain nearly uniform in appearance during the disease, but in many patients they vary in color and consistence at differ- ent periods. In the same case they may be brown and offensive at one time, green at another, and again they may contain masses of a putty-like appear- ance, the partly-digested casein or altered epithelial cells. The stools some- times consist largely of mucus, with or without occasional streaks of blood, indicating the predominance of inflammation in the colon. The stools are sometimes yellow when passed, but become green on exposure to the air from chemical reaction due to admixture with the urine or to the agency of the microbe mentioned above that produces green coloring matter. The character of the alvine discharges is interesting. In addition to undigested casein I have found epithelial cells, single or in clusters (some- times regularly arranged as if detached in mass from the villi), fibres of meat, crystalline formations, mucus, and occasionally blood, as stated above. In one instance I observed an appearance resembling three or four crypts of Lieberkuhn united, probably thrown off by ulceration. If the stools are green, colored masses of various sizes, but mostly small, are also seen under the microscope. The pulse is accelerated according to the severity of the attack. The heat of the surface is at first generally increased, though but slightly in ordinary cases ; but when the vital powers begin to fail from the continuance of the diarrhoea, the warmth of the surface diminishes. In advanced cases approaching a fatal termination the face and extremities are pallid and cool, and the pulse gradually becomes more frequent and feeble. The skin is usually dry, and, as already stated, the urinary secretion diminished. In severe cases attended by frequent alvine discharges the infant does not pass urine oftener than once or twice daily. The imperfect action of the skin and kidneys is noteworthy. Protracted cases of diarrhoea are frequently complicated by two cuta- neous eruptions — erythema extending over the perineum and frequently as far as the thighs and lower part of the abdomen, due to the acid and irritat- ing character of the stools ; and boils upon the forehead and scalp. The latter sometimes extend to the pericranium, and in case of recovery leave permanent cicatrices. This furuncular affection of the scalp has seemed to me useful in consequence of the external irritation which it causes, since it 47 738 LOCAL DISEASES. occurs at a time when, on account of the feeble heart's action and languid circulation, passive congestion of the vessels of the brain and meninges is liable to be present. Patients who are weak and wasted in consequence of protracted diarrhoea, remaining almost constantly in the recumbent position, often have an occa- sional dry cough which continues till the close of life. It is due to hypo- static congestion in the lungs, usually limited to the posterior and inferior portions of the lobes, extending but a little way into the lungs. It is the result of prolonged recumbency with feeble heart's action and feeble pulmo- nary circulation. Infants reduced by chronic diseases, lying day after day in their cribs, with little movement of their bodies, are very liable to this passive congestion of depending portions of their lungs, toward which the blood gravitates, and into which but little air enters in consequence of their distance and position and the feeble respirations. The hyperseniia which results is of a passive character, a venous congestion, and the affected lobules have a dusky-red color. This congestion, continuing, soon results in pneu- monia of the catarrhal form, subacute and of a low grade, for pulmonary lobules in which the blood remains stagnant soon exhibit augmented cell- proliferation, perhaps from the irritating effects of the elements of the blood now withdrawn from the circulation. I have made or procured a considerable number of microscopic examina- tions in these cases of hypostatic pneumonia, and the solidification of the pulmonary lobules has been found to be due to the exaggerated development of the epithelial cells in the alveoli, together with venous congestion. The affected lobules, whether in a stage of hypostatic congestion or the more advanced stage of hypostatic pneumonia, when examined at the autopsy were somewhat softer than in health, of dark color, and many of the lobules could be inflated by strong force of the breath ; but in protracted cases the alveoli in central parts of the inflamed area resisted insufflation. The lung in hypostatic pneumonia, even when it is inflated, still feels firmer between the fingers than the normal lung. Hypostatic pneumonia is so common in hospitals for infants that some physicians whose observations have been chiefly in such institutions have almost ignored other forms of pulmonary inflammation. Billard many years ago wrote : " The pneumonia of young children is evidently the result of stagnation of blood in their lungs. Under these circumstances the blood may be regarded as a kind of foreign body." Of all the chronic and exhausting diseases of infancy, no one has, according to my observations, been so frequently complicated by hypostatic pneumonia as the disease which we are considering, although it does not usually give rise to any more promi- nent symptom than an occasional cough. Limited to a small and almost immovable part of the lung, it does not ordinarily accelerate respiration or render it painful, and the cough is also apparently painless. When the progressive loss of flesh and strength has continued several weeks and the patient is much exhausted, another complication is liable to occur, known as spurious hydrocephalus or the hydrocephaloid disease, the anatomical characters of which will be described in the proper place. The commencement of spurious hydrocephalus is announced by gradually in- creasing drowsiness, perhaps preceded by a period of fretfulness. Vomiting and rolling the head are occasional early symptoms of this complication. As the drowsiness increases the pupils become less sensitive to light than in their normal state, and are usually contracted. When the drowsiness becomes profound and constant the pupils remain contracted as in sound sleep or in opium narcotism. The functional activity of the organs is now also dimin- ished, the vomiting ceases, the stools become less frequent, the buccal sur- INTESTINAL CATARRH OF INFANCY. 739 face dry. and the urine scanty, while the pulse is frequent and feeble. Spurious hydrocephalus either continues till death or by stimulation the patient may emerge from it. When profound the usual result is death. Although infantile diarrhoea in its commencement may be promptly arrested by proper hygienic and medicinal treatment, if it continue a few weeks the anatomical changes which occur are such that recovery, if it take place, is necessarily slow and gradual. Improvement is shown by better digestion, stools fewer and of better appearance, less frequent vomiting, a more cheerful countenance, and the absence of symptoms which indicate a complication. 3Iany recover after days of anxious watching and perhaps after many fluctuations. Death may occur early from a sudden aggravation of symptoms and rapid sinking, or the attack may be so violent from the first that the infant quickly succumbs ; but more frequently death takes place after a prolonged sickness. Little by little the patient loses flesh and strength till a state of marked emaciation is reached. The eyes and cheeks are sunken, the bony projections of the face, trunk, and limbs become prominent, and the skin lies in wrinkles from the wasting. The altered expression of the face makes the patient look older than the actual age. The joints in contrast with the wasted extremities seem enlarged and the fingers and toes elongated. The stools diminish in frequency from diminished peristaltic and vermicular action, and vomiting, if previously present, now ceases. A feeble, quick, and scarcely appreciable pulse, slow respiration, and diminished inflation of the lungs, sightless and contracted pupils, over which the eyelids no longer close, announce the near approach of death. The drowsiness increases and the limbs become cool, while perhaps the head is hot. The infant no longer has the ability to suckle, or if bottle-fed the food placed in the mouth flows back or is swallowed with apparent indifference. So low is its vitality that it lies pallid and almost motionless for hours or even days before death, and death occurs so quietly that the moment of its occurrence is scarcely appreciable. Anatomical Characters. — Since the prominent and essential symptoms of the disease which we are considering pertain to the digestive apparatus, it is evident that the lesions which attend and characterize it are to be found in this part of the system. Lesions elsewhere, so far as they are appreciable to us. are secondary and not essential. I have witnessed a large number of autopsies of infants who have perished from diarrhcea, chiefly in institu- tions, and they have been sufficiently marked and uniform to enable us to designate it an entero-colitis. Several years since I preserved records of the autopsical appearances in the intestinal catarrh of infants, most of them being cases of summer diarrhoea. The number aggregated eighty-two. Since then I have witnessed many autopsies in institutions in cases of this disease, and the lesions observed were similar to those in the eighty-two cases. The question may properly be asked, Can inflammatory hyperemia of the intestinal mucous membrane be distinguished from simple congestion if there be no ulceration and no appreciable thickening of the intestine ? It is pos- sible that occasionally I have recorded as inflammatory what was simply a congestive lesion, but I do not think I have incorporated a sufficient number of such cases to vitiate the statistics. In a large proportion of the cases there was evident thickening of the intestinal mucous membrane or other unequivocal evidence of inflammation. The following is an analysis of the 82 cases : The duodenum and jejunum presented the appearance of inflammatory hyperemia in 12 cases: the hyperaemia was usually in patches of variable extent or of that form described by the term arborescent. In 51 cases the duodenal and jejunal mucous membrane was pale and without any other appearance characteristic of catarrh or inflammation. In the remaining 10 eases the 740 LOCAL DISEASES. appearance of the duodenum and jejunum was not recorded, so that it was probably normal : on the other hand, in the ileum inflammatory lesions were present as a rule. In 49 cases I found the surface of the ileum dis- tinctly hypersernic, and in that portion of it nearest the ileo-csecal valve, including the valve itself, the inflammation had evidently been the most intense, since in this portion the hypersernia and thickening of the mucous membrane were most marked. In 16 cases the surface of the ileum appeared nearly or quite normal ; in 14 hypersernia in the small intestines in patches, streaks, or arborescence was recorded, but the records do not state in which division of the intestines they were observed. Billard, with other observers, has noticed the frequency and intensity of the inflammatory lesions in entero-colitis in the terminal portion of the small intestines, and thickening, in many cases, of the ileo-csecal valve, and he asks whether the vomiting which is so common and often obstinate in this disease may not be sometimes due to obstruction to the passage of fecal matter at the valve in consequence of its hyperemia and swelling ; but he has not observed any retained fecal matter above it, such as we find in any part of the colon, or any other appearance which indicated sufficient obstruc- tion to cause symptoms. But it seems not improbable that the reason why the inflammatory lesions are more pronounced at and immediately above the valve than in other parts of the small intestine is that the fecal matter, so commonly acid and irritating in this disease, is somewhat delayed in its passage downward at this point. Small superficial circular or oval ulcers were observed in the ileum in 4 cases, in 2 of which they were found also in the lower part of the jejunum. In 1 case the records state that ulcers were in the jejunum, but do not men- tion whether they were also in the ileum. In 1 case, in which there was much thickening of the ileum next to the ileo-csecal valve, many small granulations had sprouted up from the submucous connective tissue, so that the mucous surface appeared as if studded with small warts. Softening of the mucous membrane was also apparent in certain cases. The firmness of its attachment to the parts underneath varied considerably in different specimens. I was able in cases in which there was considerable softening to detach readily the mucous membrane with the nail or handle of the scalpel within so short a period after death that it was probable that the change of consistence was cadaveric. In some cases the vessels of the submucous tissue were injected and this tissue infiltrated. In all the cases, except one, lesions were present indicating inflammation of the mucous membrane of the colon. In 39 hypersernia, thickening, and other signs of inflammation extended over nearly or quite the entire colon ; in 14 the colitis was confined to the descending portion entirely or almost entirely ; in 28 cases the records state that inflammatory lesions were found in the colon, but their exact location is not mentioned. In 18 of the autopsies the mucous membrane of the colon was found ulcerated. Therefore, according to these statistics — and autopsies which I have wit- nessed that are not embraced in them disclosed similar lesions — colitis is present, almost without exception, in cases of summer diarrhoea, associated with more or less ileitis. The portion of the colon which presents the most marked inflammatory lesions is that in and immediately above the sigmoid flexure — that portion, therefore, in which any fermenting fecal matter has reached its greatest degree of fermentation, and consequently contains the most irritating elements, and where, next to the caput coli, it is longest delayed in its passage downward. The solitary glands of both the large and small intestines and Peyer's patches undergo hyperplasia. In cases of short duration and in parts of the INTESTINAL CATARRH OF INFANCY. 741 intestine where the inflammatory action has been mild, the solitary glands present a vascular appearance, like the surrounding membrane, and are slightly enlarged. The enlargement is most apparent if the intestine be viewed by transmitted light, when not only are the glands seen to be swollen, but their central dark points are distinct. If a higher grade of intestinal catarrh or a catarrh more protracted have occurred, the volume of these follicles is so increased that they rise above the common level and present a papillary appearance. Peyer's patches are also distinct and punc- tate. The enlargement of Peyer's patches, like that of the solitary glands, is due to hyperplasia, the elementary cells being largely increased in number. The small ulcers which, as we have seen from the above statistics, are present in a certain proportion of cases in the mucous membrane of the colon, and more rarely in that of the small intestine when the inflammation has been protracted and of a severe type, appear to occur in the solitary glands and in the mucous membrane surrounding them. While some of these glands in a specimen are simply tumefied, others are slightly ulcerated, and others still nearly or quite destroyed. The ulcers are usually from one to three lines in diameter, circular or oval, with edges slightly raised from infiltration. Rarely, I have seen minute coagula of blood in one or more ulcers, and I have also observed ulcers which have evidently been larger and have partially healed. When ulcers are present they commonly occur in the descending colon, or if occurring elsewhere they are most abundant in this situation. According to my observations, these ulcers are found chiefly in infants over the age of six months — during the time, therefore, when there is great- est functional activity and most rapid development of the solitary glands. Peyer's patches, though frequently prominent and distinct, have not been ulcerated in any of the cases observed by me. The appendix vermiformis participates in the catarrh when it occurs in the caput coli, its mucous membrane being hypersemic and thickened. In certain rare cases the inflammation is so intense that a thin film of fibrin is exuded in places upon the surface of the colon. It is liable to be overlooked or washed away in the examination. The rectum usually presents no inflam- matory lesions, or but slight lesions in comparison with those in the colon. It remains of the normal pale color, or is but slightly vascular in most patients, even when there is almost general colitis. Hence the infrequency of tenesmus. If tenesmus be present, probably the rectum participates in the inflammation. As might be expected from the nature of the disease, the secretion of mucus from the intestinal surface is augmented. It is often seen forming a layer upon the intestinal surface, and it appears in the stools mixed with epi- thelial cells and sometimes with blood and pus. The mesenteric glands in cases which have run the most protracted course and ended fatally are found more or less enlarged from hyperplasia. They are frequently as large as a pea or larger, and of a light color, the color being due not only to the hyperplasia, but in part to the anaemia. Occasionally, when patients have been much reduced from the long continuance of diar- rhoea, and are in a state of marked cachexia before death, we find certain of these glands caseous. The state of the stomach is interesting, since indigestion and vomiting are so commonly present. I have records of the appearance of this organ in 50 cases, in 42 of which it seemed normal, having the usual pale color and ex- hibiting only such changes as occur in the cadaver. In the remaining 17 cases the stomach was more or less hyperasmic, and in 3 of them points of ulceration were observed in the mucous membrane. 742 LOCAL DISEASES. All physicians familiar witli this disease have remarked the frequency of stomatitis. In protracted and grave cases it is a common complication. The buccal surface in these cases is more vascular than natural, and if the vital powers are much reduced superficial ulcerations are not infrequent, oftener upon the gums than elsewhere. The gums are frequently spongy, more or less swollen, bleeding readily when rubbed or pressed. Thrush is a com- mon complication of protracted diarrhoea in infants under the age of three or four months, but is infrequent in older infants. Occurring in those over the age of six or eight months, it has an unfavorable prognostic significance, indi- cating a form of diarrhoea which commonly eventuates in death. The belief has long been prevalent in the past that the liver is also in fault. The green color of the stools was supposed to be due to vitiated bile. But usually in the post-mortem examinations which I have made I have found that the green coloration of the fecal matter did not appear at the point where the bile enters the intestines, but at some point below the ductus communis choledochus, in the jejunum or ileum. The green tinge, at first slight, becomes more and more distinct on tracing it downward in the intes- tine. The manner in which it is produced has been treated of elsewhere. I have notes of the appearance and state of the liver in 32 fatal cases. Nothing could be seen in these examinations which indicated any anatomical change in this organ that could be attributed to the diarrhceal malady. The size and weight of the liver varied considerably in infants of the same age, but probably there was no greater difference than usually obtains among glandular organs in a state of health. The following was the weight of this organ in 20 cases : Age. Weight. Age. Weight. 4 weeks 5 ounces. 2 months Sh " 2 " 3| " 4 " 5 5 " 6* " 5 " 9 7 " 4J " 7 " 6 7 " 6£ " 9 " 8 10 months 6f ounces. 13 " 6 14 " 9 " 15 " 6 15 " 7J " 15 " 9J " 16 " 6 19 " U " 20 " 9£ " 23 " 15 In none of these cases did the size, weight, or appearance of this organ seem to be different from that in health or in other diseases, except in one in which fatty degeneration had occurred, but this was probably due to tuberculosis, which was also present. In most of these cases the liver was examined microscopically, and the only noteworthy appearance observed was the variable amount of oil-globules in the hepatic cells. In some specimens the oil-globules were in excess, in others deficient, and in others still they were more abundant in one part of the organ than in another. Little importance was attached to these differences in the quantity of oily matter. Hypostatic congestion of the posterior portions of the lungs, ending if it continue in a form of subacute catarrhal pneumonia and giving rise to an occasional painless cough, has been described in the preceding pages. The character of the cough in connection with the wasting might excite suspicions of the presence of tubercles in the lungs ; but tubercles are rare in this dis- ease, and when present I should suspect a strong hereditary predisposition. They occurred in only 1 of the 82 cases. The state of the encephalon in those patients in whom spurious hydro- cephalus occurs is interesting. In protracted cases of diarrhoea the brain wastes like the body and limbs. In the young infant, in whom the cranial INTESTINAL CATARRH OF INFANCY. 743 bones are still ununited, the occipital and sometimes the frontal bones become depressed and overlapped by the parietal, the depression being of course pro- portionate to the diminution in size of the encephalon. The cranium becomes quite uneven. In other children, with the cranial bones consolidated, serous effusion occurs according to the degree of waste, thus preserving the size of the encephalon. The effusion is chiefly external to the brain, lying over the convolutions from the base to the vertex. Its quantity varies from one or two drachms to an ounce or more. Along with this serous effusion, and ante- dating it, passive congestion of the cerebral veins and sinuses is also present. This congestion is the obvious and necessary result of the feebleness of the heart's action and the loss of brain-substance. Diagnosis. — In the adult abdominal tenderness is an important diag- nostic symptom of intestinal catarrh, but in the infant this symptom is lack- ing or is not in general appreciable, so that it does not aid in diagnosis. When the diagnosis of the disease is established, the symptoms do not usually indicate what part of the intestinal surface is chiefly involved, but it may be assumed that it is the lower part of the ileum and the colon. The presence of mucus or of mucus tinged with blood in the stools shows the predominance of colitis. Prognosis. — Although this disease largely increases the death-rate of young children, most cases can be cured if proper hygienic and medicinal measures be early applied. It is obvious, from what has been stated in the foregoing pages, that cholera infantum is the form of this malady which involves greatest danger. Except in such cases there is sufficient forewarn- ing of a fatal result, for if death occur it is after a lingering sickness, with fluctuations and gradual loss of flesh and strength. Patients often recover from a state of great prostration and emaciation, provided that no fatal com- plications arise. The eyes may be sunken, the skin lie in folds from the wasting, the strength may be so exhausted that any other than the recumbent position is impossible, and yet the patient may recover by removal to the country, by change of weather, or by the use of better diet and remedies. Therefore an absolutely unfavorable prognosis should not be made except in cases that are complicated or that border on collapse. The most dangerous symptoms, except those which indicate commencing or actual collapse, arise from the state of the brain. Rolling the head, squinting, feeble action or permanent contraction of the pupils, spasmodic or irregular movements of the limbs, indicate the near approach of death, as do also coldness of face and extremities and inability to swallow. It is obvious also, in making the prognosis in ordinary cases, that we should consider the age of the patient, and if the diarrhoea be that of the summer season, the state of the weather, the time in the summer, whether in the beginning or near its close, and the surroundings, especially in reference to the impurity of the air, as well as the patient's condition. Cholera Infantum, or Choleriform Diarrhoea. This is the most severe form of infantile diarrhoea. It receives the name which designates it from the violence of its symptoms, which closely resemble those of Asiatic cholera. It is, however, quite distinct from that disease. It is characterized by frequent stools, vomiting, great elevation of tempera- ture, and rapid and great emaciation and loss of strength. It commonly occurs under the age of two years. It sometimes begins abruptly, the pre- vious health having been good ; in other cases it is preceded by the ordinary form of diarrhoea. The stools have been thinner than natural and somewhat more frequent, but not such as to excite alarm, when suddenly they become 744 LOCAL DISEASES. more frequent and watery, and the parents are surprised and frightened by the rapid sinking and real danger of the infant. The first evacuations, unless there have been previous diarrhoea, may contain fecal matter, but subsequently they are so thin that they soak into the diaper like urine, and in some cases they scarcely produce more of a stain than does this secretion. Their odor is peculiar — not fecal, but musty and offensive ; occasionally they are almost odorless. Commencing simultaneously with the watery evacuations or soon after is another symptom— irritability of the stomach, which increases greatly the prostration and danger. Whatever drinks are swallowed by the infant are rejected immediately or after a few moments, or retching may occur without vomiting. The appetite is lost and the thirst is intense. Cold water is taken with avidity, and if the infant nurse it eagerly seizes the breast in order to relieve the thirst. The tongue is moist at first, and clean or covered with a light fur, pulse accelerated, res- piration either natural or somewhat increased in frequency, and the surface warm, but its temperature is speedily reduced in severe cases. The internal temperature or that of the blood is always very high. In ordinary cases of cholera infantum the thermometer introduced into the rectum rises to or above 105°, and I have seen it indicate 107°. Although the infant may be restless at first, it does not appear to have any abdominal pain or tenderness. The restlessness is apparently due to thirst or to that unpleasant sensation which the sick feel when the vital powers are rapidly reduced. The urine is scanty in proportion to the gravity of the attack, as it ordinarily is when the stools are frequent and watery. The emaciation and loss of strength are more rapid than in any other dis- ease which I can recall to mind, unless in Asiatic cholera. In a few hours the parents scarcely recognize in the changed and melancholy aspect of the infant any resemblance to the features which it previously exhibited. The eyes are sunken, the eyelids and lips are permanently open from the feeble contractile power of the muscles which close them, while the loss of the fluids from the tissues and the emaciation are such that the bony angles become more prominent and the skin in places lies in folds. As the disease approaches a fatal termination, which often occurs in two or three days, the infant remains quiet, not disturbed even by the flies which alight upon its face. The limbs and face become cool, the eyes bleared, pupils contracted, and the urine scanty or suppressed. In some instances, when the patient is near death, the respiration becomes accelerated, either from the effect of the disease upon the respiratory centres or from pulmonary congestion resulting from the feeble circulation. As the vital powers fail the pulse becomes progressively more feeble, the surface has a clammy coldness, the contracted pupils no longer respond to light, and the stupor deepens, from which it is impossible to arouse the infant. In the more favorable cases cholera infantum is checked before the occur- rence of these grave symptoms, and often in cases which are ultimately fatal there is not such a speedy termination of the malady as is indicated in the above description. The choleriform diarrhoea abates and the case becomes one of the ordinary summer complaint. Anatomical Characters. — Eilliet and Barthez, who of foreign writers treat of cholera infantum at greatest length, describe it under the name of gastro-intestinal choleriform catarrh. " The perusal." they remark, " of anatomico-pathological descriptions, and especially the study of the facts, show that the gastro-intestinal tube in subjects who succumb to this disease may be in four different states : (a) either the stomach is softened without any lesion of the digestive tube ; (b) or the stomach is softened at the same time that the mucous membrane of the intestine, and especially its follicular INTESTINAL CATARRH OF INFANCY. 745 apparatus, is diseased ; (c) or the stomach is healthy, while the follicular apparatus or the mucous membrane is diseased ; (d) or, finally, the gastro- intestinal tube is not the seat of any lesion appreciable to our senses in the present state of our knowledge, or it presents lesions so insignificant that they are not sufficient to explain the gravity of the symptoms. •• So far. the disease resembles all the catarrhs, but what is special is the abundance of serous secretion and the disturbance of the great sympathetic nerve. •• The serous secretion, which appears to be produced by a perspiration (analogous to that of the respiratory passages and of the skin) rather than by a follicular secretion, shows, perhaps, that the elimination of substances is effected by other organs than the follicles ; perhaps, also, we ought to see a proof that the materials to eliminate are not the same as in simple catarrh. Upon all these points we are constrained to remain in doubt. We content ourselves with pointing out the fact." 1 On the 1st of August, 1861, I made the autopsy of an infant sixteen months old which died of cholera infantum with a sickness of less than one day. The examination was made thirty hours after death. Nothing unusual was observed in the brain, unless perhaps a little more than the ordinary injection of vessels at the vertex. No marked anatomical change was observed in the stomach and intestines, except enlargement of the patches of Peyer as well as of the solitary and mesenteric glands. Mucous membrane pale. In this and the following cases there was apparently slight softening of the intestinal mucous membrane, but whether it was pathological or cadaveric was uncertain, as the weather was very warm. The liver seemed healthy. Examined by the microscope, it was found to contain about the normal number of oil-globules. The second case was that of an infant seven months old, wet-nursed, who died July 26, 1862, after a sickness also of about one day. He was pre- viously emaciated, but without any marked ailment. The post-mortem examination was made on the 28th. The brain was somewhat softer than natural, but otherwise healthy. There was no abnormal vascularity of the membranes of the brain, and no serous effusion within the cranium. The mucous membrane of the intestines had nearly the normal color throughout, but it seemed somewhat thickened and softened ; the solitary glands of the colon were prominent. The patches of Peyer were not distinct. In the New York Protestant Episcopal Orphan Asylum an infant twenty months old, previously healthy, was seized with cholera infantum on the 24th of June, 1864. The alvine evacuations, as is usual with this disease, were frequent and watery and attended by obstinate vomiting. Death occurred in slight spasms in thirty-six hours. The exciting cause was prob- ably the use of a few currants which were eaten in a cake the day before, some of which fruit was contained in the first evacuations. The brain was not examined. The only pathological changes which were observed in the stomach and intestines were slightly vascular patches in the small intestines and an unusual prominence of the solitary glands in the colon. The glands resembled small beads imbedded in the mucous membrane. The lungs in the above cases were healthy, excepting hypostatic congestion. Since the date of these autopsies I have made others in cases which ter- minated fatally after a brief duration, and have uniformly found similar lesions — to wit, the gastro-intestinal surface either without vascularity or scantily vascular in streaks or patches, sometimes presenting a whitish or soggy appearance and somewhat softened, while the solitary glands were enlarged so as to be prominent upon the surface. In cases which continue 1 Maladies des Enfants. 746 LOCAL DISEASES. longer evident inflammatory lesions soon appear which are identical with those which have already been described in our remarks relating to the ordi- nary form of diarrhoea. During my term of service in the New York Foundling Asylum in the summer of 1884 an infant died after a brief illness with all the symptoms of cholera infantum, and the intestines were sent to William H. Welch, now of Johns Hopkins Hospital, for microscopic examination. His report was as follows : " I found undoubted evidence of acute inflammation. There was an increased number of small round cells (leucocytes) in the mucous and submucous coats. This accumulation of new cells was most abundant in and around the solitary follicles, which were greatly swollen. Clumps of lymphoid cells were found extending even a little into the muscular coat. The epithelial lining of the intestine was not demonstrable, but this is usu- ally the case with post-mortem specimens of human intestine, and justifies no inferences as to pathological changes. The glands of Lieberkiihn were rich in the so-called goblet-cells, and some of the glands were distended with mucus and desquamated epithelium, so as to present sometimes the appear- ance of little cysts. This was observed especially in the neighborhood of the solitary follicles. The blood-vessels, especially the veins of the sub- mucous coat, were abnormally distended with blood. I searched for micro- organisms, and found them in abundance upon the free surface of the intes- tine, in mucous accumulations there, and also in the mouths of the glands of Lieberkiihn. Both rod-shaped and small round bacteria were found. I attach no special importance to finding bacteria upon the surface of the intestine. The general result of the examination is to confirm the view that cholera infantum is characterized by an acute intestinal inflammation." Nature. — Cholera infantum appears from its symptoms and lesions to be the most severe form of intestinal catarrh to which infants are liable. The alvine discharges, to which the rapid prostration is largely due, probably consist in part of intestinal secretions, and in part of serum which has trans- uded from the capillaries of the intestines. That the intestinal mucous membrane sometimes presents a pale appearance at the autopsy of an infant who, previously well, has died of cholera infantum after a sickness of twenty- four or forty-eight hours, is perhaps due to the great amount of liquid secre- tion and transudation in which the inflamed surface is bathed. Moreover, it is, I believe, a recognized fact that the hyperaemia of an acutely inflamed surface when of short duration frequently disappears in the cadaver, as that of scarlet fever and erysipelas. The early hyperplasia of the solitary and mesenteric glands, and the hyperemia and thickening of the surface of the ileum and colon in those who have survived a few days, afford additional proof of the inflammatory character of the malady. The opinion has been expressed by certain observers that cholera infan- tum is identical with thermic fever or sunstroke. There is indeed a resem- blance to thermic fever as regards certain important symptoms. In cholera infantum the temperature is from 105° to 108° ; in sunstroke it is also very high, often running above 108°. Great heat of head, contracted pupils, thin fecal evacuations, embarrassed respiration, scanty urine, and cerebral symptoms are common toward the close of cholera infantum, and they are the prominent symptoms in sunstroke. Nevertheless, I cannot accept the theory which regards these maladies as identical, and which removes cholera infantum from the list of intestinal diseases. In cholera infantum the gastro- intestinal symptoms always take the precedence, and are, except in advanced cases, always more prominent than other symptoms. It does not commence as by a stroke, like coup de soleil, but it comes on more gradually, though rapidly, and it often supervenes upon a diarrhoea or some error of diet. In INTESTINAL CATARRH OF INFANCY. 1\1 the commencement of cholera infantum the infant is usually not drowsy, and is often wide awake and restless from the thirst. Contrast this with the alarming stupor of sunstroke. Sunstroke only occurs during the hours of excessive heat, but cholera infantum may occur at any hour or in any day during the hot weather, provided that there be sufficient dietetic cause. Again, intestinal inflammation is not common in sunstroke, while it is the common or, as I believe, the essential, lesion of cholera infantum. These facts show, in my opinion, that the two maladies are essentially and entirely distinct. Nevertheless, cases of apparent sunstroke sometimes occur in the infant, and if the bowels are at the same time relaxed the disease may be regarded as cholera infantum, and if fatal is usually reported as such to the health authorities. Cases of this kind I have occasionally observed or they have been reported to me, although they are not common. With the exception of the organs of digestion no uniform lesions are observed in any of the viscera in cholera infantum, except such as are due to change in the quantity and fluidity of the blood and its circulation. Writers describe an anaemic appearance of the thoracic and abdominal viscera, and occasionally passive congestion of the cerebral vessels. The cerebral symp- toms usually present toward the close of life in unfavorable cases of cholera infantum are often due to spurious hydrocephalus, which we have described above ; but as the urinary secretion is scanty or suppressed, cerebral symp- toms may in certain cases be due to uraemia. Diagnosis. — This form of the summer diarrhoea is diagnosticated by the symptoms, and especially by the frequency and character of the stools. The stools have already been described as frequent, often passed with considerable force, deficient in fecal matter, and thin, so as to soak into the diaper almost like urine. The vomiting, thirst, rapid sinking, and emaciation serve to dis- tinguish cholera infantum from other diarrhoea! maladies. When Asiatic cholera is prevalent the differential diagnosis between the two is difficult if not impossible. Prognosis. — Cholera infantum is one of those diseases in regard to which physicians often injure their reputation by not giving sufficient notice of the danger, or even by expressing a favorable opinion when the case soon after ends fatally. A favorable prognosis should seldom be expressed without qualification. If the urgent symptoms be relieved, still the disease may con- tinue as an ordinary intestinal inflammation, which in hot weather is formid- able and often fatal. If the stools become more consistent and less frequent without the occurrence of cerebral symptoms, while the limbs are warm and the pulse good, we may confidently express the opinion that there is no pres- ent danger. The duration of true cholera infantum is short. It either ends fatally, or it begins soon to abate and ceases, or it continues, and is not to be distin- guished in its subsequent course from an attack of summer diarrhoea begin- ning in the ordinary manner. Treatment op Infantile Diarrhcea. — Obviously, efficient preventive measures consist in the removal of infants so far as practicable from the ope- ration of the causes which produce the disease. Weaning just before or in the hot weather should, if possible, be avoided, and removal to the country should be recommended, especially for those who are deprived of breast-milk during the age when such nutriment is required. If for any reason it is necessary to employ artificial feeding for infants under the age of ten months, that food should obviously be used which most closely resembles human milk in digestibility and in nutritive properties. It is also very important that the infant receive its food in proper quan- tity and at proper intervals, for if the mother or nurse in her anxiety to have 748 LOCAL DISEASES. it thrive feed it too often or in too large quantity, the surplus food which it cannot digest, if not vomited, undergoes fermentation, and consequently becomes irritating to the gastro-intestinal surface. The physician should be able to give advice not only in reference to the frequency of feeding, but also in regard to the quantity of food which the infant requires at each feeding. Correct knowledge and advice in this matter aid in the prevention and cure of the diarrhceal maladies of infancy. The reader is referred to the chapters relating to the feeding of infants. The indications for treatment are : 1st. To provide the best possible food which will aiford sufficient nutriment and be easily digested ; 2d. To aid the digestive functions of the infant ; 3d. To employ such medicinal agents as can be safely given to check the diarrhoea and cure the intestinal catarrh ; 4th. To procure fresh air, which is especially needed if the diarrhoea be that of the summer season. The infant with intestinal catarrh, the prominent symptom of which is diarrhoea, is thirsty, and is therefore likely to take more nutriment in the liquid form than it requires for its sustenance. If wet-nursed it craves the breast, or if weaned it craves the bottle at short intervals. No more nutri- ment should be allowed than is required for nutrition, and the thirst may be best relieved by a little cold boiled water to which the white of egg is added. In the dietetic treatment of the summer diarrhoea of the bottle-fed infant, in which not only diarrhoea but indigestion and vomiting are prominent symp- toms, I at first withhold cow's milk and allow only barley gruel, described in a previous page, to which the reader is referred. The occasional cases of infantile diarrhoea which result from taking cold require to be treated by the use of bland and easily-digested diet, and med- icines that are soothing and such as restrain the evacuations and relieve pain ; prominent among which remedies are bismuth and an opiate, with the digest- ive ferments. We have seen that the two factors which produce the microbic diarrhoea of infancy, of which the summer epidemic of the cities is the type, are improper food and foul air. It is therefore obvious that measures should be employed to render the atmosphere in which the infant lives as free as pos- sible from noxious effluvia. Cleanliness of the person, of the bedding, and of the house in which the patient resides, the prompt removal of all refuse ani- mal or vegetable matter, whether within or around the premises, and allowing the infant to remain a considerable part of the day in shaded localities where the air is pure, as in the parks or suburbs of the city, are important measures. In New York great benefit has resulted from the floating hospital which every second day during the heated term carries a thousand sick children from the stifling air of the tenement-houses down the bay and out to the fresh air of the ocean. But it is difficult to obtain an atmosphere that is entirely pure in a large city with its many sources of insalubrity ; and all physicians of experience agree in the propriety of sending infants affected with the summer diarrhoea to localities in the country which are free from malaria and sparsely inhab- ited, in order that they may obtain the benefits of purer air. Many are the instances each summer in New York City of infants removed to the country with intestinal inflammation, with features haggard and shrunken, with limbs shrivelled and the skin lying in folds, too weak to raise (or at least hold) their heads from the pillow, vomiting nearly all the nutriment taken, with stools frequent and thin, resulting in great part from molecular disintegration of the tissues — presenting, indeed, an appearance seldom observed in any other disease except in the last stages of phthisis — and returning in late IXTESTIXAL CATARRH OF IXFAXCY. 749 autumn with the cheerfulness, vigor, and rotundity of health. The localities usually preferred by the physicians of this city are the elevated portions of New Jersey and Northern Pennsylvania, the Highlands of the Hudson, the central and northern parts of New York State, and Northern New England. Taken to a salubrious locality and properly fed, the infant soon begins to improve if the disease be still recent, unless it be exceptionally severe. If the disease have continued several weeks at the time of the removal, little benefit may be observed from the country residence until two or more weeks have elapsed. An infant weakened and wasted by the summer diarrhoea, removed to a cool locality in the country, should be warmly dressed and kept indoor when the heavy night dew is falling. Patients sometimes become worse from inju- dicious exposure of this kind, the intestinal catarrh from which they are suf- fering being aggravated by taking cold and perhaps rendered dysenteric. Sometimes parents, not noticing the immediate improvement which they have been led to expect, return to the city without giving the country fair trial, and the life of the infant is then, as a rule, sacrificed. Returned to the foul air of the city while the weather is still warm, it sinks rapidly from an aggravation of the malady. Occasionally, the change from one rural locality to another, like the change from one wet-nurse to another, has a salu- tary effect. The infant, although it has recovered, should not be brought back while the weather is still warm. One attack of the disease does not diminish, but increases, the liability to a second seizure. Medicinal Treatment. — Opiates. — It is evident that opiates are less used than formerly in the treatment of the microbic diarrhoeas of infancy. A proper appreciation of the pathology of these diarrhoeas naturally leads to the belief that the opiates are less important as curative agents than they were formerly supposed to be. Opiates diminish the peristalsis and the num- ber of stools, but they do not destroy the microbes or the ptomaines. Their use should, I think, be limited to cases of restlessness, of tenesmus, and of frequent watery stools. They may be useful in controlling symptoms till other remedies have time to act. One drop of laudanum or fifteen drops of paregoric may be given to an infant of ten months and repeated in three hours. I prefer paregoric to any other opiate in the treatment of the sum- mer diarrhoeas of infancy, since they are attended by marked prostration, and this agent is highly stimulating, from the camphor which it contains. Fret- fulness without diarrhoea is, as a rule, best relieved by one of the bromides. Antiseptics. — Although the pathology of microbic diarrhoea suggests the use of antiseptics, my observations have not been favorable to the use of salol, naphthaline, or corrosive sublimate. They have seemed to me to do more harm than good. Guaita employs sodium benzoate. He administers in twenty -four hours one drachm or a drachm and a half in three ounces of water, with, it is stated, good results. 1 The antiseptic which is more largely used than any other, and which more than any other has the confidence of the profession — and justly so — is the subnitrate of bismuth. It undergoes a chemical change in the stomach and intestines, becoming a bismuth sulphide and causing dark stools. It may be combined with pepsin, in doses of six to eight grains for an infant of six months. Irrigation of the Stomach. — Physicians of experience in New York and elsewhere recommend irrigation of the stomach with warm water in the treatment of malnutrition and gastro-intestinal catarrh. It removes from the stomach thick curds that digest with .difficulty, as well as other aliment that may be undergoing gastric digestion. It has not, perhaps, been sufficiently employed to determine its full value, but from what I have seen of its effects 1 X. Y. Med. Record, May 31, 1884. 750 LOCAL DISEASES. I am not able to recommend it. The nutriment should be given so prepared and with such aids to digestion that the heavy casein curds do not form in the stomach. Moreover, the gastric juice is the one of the digestive fer- ments that is especially destructive to microbes, so that it is needed in the stomach for its germicide as well as digestive action. We have seen from the observations of Dr. Max Einhart that after two hours the stomach digestion of properly prepared milk or milk and barley gruel is completed and the stomach in a state to receive more food. For these reasons irriga- tion of the stomach, habitually practised even in cases of indigestion or catarrh, seems to me more likely to be injurious than beneficial. On the other hand, when the stools are fermenting and imperfectly digested, and are accompanied by tenesmus, irrigation of the rectum with a pint of hot water to which one teaspoonful of acid boraci and one of bismuth nitrate are added frequently gives considerable relief. Alkalies. — Acids, especially the lactic and butyric products of faulty digestion, often collect in the stomach and intestines. These acids, which are active irritants, should be neutralized, while we endeavor to prevent their production by improving the diet and aiding the digestion. In a few days the inflammatory irritation of the mucous follicles causes an exaggerated secretion of mucus, which is alkaline, and which neutralizes the acids to a considerable extent. It is especially useful when the infant has acid vomit- ing and acid stools. Lime-water, the sodium bicarbonate, and the various preparations of chalk are the antacids which may be employed to neutralize the acids, given midway between the nursings or feedings. An alkali is incompatible with pepsin, and, as pepsin preparations are needed to assist digestion, they should not be given at the same time with the alkali. Astringents. — The vegetable astringents were formerly much used in the treatment of the diarrhoeal diseases of infancy, but they are now seldom pre- scribed for these cases. Even the mineral astringents, acetate of lead and nitrate of silver, have gone out of use in the treatment of the infantile diar- rhoeas. The pepsin preparations and bismuth have taken their place. Stimulants. — The diarrhoea, if severe, soon produces symptoms of pros- tration or heart failure, so that alcoholic stimulation is needed. Brandy or whiskey is the best stimulant in this disease : from ten to twenty-five drops, according to the age, may be given every second hour. Occasionally it is proper to commence the treatment by the employment of some gentle purgative, especially when the diarrhoea begins abruptly after the use of irritating and indigestible food. A single dose of castor oil or syrup of rhubarb, or the two mixed, will remove the irritating substance, and afterward remedies designed to control the disease can be more successfully employed. Some physicians of large experience, as Prof. Henoch of Berlin, recom- mend small doses of calomel, as a twelfth or twentieth of a grain, three or four times daily. If it be useful, it probably acts as a germicide, but we have, it seems to me, more efficient and safer remedies. It is very important in the treatment of the summer diarrhoea to aid digestion while we employ an antiseptic, and the following are formulae which I have employed with apparently the best results : R. Acidi hydrochlorici dil., ^xvj ; Pepsini puri, in lamellis, £j ; Bismuthi subnitrat., ^ij ; Syrupi, f%ij ; Aquae, fspriv. — Misce. Shake bottle. Give one teaspoonful before each feeding or nursing to an infant of ten months ; half a teaspoonful to an infant of five months. INTESTINAL CATARRH OF INFANCY. 751 R . Pepsini saccharati, ^i-ij ; Bismutbi subnitrat., 313. — Misce. Divide in chart No. xii. Give one powder before each nursing or feeding to an infant of ten months. R . Pepsini pari, in lamellis, 3j ; Bismutbi subnitrat. , 5ss ; Yini pepsini, N. F. , ^ss ; Aquas destillat., 3iiiss. — Misce. Shake bottle. Give one teaspoonful before each feeding to an infant at or above the age of six months ; half a teaspoonful between the ages of two and six months. R. Pepsini puri, in lamellis, £j ; Bismutbi subnitrat., 3SS. — Misce. Give as much as goes on a ten-cent piece or a five-cent nickel piece before each nursing or feeding. If the diarrhoea and vomiting have ceased, but the digestion be slow and incomplete, the following prescriptions will be found useful : R. Bismuth, subnitrat., ^ij ; Fairchild' s essence of pepsin or Wyeth' s > f z • . elixir of digestive ferments, j ^ 3J > Aqua? destillat., ^ij. — Misce. Shake bottle. Give one teaspoonful every two hours. R. Pepsini puri, in lamellis, gj ; Vini pepsini, N. F., Jss ; Aquse destillat., ^iiiss. — Misce. Give half a teaspoonful to one teaspoonful, according to the age, before each feeding. If cerebral symptoms appear, as rolling the head, drowsiness, etc., indi- cating the commencement of spurious hydrocephalus, an alcoholic stimulant, as whiskey or brandy, is required ; and although there may be, at times, great restlessness, explicit and positive directions should be given to withhold opiates if they have been previously employed. One of the bromides, with an alcoholic stimulant or the aniseed cordial of the National Formulary, to allay restlessness, would be the proper remedy in addition to bismuth and pepsin if symptoms of heart failure or spurious hydrocephalus occur. External Treatment. — In the gastrointestinal catarrh of the cool months, produced by exposure to cold, light and mildly stimulating applications over the abdomen are sometimes useful, as a light poultice of flaxseed to which one-sixteenth or one-twentieth part of mustard is added, or a poultice of flaxseed the under surface of which is covered with 1 part of oil of cloves and 8 parts of camphorated oil. But in those forms of gastrointestinal catarrh due to improper feeding or insanitary conditions, and having a bac- terial origin, external measures are commonly useless, and in the summer months they might do injury by increasing the warmth. 752 LOCAL DISEASES. CHAPTER IX. EXTEKITIS AND COLITIS IX CHILDHOOD. Intestinal inflammation in childhood differs materially from the form or type which it commonly presents in infancy. Its causes, symptoms, and extent vary in important particulars in the two periods. In childhood there is not ordinarily such extensive inflammation of the mucous membrane of the intestines as we have seen is present in the majority of cases in infancy, and it may therefore be properly treated as two diseases, according to the seat of the morbid process — to wit, enteritis and colitis. Both these affections in childhood resemble so closely the form which they exhibit in adult life that no extended description is needed in this connection. Causes. — A main cause is sudden reduction of temperature by exposure to cold or to currents of air, which checks perspiration and causes determina- tion of blood from the surface to the viscera. These inflammations are also caused sometimes by irritating substances in the intestines. I have known fecal accumulations, and even rarely worms, to produce severe dysentery in the child, accompanied by the characteristic tenesmus and muco-sanguineous stools, and ceasing as soon as the offending substances were expelled. The use of unripe or stale vegetables, if there be a strong predisposition to mucous inflammation, may be a sufficient cause, and some of the most dan- gerous cases are due to the accumulation in the intestines of seeds and the parenchyma of fruits. But the most common cause is that mentioned — to wit. sudden exposure to cold when the body is heated, a danger to which children are especially liable on account of the easy disturbance of the cir- culatory system in them, and their heedless exposure of themselves unless incessantly watched. Enteritis and colitis are also frequently secondary dis- eases occurring in childhood as complications or sequelae of the eruptive fevers, especially measles. Symptoms. — The alvine discharges in enteritis and colitis in childhood are such as occur in these diseases at a more advanced age. In enteritis they are thin and of the natural color, or occasionally green ; in colitis they are more consistent than in enteritis and are largely muco-sanguineous. Some- times in enteritis, if the inflammation be not intense, the diarrhoea is slow in appearing, or it may be slight, so as not to attract special attention. The disease may then resemble remittent fever, for which it is at times mistaken. The upper part of the small intestines is less frequently affected than the lower. If there be duodenitis, the flow of bile is occasionally impeded from tumefaction of the mouth of the common bile-duct, and the icteric hue appears. In both enteritis and colitis there is abdominal tenderness, with more or less constant pain if the disease be severe, and in colitis tormina and tenesmus. The pulse is accelerated, the heat of surface augmented, the face flushed and, except in mild cases, expressive of pain. In many children at the commencement of the inflammation the nervous system is profoundly affected, as indicated by headache, stupor, twitching of the limbs, and some- times by convulsions. The chief danger at the commencement of the dis- ease is, indeed, from this source. Sometimes irritability of the stomach occurs and the food is rejected, though much less frequently than in the intestinal inflammation of infancy. Anorexia and thirst are common symp- toms. If the inflammation continue, there is soon perceptible emaciation, with loss of strength. The eyes become hollow, the face pallid, and the surface cool. Death may occur at an early period, the vital powers succumb- EXTEBITIS AND COLITIS IN CHILDHOOD. 753 ing from the intensity of the inflammation. In other cases the acute dis- ease ends in a subacute or chronic inflammation ; the patient becomes grad- ually more reduced, till he dies in a state of extreme emaciation, such as we often observe in the entero-colitis of infancy ; or from this state he may recover by degrees, though perhaps with an irritable state of the bowels, which continues for months. In a majority of cases, however, enteritis and colitis in childhood, if properly treated, soon begin to yield, and they termi- nate favorably in one or two weeks. Diagnosis. — It is not difficult to determine the existence of the inflam- mation. This is indicated by the fever, abdominal tenderness, and the relaxed state of the bowels. Whether the disease be enteritis or colitis is determined by the character of the stools, the seat of the tenderness, and the presence or absence of tenesmus. Prognosis. — It has been stated above that enteritis and colitis in chil- dren commonly terminate favorably. The result depends not only on the extent and severity of the inflammation, but the constitution and previous health. The inflammation is more serious when secondary than when pri- mary. Extensive and great tenderness of the abdomen, features pallid, anx- ious, and expressive of suffering, pulse frequent and feeble, should excite the most serious apprehensions. Frequent vomiting also denotes a grave form of the disease. Stupor, and especially convulsive movements, show that the nervous centres are affected, and should make us guarded in the prognosis. Improvement in the disease on which to base a favorable prediction is appa- rent in the diminution of the tenderness, improvement in the pulse and character of the stools, a more cheerful countenance, and less disrelish of food. Treatment. — This should be similar to that employed for the adult. In enteritis at the commencement of the disease, if there be reason to sus- pect the presence of any irritating substance in the intestines, and ordi- narily in colitis, it is advisable to commence treatment by the use of some simple evacuant, like castor oil. After this our reliance, so far as internal treatment is concerned, must be mainly on opiates and antiphlogistic medi- cines. One of the best remedies of this class is the Dover's powder, which may be given to a child five years old in doses of three grains every three hours. A corresponding dose of any of the other opiates may be given, but with less sudorific effect. In colitis the occasional administration of a laxa- tive should not be neglected if the stools be entirely or mainly muco-sanguin- eous. It should be employed so as to prevent accumulation of fecal matters in the colon which would serve as an irritant and increase the inflammation. The dose should be small, merely sufficient to produce fecal evacuation, and repeated as required, daily or less frequently. The laxatives commonly preferred are magnesia, rhubarb, or castor oil. The physician may prescribe an opiate mixture containing sufficient of the laxative to have the effect desired, though ordinarily it is better to prescribe the two sepa- rately, so that the laxative can be given or withheld according to circum- stances, while the opiate is continued more regularly. Except that there be some irritating substance which requires removal, the effect of laxatives is injurious instead of beneficial. Instead of a laxative given by the mouth, the use of a clyster of glycerin and sweet oil in tepid water is often prefer- able. The following prescriptions may be employed for a child of five years : R. Pulv. opii, gr. v; Bismuth, subnitrat., gij. — Misce. Divid. in pulveres No. xx. Give one powder every two to four hours. 48 754 LOCAL DISEASES. R. Pulv. ipecac, comp., gj ; Bismuth, subnitrat., ^ij. — Misce. Divid. in pulveres No. xxiv. Give one powder as above. R . Tine, opii deodorat., ^ss ; Bismuth, subnitrat., £ij ; Aq. menth. piperit., Syr. zingiberis, da. ^j. — Misce. Shake bottle. Give one teaspoonful from two to four hours. The local treatment which is found most beneficial consists in the use of emollient applications covered with oil-silk, and made sufficiently irritating by mustard or otherwise to cause constant redness. The diet should be bland and unirritating. In the first stage of the inflammation rice- or barley-water or arrowroot boiled in water and similar drinks should constitute the main diet. When the active inflammation has abated, and at any period of the disease if there be a tendency to prostra- tion, more nourishing food should be given. Milk and animal broths may then be allowed. In cases which are protracted or attended with symptoms of exhaustion alcoholic stimulants are required. CHAPTER X. CONSTIPATION. The gastro-intestinal portion of the digestive apparatus has a double function. First, it receives and retains the food during the process of diges- tion ; it furnishes the most important of the liquids by which digestion is effected ; and it absorbs those products of digestion which are required for the nutrition of the body, while it serves as a barrier against the admission of refuse matter. Secondly, it has an excretory function, so that a large part of the waste and noxious products of the system are eliminated from its surface. Having, therefore, a relation so close and fundamental to the gen- eral nutrition, it is necessary, for the normal activity of the organs and the maintenance of health, that its functions be regularly and fully performed. But retention of fecal matter beyond the normal period is one of the most common ailments both in infancy and childhood, and occasionally it consti- tutes a grave disease. The reader is referred to page 130 for remarks relating to constipation of the newly-born. Constipation is of two kinds — namely, symptomatic and idiopathic. Symptomatic Constipation. — Causes. — Many of these are obstructive. The more common of them are the following : (a) Congenital stenosis, or occlusion of the anus or rectum. The anus is not formed or it terminates in a cul-de-sac, while the lower end of the large intestine forms another cul-de-sac. These two cul-de-sacs, lying opposite to each other, one look- ing upward and the other downward, may be separated from each other by a small interspace, a fibrous septum, so that relief can be obtained by a punc- ture or incision, or they may be widely separated, so that there is no possible mode of relief, and death is inevitable unless the fecal matter escape through a congenital fistulous passage upon one of the adjacent mucous surfaces ; which mode of relief was present in 40 per cent, of the cases of this obstruction collected by Leichtenstern. Exceptionally, this malformation COXSTIPATION. 755 occurs in the sigmoid flexure, while the rectum is normal. The stenosis, if slight, may produce little delay in the evacuations, except when hardened masses or coarse, indigestible substances descend upon it, and it may there- fore, with careful selection of diet, cause little inconvenience for a length- ened period, while much stenosis causes early obstructive symptoms. Rarely the stenosis is at the ileo-cgecal orifice. (See page 130.) (6) Intestinal Displacements. — These produce obstructions of a very pain- ful and dangerous kind. Intussusception and external hernia are too well known to require description. Both are likely to produce complete obstruc- tion if not soon relieved, but there are cases of intussusception in children in which the displaced intestine remains pervious, and the evacuations occur with more or less regularity ; and the same is true of one form of hernia — namely, the congenital — which, although painful, seldom produces serious obstruction. Painful and dangerous occlusion and consequent arrest of alvine evac- uations occasionally result from the imprisonment of a loop of intestine in an opening, usually congenital, in the mesentery or diaphragm, or from the knotting of one portion of intestine with another, as described by Leichten- stern, or again from the twisting of the intestine. Epstein and Soyka * relate the case of a new-born infant that died in the second week after birth with symptoms of obstruction. At the autopsy a portion of the small intestine with its mesentery was found twisted upon its axis from right to left, without any marked evidence of inflammation. (c) Substances which have been swallowed or substances whose nuclei have been swallowed, and which consist of a deposit of carbonate and phos- phate of lime, or substances which have been produced entirely in the sys- tem, and which, lodged in narrow parts of the intestine, cause obstruction. Such substances, some of which occur most frequently in children and others in elderly people, produce acute constipation. Indigestible matter contained in the food, as seeds or the parenchymatous portions of fruits, occasionally collects in considerable quantity and obstructs the intestine. A large gall- stone, having escaped from the common bile-duct, sometimes lodges in the intestine, either at the ileo-csecal valve or more rarely at some other point, and retards the passage of fecal matter. But this seldom occurs in children. In one instance, and in only one, have I known obstinate constipation to be produced by worms. The patient was a girl of about four years, in whom constipation came on suddenly, and was accompanied by distention of abdo- men and great suffering. This continued nearly one week, when a mass of intertwined round-worms was expelled, with immediate relief. The records of medicine also contain cases in which neoplasms, growing from the coats of the intestines internally, have attained such a size as to retard the evac- uations. (d) Abscesses and tumors, especially when occurring in the pelvis, also sometimes cause constipation by pressing upon the intestine and obstructing or narrowing the passage through it. Thus, in 1868, Mr. Thomas Smith related to the London Pathological Society the case of an infant, aged four- teen months, in whom both alvine and urinary evacuations were retarded by a cancerous tumor growing between the rectum and bladder, and ending fatally in three months after the occurrence of the first symptoms. (e) Peritonitis, during its continuance, is known to constipate the bowels. It is supposed that inflammatory cedema occurs around the muscular fibres of the middle coat, by which their contractility is impaired. Hence the lax state, the meteorism, and inaction of the intestines in this disease. When the peritonitis abates the normal action is restored, and the evacuations occur 1 Centralb. f. d. med. Wissensch., April 24, 1879. 756 LOCAL DISEASES. regularly if the free surface of the peritoneum have undergone no unfavor- able change. But, unfortunately, peritonitis often produces more lasting injury, so as to interfere seriously with the intestinal movements and produce an habitually torpid state of the bowels. This occurs from adventitious bands of inflammatory origin which lie across the intestines, compressing them at the points of contact and restraining their movements, and from adhesion of the intestinal loops. The most marked cases which I have observed of this were children who had had tubercular peritonitis. Interesting examples of constipation from this cause might be related. Occasionally a false band, the result of peritonitis, lies across the intestines, without restraining their movements and producing no marked symptoms, and probably no symptoms at all, until a loop happens to pass underneath it, when, if not soon released, it is liable to become strangulated, with com- plete obstruction to the passage of fecal matter. This displacement might properly be classified with the internal hernias described above. In my own person at the age of twelve years such an accident occurred about two months after the peritonitis. Upon the abatement of the inflammation a sensation of traction had been noticed in the umbilical region almost daily during exercise, and the displacement was indicated by the extreme pain which characterizes such cases, and which ceased suddenly when the parts were released after about eighteen hours. (/) While it is important that the diet and glandular secretions should be such that the feculent matter may have proper consistence for easy pro- pulsion along the intestinal tube, the important agent by which alvine evacuations are effected is obviously muscular contraction. The muscular fibres of the intestines produce the vermicular and peristaltic movements by which excrement is carried forward, and the abdominal muscles by their powerful contraction are the chief agents of expulsion. Now, any pathological state which impairs the innervation of these muscles or renders it abnormal, destroying the proper balance between " exciting and inhibiting impulses," is likely to cause constipation. Hence meningitis, myelitis, and certain other diseases of the cerebro-spinal axis, rachitis, general weakness, etc., are commonly attended by a sluggish state of the intestines. Idiopathic Constipation. — Causes. — These are quite numerous. The more prominent of them are the following : First, too little liquid in the excrement, so that it is too firm for ready evacuation. There may be too little liquid taken in the ingesta or too scanty secretion of the liquids which mix with the food, as those of the pancreas, liver, and mucous follicles, or there may be too great an absorption of liquid through the coats of the intestines, and too active an excretion of water from the skin, kidneys, or lung. The firmer the fecal matter the greater the tendency to constipation. Those who lose a large amount of water, as in diabetes, night-sweats, or from occupations which expose to heat or from residence in a hot climate, are especially liable to constipation, except as the loss of liquid is compensated by an increased amount of drink. The character of the food, apart from the amount of liquid which it con- tains, obviously has a marked influence upon the consistence and frequency of the stools. Occasionally, the intestines act sluggishly from insufficiency of food. Thus, the infant sometimes hangs an unusually long time on the breast, and the mother or wet-nurse believes it to be a hearty nurser, when there is really a deficiency of milk, and the stools are scanty and infrequent from lack of material. Again, constipation is not uncommon in infants who nurse heartily and seem to obtain a sufficient quantity of milk, and the cause of it is not in the state of the digestive organs, but in the milk. We find COXSTIPA TIOK Ibl that now and then breast -milk has a constipating effect, although we discover nothing to cause this result in the mother's diet or health. The comparison of ordinary milk with colostrum may furnish a clew to the explanation. Colostrum is known to be more laxative than ordinary milk, and it differs from it chemically in containing more butter, sugar, and salts. Hence the theory seems plausible that when breast-milk is constipating these elements occur in less than the normal quantity. And we shall see hereafter that treatment suggested by this theory obviates the constipation. The use of a diet which consists chiefly of assimilable substances, as animal food, and from which, after the digestive process, little coarse and stimulating residuum remains, is obviously liable to produce a sluggish state of the bowels. On the other hand, coarse food, as fruits with their seeds, coarsely-ground meal, etc., which stimulates the peristaltic action and the secretions, increases the number and frequency of the alvine discharges. Habit also exerts a decided influence upon defecation. One who, for whatever reason, neglects or resists the desire for a stool soon becomes less conscious of the daily recurring need and establishes a constipated habit. Constipation is more liable to occur in those who lead a quiet life than in those who are active. A constipated habit is established in many school- children by neglecting or repressing the desire for a stool during school- hours. But there are cases in which there seems to be a constitutional tendency to constipation — a tendency quite independent of the usual conditions. Thus I have met children who were bright and active, free from obstruction or disease which might retard the evacuations, apparently far from having sluggish muscular contractility, and, so far as I could see, with proper diet, and yet with defecation, except as it was produced by measures employed, occurring no oftener than each second, third, or fourth day. But it must be borne in mind that what is constipation in one child may not be in another, for occasionally one does well with only one evacuation every second or third day, while a large majority require daily defecation in order to the maintenance of perfect health. In the adult the sacculi or pouches which occur in the walls of the colon, produced by contraction of the longitudinal bands acting at right angles to the direction of the circular fibres, and consisting of the internal and exter- nal tunics without the muscular, become the receptacles for fecal matter in those who are constipated, and obviously tend to increase the constipation. In children these sacculi are much less developed relatively, and in young- infants, whose intestines lack the longitudinal bands, are absent, so that this anatomical condition, by which the passage of fecal matter is delayed, is unimportant as a cause of constipation in the young. On page 131 we have stated that Gautier of Geneva, Switzerland, has called attention to an anal fissure as a cause of constipation in the newly- born and in older children. The constipation occurs from the endeavor to resist defecation on account of the pain. We have also remarked on page 131 that constipation has a tendency to perpetuate itself, since retained feculent matter becomes more consistent and firmer, and the contractile power of the muscular tunic becomes weakened by long distention. Obviously, also, an abnormal length of the large intes- tine, so that it doubles on itself, whether congenital or the result of con- stipation, and a malposition which diminishes the space occupied by the colon, and therefore increases its flexures, have a tendency to produce constipation. Symptoms. — When there is a mechanical cause which retards the pas- sage of fecal matter the acuteness of symptoms and the suffering are gen- erally proportionate to the degree of obstruction. Symptomatic constipa- 758 LOCAL DISEASES. tion occurring in an obstructive disease, whether adhesions, peritoneal bands, intussusception, knots or twisting of the intestine, incarceration in a false passage, or from biliary or intestinal stones or fecal masses, is attended by severe symptoms, such as intense colicky pain, vomiting, loss of appetite, and rapid prostration. The ingesta accumulate above the point of obstruc- tion, producing distention of the intestine with fecal matter and gas, while below the point of obstruction the intestine is soon empty. The symptoms indeed have the severity and the state involves the danger present in ordinary strangulated hernia, while, from being internal, and therefore less accessible for treatment, the danger is even greater. If the intestinal tract be narrowed, whether by a false ligament, the result of an old peritonitis, or other cause, and there be still perviousness, so that excrementitious matter passes by the obstruction, though slowly and with more or less difficulty, the patient may be comparatively comfortable if the food be such that no hard masses remain ; but according to the degree of stenosis and the amount and coarse- ness of the fecal matter symptoms occur referable to the obstruction. If the excrement be propelled with difficulty through the narrowed part, the mus- cular coat above the obstruction gradually becomes more developed from hypertrophy of the muscular fibres, just as the heart enlarges from obstruc- tive disease of its valves, while below the obstruction the intestine atrophies and its calibre diminishes from disuse. Colicky pains, accumulation of fecal matter above the obstruction, distention of abdomen, eructation of gas, vom- iting, impaired appetite, and consequent decline of the general health, are common results. There is constant danger in these cases that the narrow passage may become obstructed by fecal matter if it happen to contain hard masses or coarse, indigestible substances. The gravest form of constipation is obviously that due to mechanical agencies which act as obstacles, but as the obstacles are numerous, differently located, and of different character, so there is great difference in the gravity of the cases. Idiopathic constipation generally comes on gradually. It at first attracts little attention and is neglected. The symptoms of course vary greatly according to the degree and stage of constipation. In mild cases the reten- tion is only in the rectum or rectum and sigmoid flexure, and there are no marked symptoms except a sensation of fulness or distention of these parts, which one or two evacuations relieve. Between these mild cases and the graver forms of constipation there is every intermediate grade, attended by symptoms proportionately severe. It is surprising sometimes to observe how long patients live with extreme constipation, though with constant suffering and ill-health ; and I wish it especially to be noticed in this connection that a large proportion of the fatal cases of idiopathic constipation occurring in adults and recorded in the literature of the profession began in early life, even in infancy, at which time they probably might have been relieved by proper remedies and a life of suffering prevented. This important practical fact shows the need of greater attention on the part of parents and nurses to the state of the bowels in children, that their sluggish action may be cor- rected before it becomes habitual and those anatomical changes of distention and muscular paralysis occur which are with difficulty corrected. A case quite remarkable and of recent date occurred in the practice of Dr. Strong 1 of Westfield, N. Y. : Case. — This patient at the age of two years usually had one stool in two weeks, and several years later only one in six weeks. When an adult he was treated by Dr. Strong, who found great distention of the abdomen, so that the lower ribs were pressed outward in nearly a horizontal direction, and the thoracic organs upward, so that the apex-beat of the heart was about one inch above the nipple. At this 1 Amer. Journ. of Med. Sei., 1874 and 1876. CONSTIPATION. 759 time months elapsed between the stools, the longest intervals being eighteen months and sixteen days. Defecation when it did occur lasted from two to four days, and was attended by violent gastric and intestinal pain, vomiting, and prostration. At one of these prolonged stools forty pounds of feces, resembling, as it usually did, chewed brown paper, were evacuated, the quantity being accurately ascertained by weighing the patient before and afterward. He had appetite and was able to do certain kinds of farm-work during the year preceding his death, which occurred at the age of twenty-eight years. At the autopsy the colon was found to have a length of sis feet' and three inches and a circumference of thirteen inches, while the lungs were pressed upward and backward as when compressed by a pleuritic exudation. While such extreme cases are infrequent, all physicians of experience are consulted from time to time by adults who have had habitual constipation from their earliest recollection ; and these cases, that aggregate so large a number, might, there is little reason to doubt, have been prevented for the most part during childhood when the habit was being formed. In long-continued constipation, in which there is a large fecal accumula- tion, not only is the diameter of the colon increased, as stated above, but this part of the intestine becomes elongated. This may lead to change in its position, the curves of the sigmoid flexure extending farther to the right, and the central part of the transverse colon by its weight curving downward. This abnormal lengthening and the consequent curvatures have a tendency to increase the constipation, as has been stated above in our remarks relating to the etiology. In these cases of extreme constipation, which fortunately are rare in chil- dren, as they are also in adults, the distention of the colon at the ileo-csecal orifice has a tendency to widen this orifice, so that the valve, which in the ordinary state prevents the return of any substance which has once passed by it, is liable to become insufficient. The adjacent folds which constitute the valve become separated, so that, if vomiting and antiperistaltic move- ments occur, fecal matter may pass from the colon toward the stomach. In aggravated cases, in which there is retention of a large amount of fecal mat- ter, distention, muscular paralysis, etc., similar to those which we have seen produced in the colon, are liable to occur, though to a less extent, in the small intestines, especially in the ileum. Retained excrementitious matter accumulating in large masses evidently becomes an irritant, so that by its pressure it excites muscular contractions, which if ineffectual in propelling the mass cause colicky pains. The retained fecal matter also undergoes more or less decomposition, producing gases which by increasing the distention also increase the pain. Any irritating substance applied to a mucous surface is liable to excite increased secretion from the mucous follicles or from the glands whose ori- fices connect with the mucous membrane at the point of irritation. Many familiar examples will at once be recalled to mind, as the defluxion from the nostrils from the use of snuffs and increased mucous secretion and salivation from objects held in the mouth. In the same way, retained excrement, form- ing hard masses which press upon the intestinal surface, excite a secretion, and not infrequently produce thereby a diarrhoea which is conservative, and which may for the time unload the bowels, or it may remove a part of the scybalse, while the rest remain. Hence we sometimes hear patients speak of having irregular evacuations, constipation alternating with diarrhoea. In aggravated cases the pressure of impacted feces sometimes produces inflam- mation of the surface, when, in addition to abdominal pain, there are tender- ness on pressure and some (usually quite moderate) elevation of tempera- ture. In cases which have terminated fatally after a longer or shorter time destruction of the mucous surface has been found in places in conse- 760 LOCAL DISEASES. quence of the pressure and inflammation. "We can readily believe that, as in cases of typhoid ulcerations, if the ulcers reach a certain depth they may also give rise to localized peritonitis, and that occasionally perforation may result at the ulcerated or gangrenous point. The expulsion of hardened masses which have collected in the rectum is slow and painful, and accom- panied by more or less tenesmus, which not infrequently causes a portion of the mucous membrane at the anal orifice to descend below the sphincter ani and protrude, by which hemorrhoids are produced. Occasionally, as I have observed in certain cases, the entire circumference of the rectal mucous mem- brane, to the distance of half an inch or more above the anus, becomes so loosened from its attachment to the connective tissue that it descends below the sphincter ani and protrudes during each defecation. But this displace- ment, known as prolapsus recti, more commonly results in children from pro- tracted intestinal catarrh, attended by diarrhoea, loss of flesh, and by dimin- ished tonicity of the tissues. A beautiful and conservative provision in the system is that by which vicarious functions are established to relieve organs which imperfectly per- form their part. While the intestinal surface is to a great degree elimina- tive, so that noxious and effete products are largely expelled from the system in the stools, it possesses also in high degree an absorbent function, as all who employ rectal alimentation are aware. Xow, if the intestine fail to per- form its function of defecation and feculent matter collect within it and begin to exert pressure upon the intestinal surface, more or less of the liquid portion is taken up by the vessels, and, entering the general circulation, finds a mode of escape through other emunctories. The general ill-health or languor, the furred tongue, headache, and foul breath which characterize these cases are. no doubt, due to the absorption into the blood or retention in it of noxious products contained in, and which in part constitute, the feculent matter. The fact that patients may live for years with tolerable appetite, and with only one dejection every second or third week, receives explanation in the fact that other organs, as the lungs, kidneys, skin, etc., act as depur- ants for such excrementitious matter as can be taken up in a liquid or gas- eous form by the intestinal surface. In infants, constipation, even when slight and temporary, often causes fret- fulness, which is indicated by the character of their cries and the movement of the thighs over the abdomen. Continuing for a time, it causes more or less fever, and in those young children who are liable to eclampsia it predis- poses to an attack, and it may be the chief cause. Treatment. — If there be reason to suspect the presence of a mechanical obstacle which prevents normal defecation, a careful examination should be made in order to discover, if possible, its nature and location. Often it is of such a nature that it cannot be removed, but its constipating effects may sometimes be in a measure obviated. In one of the published cases in which constipation continued from early childhood to adult life, and finally proved fatal, its cause was ascertained to be a septum in the rectum, which probably might have been relieved by surgical measures. In all cases of constipation which the history shows may be produced by mechanical causes, whether the obstruction be complete and the colicky pains and other symptoms severe, or there be occasional scanty evacuations with but slight or moderate suffering, the history of the patient should be obtained in order to ascertain if there had been at any previous time symptoms of peritonitis or other pathological state which might throw light on the etiology. The abdomen and the usual sites of hernia should be carefully explored by palpation, and the rectum by the finger, large-sized catheter, or rectal tube. A thorough examination thus COXSTIPA TION. 761 instituted, painless to the patient, will usually enable the practitioner to deter- mine either the exact or probable obstacle if any be present. The proper treatment of symptomatic constipation obviously requires the removal, so far as possible, of the primary disease or the cause, whether it be obstructive or otherwise. We need not stop to consider the special meas- ures which are required, and will pass to the consideration of the treatment of idiopathic constipation. Hygienic Measures. — We have already alluded to the fact that habit has a powerful control over the action of the intestines, so that it is important to obtain a daily alvine evacuation at a certain hour, and by establishing the habit the need will usually be experienced when that hour arrives each day. Many cases which become troublesome and obstinate might no doubt have been prevented had this physiological law been heeded and a daily evacuation obtained at a certain hour. The constipated habit, mild and not yet fully established, is more liable to be overlooked when it occurs in childhood than in infancy, for the infant is closely and constantly under observation, and it soon presents symptoms, as fever and fretfulness, if it do not have the regu- lar evacuation, while children over the age of four or five years tolerate better a sluggish state of the bowels, and are likely to be constipated for a consider- able time before the fact is ascertained. They therefore require more atten- tion in this regard than is usually bestowed by parents. The nature of the diet is obviously important, since certain kinds of food are more laxative than others. Chicken tea and, to a certain extent, beef and mutton tea, are laxative, and made plainly are therefore useful in con- nection with other articles. The apple scraped or baked, or apple sauce, may be given to quite young children, and for those that are older certain dry fruits, as prunes and figs, are laxatives. Unfermented cider in its season, which has been found so useful for adults, may also be given to children in moderate quantity, at least to those who have reached the age of two or three years. Oatmeal is more laxative than most other kinds of amylaceous food. Made into a gruel and strained, it may be given to the nursing infant, and unstrained to those who are older. Bread or pudding from coarsely-ground or unbolted flour or meal, and vegetables which contain saline and fibrous substances, have a stimulating and laxative effect on the surface of the intes- tines, and therefore are useful for constipated children of the age of two or three years and upward. Also farinaceous food treated by diastase may be employed. There can be no doubt that the free use of water in the ingesta materially aids in relieving costiveness. In one of the numbers of the London Lancet a physician asks the profession how to cure obstinate constipation in adults. Among the replies, one physician suggests drinking a tumblerful of cold water on retiring to bed and another tumblerful in the morning ; and there can, I think, be little doubt that the laxative effect of broths, gruels, fruits, and mineral waters is partly due to the amount of water which they contain. One of the chief causes of constipation, we have seen, is too great firmness or consistence of the stools, due to absorption of the water ; and if a larger quantity of water be swallowed during or after the meals than is removed b} r absorption, so that the stools have their normal or less than normal consist- ence, this cause of constipation is removed. An excess of water introduced into the system is to a great extent eliminated by the kidneys, and in hot weather by the skin, and to a certain extent exhaled from the lungs ; but experience shows that if the amount of liquid received be so great that the vessels in the coats of the intestines continue in a state of repletion, only a 762 LOCAL DISEASES. certain part of it is absorbed, while the rest descends and mixes with the excrementitious matter and acts as a laxative. Another safe and effectual aid in overcoming habitual constipation is frequent kneading of the abdomen. My attention was first particularly directed to this in the treatment of the case related above, in which obsti- nate constipation, occurring in a child of three years from peritoneal bands and adhesions, was to a great extent corrected by friction over the abdo- men for three or four minutes at a time, with cod-liver oil three or four times daily. The manipulation probably did the good, and not the oil, but the use of one of the oils for inunction renders the kneading less painful and ensures its more thorough performance by the nurse. All obstetricians in certain emergencies stimulate the uterine muscular fibres to contraction by kneading the abdomen, and it is probable that the muscular fibres of the intestines are stimulated in a similar manner, so that the intestinal move- ments are increased by which feculent matter is carried forward. The external application of cold, so effectual in contracting the uterine muscular fibres, also stimulates the contractile power of the muscular fibres of the intestines. Cold-water bathing, the sudden application of a cloth wrung out of cold water to the abdomen, and in certain obstinate cases even the douche, may be used to stimulate the muscular coat of the intestines and the abdominal muscles to greater activity. Trousseau says : " Before leaving the subject of the treatment of constipation, let me refer to the application of cold to the abdomen — a minor method which I have seen recommended,, and have myself prescribed with astonishing success. On rising in the morn- ing let there be placed on the abdomen a compress of several folds soaked in cold water, and let it be separated from the clothes by a sheet of gutta-percha or caoutchouc. This compress ought to remain on for three or four hours." This recommendation by Trousseau is for adults, who are much less suscept- ible to the influence of cold than children. So prolonged an application of cold and wet to a child, even the most robust, would involve danger, while its application during the brief period occupied in an ordinary bath, with proper exercise afterward or with other measures to prevent chilling, could have no ill-effect. Therapeutic Measures. — For temporary constipation and many cases that are habitual enemata should be employed, since they promptly unload that part of the intestines in which feculent matter is ordinarily retained, while they do not impair the appetite or produce the prostration which so often results from purgatives. For temporary constipation a warm clyster may be given, and it commonly is more agreeable to the patient than one of lower temperature than the body. Among the enemata which have been found useful are castile soap with molasses and water, salt and water, the various oils, as sweet oil with or without castor oil, linseed oil alone or with molasses, and the gruels, as that of oatmeal or cornmeal made thin. The belief that the frequent use of warm clysters produces a relaxing effect is probably cor- rect, so that if it be necessary to employ clysters often in consequence of the torpid state of the intestines, cool water, the effect of which is tonic and stim- ulating, should be used. I prefer the use of glycerin and water as a laxative enema. For ordinary constipation in an infant the injection into the rectum of one teaspoonful of glycerin and one teaspoonful of water from a gutta- percha or glass syringe, at a certain hour each day, will rarely fail to give relief. For infants, a clyster of* one or two ounces usually suffices, administered by a gutta-percha or glass syringe, while for older patients a proportionately larger quantity is required, administered by preference through a Davidson, India-rubber, or a fountain syringe. In certain long-continued, aggravated CONSTIPATION. 763 cases the frequent injection of a large quantity of tepid water is indispensa- ble in order to wash away the accumulation of fecal matter. Thus in 1854, Mr. Gay exhibited to the London Pathological Society a boy of seven years who at the age of three years had had typhus fever with dysenteric stools. After convalescence he had habitual obstinate constipation, so that when Mr. Gay began treatment there had been no fecal evacuation for nearly four months, and the girth of the body over the abdomen was forty-nine inches, and yet the appetite and general health were not seriously impaired. The shape of the abdomen and the examination showed great distention of the rectal ampulla and the descending colon. Mr. Gay first distended the sphincter ani, so that it admitted a speculum, and through a rectal tube, well introduced into the colon, the excrement was repeatedly washed away, so that at the time of the exhibition of the boy to the society the measurement in girth gave only twenty-four inches. Evidently in cases like the above no other treatment except repeatedly washing out the intestines with warm water would have answered, and the dilatation of the sphincter ani and the introduction of the speculum to facilitate the escape of fecal matter are noteworthy. Suppositories may sometimes be usefully employed in place of enemata ; cocoanut butter, molasses candy, or soap cut in shape of a pencil may be used for this purpose. In the adult, long-continued constipation is not very rare in which the rectal ampulla becomes so impacted that it is necessary to use the anal curette, the handle of a spoon, or the finger introduced, in order to break up the masses and allow them to pass. In children necessity for such treatment is much more rare, but there are occasional cases, like that above described by Mr. Gay, in which it may be needed. Dr. Nagel states that the evil may be removed by the introduction of a suppository of brown gelatin. This is steeped in water for twelve hours, and, having been thus softened, is introduced into the rectum and an evacuation obtained. The doctor attributes the laxative effect to the hygrometric action of the gelatin. The glycerin suppository of the shops is also very effectual. The known effect of the galvanic current in producing contraction of the uterine muscular fibres suggests its employment to relieve constipation by stimulating the muscles of the abdomen and the muscular coats of the intes- tines ; and those who have employed it speak favorably of its use. Habershon says : " A galvanic current, transmitted through the abdominal walls, induces a very speedy action, or rather emptying, of the colon. .... A case of partial paraplegia, in which injections did not act satisfactorily and drastic purgatives were undesirable, was treated by a galvanic current passed through the abdomen every morning. In a few hours a free evacuation was produced without any discomfort." But the constipation of children very seldom requires the use of galvanism. The ordinary purgatives should not be given habitually to relieve a con- stipated habit. They are liable to irritate the intestines, causing a catarrh, or else the intestines become accustomed to their action and a larger dose is needed to effect purgation. Given habitually, they cannot fail also to disturb the digestive and nutritive processes. One or two doses for present relief, both in habitual and temporary constipation, are sometimes required, provided that an injection is for any reason not preferred. For this purpose, castor oil or a few grains of calomel mixed with syrup of rhubarb, the syrup of senna, or the compound liquorice-powder of the German Pharmacopoeia, may be administered with advantage. But for habitual constipation I strongly advise to discard the ordinary purgative medicines, and, if the measures of a dietetic or hygienic character recommended above are not sufficient, to employ such remedial agents as promote, or at least do not impair, nutrition. 764 LOCAL DISEASES. Probably the best purgative for habitual use is rnaltine with fluid extract of cascara sagrada. Belladonna, so highly recommended by Trousseau and others. I have often administered to children, especially in pertussis, in large doses during several consecutive days, but it has not seemed to me to have any decided laxative effect. Though it may be useful in certain mixtures for adults, our experi- ences in this country with reliable preparations certainly have not been such as to justify its employment as the sole or main remedy for constipation. It diminishes reflex irritability, and may render the action of purgatives less painful, but from its known physiological effects we cannot believe that it increases the intestinal secretions or the action of the muscular fibres, one or the other of which results we expect from the use of an agent which is really laxative. On the other hand, nux vomica and its active principle, strychnia, are doubtless valuable adjuncts to purgative mixtures from their effect in increasing the action of muscular fibres. Physicians are not infrequently at a loss what to prescribe for the habitual constipation of nursing infants, which is by no means infrequent. But recollecting that colostrum is more laxative than ordinary milk, and that it differs from it in containing more sugar, salts (largely phosphates), and butter, we have a hint, as stated above, as to what is probably lacking in the milk, and what, therefore, should be supplied. I am in the habit of giving the oil, sugar, and salts in the following formula, and usually with the desired laxa- tive effect : R. 01. morrhuae, 2 parts ; Aq. calcis, Syr. calcis lactophos. , da. 1 part. One-quarter, one-third, or one-half teaspoonful may be given with each nursing, or a larger quantity, as a teaspoonful or more, three times daily. Breast-milk with this addition becomes more nearly like colostrum in its laxative properties, while it does not possess those properties of colostrum which disturb the digestive process. I know no agent of a medicinal nature which meets the indication so well as this for infantile constipation. But in my practice I have found it necessary, in not a few instances, to rely mainly on enemata of glycerin and water for the relief of the constipated habit till the infants reached the age when a mixed diet was proper. The habitual constipation of older children may ordinarily be relieved by the remedies recommended above, but occasionally a more active purgative effect may be needed. Since the portion of intestine which is chiefly impli- cated in ordinary forms of constipation is the colon, it is evident that if it be necessary to employ frequently any of the active purgatives of the Phar- macopoeia, such should be selected as produce little or no irritation of the long tract of the small intestines, while they stimulate the function of the colon. The aloetic preparations are used for this purpose, as the tincture of aloes and myrrh or the simple tincture of aloes, which may be given in dose of part of a teaspoonful in a convenient syrup or in coffee or milk. But I think a preferable remedy is maltine with fluid extract of cascara sagrada, as recommended above, a half teaspoonful of which may be given daily, if necessary, to a child of eight years. INTESTINAL WORMS. 765 CHAPTER XI. INTESTINAL WORMS. The belief has been prevalent in the profession in former times, and is now among the people, that worms in the intestines constitute a frequent disease, especially in children. As pathology and the means of diagnosticat- ing diseases are better understood, this idea has been gradually abandoned by physicians and the intelligent portion of the community. Still, these parasites must be considered an occasional cause of serious derangements, and in rare instances a cause even of death. They indeed often exist in small numbers without producing any appreciable deviation in the individual from the healthy state ; but the most common and best-known species, when they have once effected a lodgement in the intestines of man, ordinarily grow and multiply so as to produce symptoms and require medicines for their expulsion. So far as is now ascertained by observations in different countries, about fifty animal parasites make their abode in man. It is not improbable that the number will yet be found greater by observations in distant uncivilized countries. Of these fifty, twenty-one reside in the alimentary canal (Heller), several of them being microscopic. Of those occupying the intestines only, the following species are specially interesting to the practising physician on account of their relation — for the most part causative — to certain path- ological states : to wit, the ascaris lumbricoides, or round-worm ; the oxyuris vermicularis, or thread-worm ; the bothriocephalus latus ; and three species of taenia, or the tape-worm ; and the trichocephalus dispar, or whip-worm. Ascaris Lumbricoides. — The round-worm has a dingy reddish or yellowish- red color and a cylindrical form, tapering toward both extremities from the point of its greatest diameter, which is a little posterior to the middle. The dead worm is paler than the living. The anterior extremity is tipped with three nodules, between which and the body is a circular groove. Between these nodules anteriorly is the aperture of the mouth, from which the oesoph- agus extends to the distance of one-fourth to one-third of an inch. The intes- tine, which has a light brownish color, extends from the oesophagus to near the posterior extremity of the animal, where it terminates in the anus. The fe- males are in numerical excess of the males, and their size is also greater. The shape of the worm is like that of the common earth-worm, from which it derives the name lumbricus, but it is somewhat more pointed and its color paler red. The tail of the male worm is curved like a hook, while that of the female is straight. The total number of eggs contained in a fully-developed female has been estimated at sixty millions. The eggs when immature are conical and are attached to a longitudinal band ; when mature they are oval, with dark gran- ular contents and a strong double shell, and their diameter is about --i--^ of an inch. They are expelled in countless numbers with the feces, and at the time of expulsion are surrounded by an albuminous coating stained with bile. Their vitality is retained under apparently very unfavorable circumstances, even for years. They hatch after they have been repeatedly frozen or desiccated. The ascaris lumbricoides inhabits the small intestines, where it is rapidly developed from the embryonic state. The remark made by Heller, that when found in the colon it is always dead, cannot be true, for many live worms are expelled in the stools. 766 LOCAL DISEASES. The round-worm, more than all other intestinal worms, is inclined to wan- der away from its usual abiding-place — namely, from the jejunum and ileum — producing symptoms of more or less gravity referable to the part over which it crawls. It occasionally enters the stomach, from which it is vom- ited, or it ascends the oesophagus into the fauces, from which it is soon removed by the efforts of the individual. Cases are on record — one of which Andral witnessed — in which the worm entered the larynx, producing suffoca- tion and speedy death. M. Tonnelle also witnessed such a case. A child nine years old was suddenly seized with great difficulty of respiration and pain in the upper part of the chest. A careful examination of the thorax gave a negative result. Death occurred in from twelve to fifteen hours, and at the post-mortem examination a iumbricus was found filling the cavity of the larynx. M. Blandin also witnessed a case when interne of the Hopital des Enfants. An infant was suffocated by one of these worms, which had pene- trated as far as the right bronchus. Very rarely they crawl from the fauces into the nasal passages. This worm is so strong and active that there is no recess or reflexion of the mucous membrane of the digestive apparatus which it could possibly penetrate in which it has not been found. It has been dis- covered in the appendix vermiformis. in the pancreatic duct, in the common bile-duct, and even in the gall-bladder. The number of these worms found in the intestines varies. There may be only one worm or the number may be incredibly large. Thus, Barrier relates the case of an infant thirty months old who died in Hopital Xecker. It was believed to be tubercular. Numer- ous tumors which could be felt in the abdomen were supposed to be tuber- cular masses. On making the post-mortem examination the mesenteric glands were found healthy, but the intestines throughout their entire extent were filled with lumbrici. The masses which during life were supposed to be tubercular glands were found to consist of worms. The caecum especially was greatly distended by them. The intertwining or collection in balls of these worms constitutes, indeed, one of the chief dangers, as it renders them so much the more difficult of expulsion. The round-worm possesses no organs of penetration ; still, if the intestine be weakened by disease, especially by ulceration, it may, by pressure with its head, force an opening, through which it escapes into the cavity of the abdo- men, causing peritonitis and death. This worm is commonly found, whether single or in masses, surrounded by mucus, which serves as a partial protec- tion to the intestines. The length of the male round worm is about four to six inches ; that of the female, eight to ten inches. The portion of the mucous membrane in contact with lumbrici is often found inflamed, either from movements of the worm or from pressure of a mass of worms, or even of a single worm in a confined position, as the appendix vermiformis. This inflammation, continuing and increasing, may end in ulceration, and thus a weakened spot be produced which may be rup- tured by simple pressure of the mouth of the worm. In this way are to be explained those apparent cases of perforation which have led some observers to believe that lumbrici have actually the power of penetrating the healthy coats of the intestines. The perforation is obviously most liable to occur in those who have been enfeebled and whose tissues have been rendered less firm and resisting by antecedent disease, as by typhoid fever. M. Guersant describes a case in which the appendix vermiformis con- tained an ulcerated opening through which two round-worms had partly passed into the abdominal cavity, producing fatal perityphlitis. The effect of their impaction in this narrow cul-de-sac was much like that of a bean or a seed lodged in the same situation. The ascaris lumbricoides has occasionally been found in the most remark- INTESTINAL WORMS. 767 able locations — namely, in abscesses lying without the intestines. They have been known to effect a lodgement in the liver and produce an abscess there, no doubt by crawling up and distending a bile-duct. Their lodgement in other viscera which have no pervious connections with the intestinal tract is probably accomplished through fistulous openings produced by inflamma- tion, which they had no part in causing, as, for example, in the bladder and kidneys, of which there are well-authenticated cases. Worm -cysts in the abdominal walls have been found to occur in most instances in the usual site of hernias — namely, at the umbilicus in children and in the inguinal region in adults. It is presumed, therefore, that the worms had entered hernial protrusions, from which they had passed by ulceration into the abdominal walls, and had there become encapsulated. The oxyuris vermicula/ris, or thread-worm, so called from its resemblance to pieces of ordinary white sewing-thread, is also frequent in childhood and not infrequent in the adult. The length of the male oxyuris is from one- sixth to one-fifth of an inch ; that of the female, from one-third to one-half an inch. The posterior extremity of the male is blunt, and is curved or rolled up toward its abdomen ; that of the female is slender and pointed like an awl. The head of this worm is relatively broad, from an unusual thickness or fulness of the cuticle, and the mouth, surrounded by u three nodular lips," is situated in the centre of the extremity. The oesophagus extends back- ward from the mouth, gradually growing larger like the segment of a long and narrow cone, and ending in a globular enlargement which has been desig- nated the pharynx. From the pharynx the intestine runs in nearly a straight line through the worm. The eggs are numerous, so completely filling the interior of the female as to conceal the organs from view. They are flattened on one side, but are rounded or convex on other parts of their circumference. One end is more pointed than the other, as in the eggs of birds. Certain of the eggs in the mature female are seen to be undergoing segmentation preparatory to hatch- ing, while others more advanced contain tadpole-shaped embryos, and others still contain worm-shaped embryos either lying within the shells or protrud- ing from them. The hatching and growth of this worm, which have been observed under the microscope, are very rapid under favorable circumstances. '• I once," says Heller, " saw the metamorphosis from the tadpole-shaped embryo to the worm-shaped embryo completed in about one hour," but the usual time is longer. Leuckhart saw oxyurides one-fourth of an inch in length fourteen days after the eggs had been swallowed. Oxyurides may be developed so rapidly from eggs swallowed in the ingesta that they attain nearly or quite their full growth while still in the small intestines, so that, although their chosen residence is in the large intes- tines, some of them are not infrequently found in the ileum, and even in the jejunum, of full size and active. The part of the intestinal tract which the oxyurides prefer, and in which the largest colony of them reside, is the caecum and appendix vermiformis, and not in the rectum, as stated in most of the books; and in this situation, where they have been little disturbed, their habits and the relative proportion of the sexes can be best observed. But they are ordinarily found both in the caecum and rectum in the same individual, and indeed upon all parts of the intervening surface of the colon. The number of oxyurides in the individual varies greatly. They are occasionally so numerous upon the intestinal surface that the} 7 resemble fur, and when they are so abundant they are commonly found above the ileo- caecal valve as well as below it. The males are smaller and apparently more fragile and perishable than the female. Therefore in the rectum and other 768 LOCAL DLSEASES. exposed situations there is a numerical excess of the females ; but in reflex- ions of the intestines, where they are securely lodged, as in the appendix vermiformis, no marked difference has been observed in the relative number of the two sexes. Since the males are more delicate, transparent, and smaller than the females, they are more likely to be be overlooked in a hasty post-mortem examination. The term tape-worm is applied to several species of the taenia and to at least two species of the bothriocephalus, but all except four — to wit, the taenia solium, taenia saginata or medio-canellata, taenia elliptica or cucumer- ina, and the bothriocephalus latus— are rare in Europe and North America, and are therefore of little interest to the practising physician. The tape-worm is an hermaphrodite, each segment containing the two sexual organs. The head, or scolex, is small, or about the size of a pin's head, and segment after segment is produced by a budding process from the head. The segments are attached to each other at their extremities, and each segment as it becomes farther and farther removed from the head by the formation of new intervening segments at the upper end of the chain, becomes also larger and more matured. The oldest segments, having attained their full growth, are detached, and have an independent existence. A separation of the chain of segments at any point does not compromise the life of the parasite. If only the head remain uninjured, the segmentation continues from it, and in time the former number of segments and former length of the chain are restored. This worm resides in the small intestines, the larger species sometimes extending from the upper part of the jejunum to near the ileo-caecal valve. The taenia solium is developed from an embryo known as the cysticercus cellulosae contained in the muscles of the hog. It has also been found in some other animals, as the dog, deer, and polar bear. It is a vesicle about the size of a pea or small bean, having a delicate cell-wall, and is nearly spherical, except as its shape is changed by compression between the muscu- lar fibres. At one point of the cell-wall is a depression, attached to the inner surfaces of which, and lying within the cyst, is a whitish, pear-shaped, solid body, which is the head of the cysticercus, and is identical in appear- ance and character with the head of the taenia solium turned inside out. Many experiments have shown the close relationship of the cysticercus and taenia solium — that they are two forms of existence of the same parasite. Segments of the taenia solium have been repeatedly fed to pigs, and the cysticercus produced in their muscles, though in what way the ovum or embryo passes from the stomach to the muscles is not known. On the other hand, swine-flesh containing cysticerci has been fed to animals who were soon after killed, when the taenia was found in their intestines. It is evident that this parasite occurs only in those who eat swine-flesh, as sausages, either raw or but slightly cooked. The head of this species of taenia, which is about the size of a small pin's head, has at the top a conical protuberance, upon which is a corona of hook- lets arranged in two circles, the hooklets of the outer circle being smaller than those of the inner. The projecting points, however, of the two rows fall together, forming one circle. The hooklets are inserted into depressions in the head, and many of them have fallen out in most specimens which we have had an opportunity of examining. The depressions in which the hook- lets are lodged are often dark from pigmentation. Back of the circle of hooks are four sucking disks, which the worm is able to protrude and move freely. When protruded they appear as small tubercles with slender pedi- cles. The neck, which is slender and about one inch in length, shows mark- ings from commencing segmentation, and it is succeeded by very small and INTESTINAL WORMS. 769 delicate segments, which gradually increase in size as the distance from the head increases. The mature segments (proglottides) vary in size accordingly as they are in a state of contraction or relaxation. When relaxed their length is about half an inch and breadth one-quarter of an inch. The genital organs are situated on the margin of each segment, a little posterior to the middle, and there is an alternation in their location between the right and left margins in the chain of segments. The uterus lies in the centre of the segment, form- ing a longitudinal straight line. From seven to twelve branches are given oft' from each side of the uterus, and these divide and subdivide like the branches of a tree. The male genital organs lie in the same aperture or pore in the margin of the segment, with which the uterus and ovaries connect. The eggs of the taenia solium are globular, with a diameter of about yi^th of an inch, and with thick shells, which are striated like mosaic-work by lines which cross each other. It is estimated that not less than fifty mil- lion eggs are contained in all the segments of a matured taenia. This parasite is very liable to abnormal development. In some instances two or more segments are fused together, and often they are stunted in their growth, or they contain holes, fissures, and flaws, either from their original development or produced by rupture of the distended uterus. Again, rarely, two taenia are blended, so that along the flat side of one chain another is united by the margin, so that a section of the double parasite resembles the Roman letter T or Y. The nutrition of the segments is maintained through a vessel running the whole length of the worm near each margin and having communicating branches. The taenia saginata, designated also medio-canellata, is much larger, stronger, and thicker, both as regards the head and segments, than the taenia solium. When fully matured it measures eighteen feet. The diameter of the head is nearly one line (yf-g- inch). It is furnished with four strong sucking-disks, but it lacks the circlet of hooks which characterizes the taenia solium. Instead of the hooks the head is furnished with a small frontal sucking-disk. The heads of some specimens of this worm are free from pigment, but other specimens present various shades of pigmentation, from a slight staining to a jet-black color. The neck is short, and very near the head are markings which indicate commencing segmentation. The matured segments vary in measurement when relaxed — from a length of eight lines and breadth of two lines to a length of nine lines and breadth of three lines. As in the taenia solium, the genital pores are situated on the margins of the segments, vary- ing irregularly from side to side, and the uterus has lateral branches which divide dichotomously. There is but little difference in the sexual apparatus of the taenia solium and taenia saginata, but the eggs of the latter are some- what larger than those of the former, and are oval. The development of the taenia saginata is sometimes irregular, producing monstrosities, as in the taenia solium. The embryos of this parasite occur chiefly in the muscles of ruminating animals, as the ox, sheep, goat, etc., and therefore its presence in man is attributable to the use of the flesh of these animals, either slightly cooked or raw. The cysticercus of this species appears to be less tenacious of life than that of the taenia solium, and when it perishes it becomes changed into a greenish-yellow pulp, surrounded by the capsule and imbedded in the muscular or other tissue where it had lodged. It is easy to distinguish this worm from the taenia solium, if the head be found, by its larger size, the larger size of its sucking-disks, and the absence of the circle of hooks. The segments are distinguished by their greater size and greater number and the dichotomous division of the branches of the 49 770 LOCAL DLSEASES. uterus. This species occurs over a mucli greater area of the earth's surface than the taenia solium. The taenia elliptica or cucumerina is a more delicate worm than the pre- ceding species, measuring, when fully grown, from seven to ten or eleven inches in length. Upon its head is a rostellum or beak, which the worm is able to thrust forward, and on which are about sixty hooks irregularly arranged. The anterior portion of the parasite is very delicate, like a thread, and its segments are small, but, as in the other species, they become larger as their distance from the head increases. The matured segments, which have a reddish-white color, are readily detached, and when separated they move about actively. This taenia is also an hermaphrodite, and a genital pore con- taining a double set of genital organs is located on each margin of the seg- ment. The taenia elliptica inhabits the small intestines of the dog and cat, and many children in different localities have been affected with it. Heller states that the segments of another and rare species of taenia, which were expelled from a child of nineteen months, are preserved in the Museum of Pathological Anatomy in Boston. Nearly in the middle of the posterior half of each segment is a yellow spot — namely, the receptaculum — full of ova. and therefore the name flavo-punctata has been applied to this worm. Little is known in regard to the taenia nana and taenia Madagascarien- sis, since they occur in distant countries. The hotliriocephalus lotus is the largest of the tape-worms, attaining the length of fifteen to twenty-four feet. It is one of the most important of the intestinal parasites. The head has an almond-shape or the shape of an elongated and somewhat flattened globe, its length being about one line and its diameter from one-third to one-half a line. Running longi- tudinally along each flattened side of the head is a groove or fissure contain- ing the apparatus of suction. Those segments which are still in the process of growth have a breadth three or four times greater than their length, while the matured segments are nearly square. The genital pore occurs in the centre of one side of the segment, and in the chain of segments all the pores are found on the same side. A brownish, rosette-shaped spot is observed at the site of each ripe pore, produced by the convolutions of the uterus and the numerous eggs which this organ contains. The egg. which is oval, has a thin shell, a light-brown color, and at one end of it is a lid or operculum which is separated from the rest of the egg by a well-defined line. At the hatching an embryo provided with six hooks escapes from the lid. When it has separated from the egg it is provided with an albuminous covering from which cilia radiate in all directions, by the move- ment of which it is propelled. After a few days this covering is lost, and the embryo now moves about by amceboid extension and contraction. It is believed that in this embryonic state it enters an aquatic animal, a mollusk or fish, where it undergoes further development, and from the mollusk it is received into the stomach in the food. The bothriocephalus occurs not only in man. but also in some of the domestic animals which eat fish, as the dog. This parasite is believed to be rare outside of Europe, and in Europe it is chiefly met in countries bordering on inland lakes and seas. The trichocephalus dispar is comparatively unimportant to the physician, since it is uncertain whether it materially impairs the health or produces symptoms. It inhabits the caecum, but in rare instances it has been found in the ileum and appendix verniif oralis. The number of these parasites is usually small, but as many as seventy to one hundred have been observed in the intestine of the adult. The trichocephalus dispar occurs also in the monkey, and a very similar INTESTINAL WOBMS. 771 if not identical worm has been found in the pig. It is not frequent in children, and has not been observed in the very young. It occurs in man in every part of the globe, and in some countries, as Egypt, Nubia, and Syria, it is said to be very common. This worm, which is also sometimes desig- nated the whip-worm from its shape, attains the length of one and a half to two inches, the female being longer than the male. Its anterior two-thirds are thin, delicate, and flexible, like a small thread. The posterior one-third, which contains the generative organs and intestinal canal, is considerably thicker, and it ends abruptly. On the under surface, extending nearly the whole length of the body, is a longitudinal band, the width of which is about one-third the circumference of the body. In the female the posterior or thick portion of the worm is slightly bent or curved like the stock of a hunt- ing-whip, while that of the male is rolled in the spiral form. The digestive tube consists of an oesophagus, which extends through the anterior thread- like part, and the stomach and rectum, which lie in the posterior thick division. The genitals of the female lie in the commencement of the thick portion, and the uterus, when distended with eggs, occupies nearly the whole of this section. In the male the pore which contains the genitals lies in the posterior extremity of the thick part, where it forms a cloaca with the termi- nation of the intestinal canal. The eggs, which are numerous, are oval, brownish, and with a glistening protuberance at each extremity, giving them the shape of a lemon. They have great vitality, hatching after repeated desiccation and freezing. Their development from the egg is slow. It is believed that the trichocephalus is produced directly from the egg, which has lodged in the intestine, and therefore does not have or require an inter- mediate stage of preparation in another animal. This parasite resides in the caecum, but when many are present some are found in the ascending colon, and occasionally a few are observed in the small intestine. The taenia is rare in early life, but it now and then occurs in young chil- dren. I have met cases in this city under the age of five years. Rosen and Bremser report cases between the ages of six and eleven years, and Hufe- land one at the age of six months. Wawruch collected 206 observations of taenia, in 22 of which the age was less than fifteen years ; the youngest was a girl of three years. A most remarkable case of taenia is reported in the Gazette medicate of Paris in 1837. M. Muller was called to treat a foster- child five days old for slight constipation. The bowels were evacuated by the use of rhubarb, manna, and a few grains of salt, and in the excrement a foot and a half of taenia were discovered. This worm had evidently existed during the foetal life of the infant. A similar case was treated by Prof. Skene in the Long Island Hospital in September. 1871, and reported by Dr. Armor. 1 The infant was born Septem- ber 3d of a hearty Irish servant-girl. On the 7th it refused to nurse, and was observed to have a mild form of tetanus. On the 8th, small doses of calomel having been given, followed by castor oil, two segments of a taenia solium were passed from the bowels, and on subsequent days ten more seg- ments, after which the tetanus ceased. The remedies employed after Sep- tember 8th were the oil of male fern and turpentine. The mother, who had presented no symptoms of taenia, was ordered an emulsion of pumpkin-seeds, which " she faithfully took for twenty-four hours, at the end of which she passed over seventy segments of taenia." This case is interesting as throw- ing light on a possible mode of the production of taenia quite different from the ordinary and recognized mode, and also as showing the causative relation of intestinal worms to tetanus infantum. Causes. — It is obvious that intestinal worms are developed from eggs or 1 New York Medical Journal. 772 LOCAL DISEASES. embryos which are introduced into the stomach in the ingesta. The eggs of the ascaris lumbricoides have been found by Mosler * in drinking-water, but it is_ probable that in most instances they are contained in fruits and vegetables which are eaten raw. The eggs of the oxyuris vermicularis are received from some one who is himself aifected with the disease. Both Zender and Heller state that they have frequently discovered ripe eggs of this worm around the nails of persons who were troubled with oxyurides — a fact readily explained from the itching which they cause. If these eggs are upon the fingers of the mother or nurse, it is easy to understand how they are acquired by the child. We can understand also why this worm is so common in degraded and filthy families. In reference to the etiology of the tape- worm nothing need be added to what has been stated above, and little is known in reference to the manner in which the eggs of the trichocephalus are received. Certain conditions of the intestinal surface favor the recurrence of worms. Thus children in advanced typhoid fever are not unfrequently affected with the ascaris lumbricoides. Symptoms of the Ascaris Lumbricoides. — These are in part constitu- tional and in part local, due to the mechanical effect of the entozoa on the coats of the intestines. Writers, especially Billiet and Barthez, have described with minuteness the symptoms supposed to indicate lumbrici. Those of a constitutional character are the following : Features at one time flushed, at another pallid, and in some children of a leaden hue ; lower eye- lids swollen, and sometimes surrounded by a blue semicircle ; thirst, nausea, or even vomiting ; appetite diminished or augmented or variable ; breath foul ; papillae of the tongue red and projecting ; pulse accelerated and irreg- ular. Billiet and Barthez state that they observed this irregularity of the heart's action in a boy three years old at the time he was passing a large number of lumbrici. The irregularity afterward disappeared. Acceleration of the pulse and increase in temperature are common symptoms of these worms, and hence the popular belief in a worm fever. This fever is often remittent and mild, but occasionally it is continuous and of a high grade. The symptoms pertaining to the nervous system are important. In mild cases these may be absent, as when there are few lumbrici and the child is robust and over the age of five years, but in severe cases certain neuropathic symptoms are frequently present, such as dilatation of the pupils, especially inequality of dilatation, to which Munro attached diagnostic value, strabis- mus, twitching of the muscles, clonic convulsions, somnolence, headache, neur- algic pains, delirium. Barely, chorea, deafness, and paralysis, it is believed, may result. 2 Dr. Leedom 3 of Montgomery county. Pa., relates the case of a boy of seven years who had night-blindness due to a large number of lum- brici in the intestines. By the employment of pinkroot and calomel these were passed and the blindness ceased. Hypersesthesia of the abdominal surface was present in a case which I attended, and which subsided as soon as the lumbrici were expelled. Grinding the teeth in sleep and picking the nos- trils are symptoms to which families attach great value. Observations, how- ever, show that though sometimes due to worms they more frequently have another cause. The local symptoms or disorders — in other words, those having a mechan- ical origin — are colicky pains, experienced chiefly in the umbilical region ; stools sometimes natural ; in other cases diarrhoea with fecal or muco-san- guineous stools ; flatulence. M. Davaine at a recent period made the import- ant discovery that the feces of patients affected with worms contain the ova 1 Virchovfs Archiv, 1860. 2 Gaz. de Hopitaux, 1867. 3 Amer. Journ. of Med. Sci., for July, 1867. INTESTINAL WORMS. 773 of the particular species present in large numbers. These ova. which have been described above, can be seen through a lens magnifying one hundred and fifty diameters. In exceptional cases there are local symptoms, due to the presence of these worms in unusual situations, such as a crawling sensation in the oesoph- agus : a sense of constriction in this tube or the pharynx ; nausea and vomit- ing : a cough, especially if the worm have crawled to the upper part of the] oesophagus ; rarely the most urgent dyspnoea and probable suffocation if a lumbricus have entered the larynx. Earache and perhaps convulsions if the worm have entered the Eustachian tube (case Davaine, p. 144). The most dangerous symptoms arise from the crawling of the worm into narrow openings. The enteritis and colitis to which these worms sometimes give rise are ordinarily mild, but in rare instances ulceration occurs, which may be attended by profuse and even fatal hemorrhage. Occasionally very painful and dangerous constipation results from an accumulation of worms in a ball or mass too large to be expelled, unless with much delay and suffering, prevent- ing the passage of fecal matter and producing severe abdominal pains. The symptoms in these cases resemble closely those of intussusception. A marked example of constipation produced in this way occurred in a family with whom I am acquainted, and who then resided in the interior of this State. A little girl of three or four years was suddenly affected with obstinate constipation. The physicians prescribed active purgatives, calomel among others, and finally croton oil and various injections, without relief. There was great pain with distention of the abdomen, and death seemed inevitable, when after the lapse of several days a free evacuation occurred, and in the stool was a mass of worms firmly intertwined. Children often have lumbrici without any appreciable impairment of the general health, but their presence may intensify the symptoms of inter- current diseases and greatly increase the danger. Thus I recollect two children of three and three and a half years with pneumonia who at the same time had lumbrici, one passing in the course of a few days thirty and the other twelve of these entozoa. Both presented well-marked physical signs of pneumonia, and, though they recovered, the fever and nervous symptoms were apparently aggravated by the intestinal affection. One had convulsions in the commencement of the inflammation, followed by profound stupor and amaurosis lasting two or three days. Often the symptoms due to lumbrici coexist with those of a protracted and distinct intestinal disease. Thus, as we have seen, the intestinal secre- tions of typhoid fever and of chronic diarrhoeal maladies afford a nidus for the growth of worms, and accordingly at an advanced stage of these diseases lumbrici are common. The symptoms produced by the oxyuris vermicularis are somewhat differ- ent. These worms do not usually cause the fever, disturbed digestion, the colicky pains, or the dangerous nervous symptoms which arise from the presence of lumbrici. Nor do they, like lumbrici, endanger life by crawling into unusual situations. In one recent case I could detect no other cause of chorea than the presence of oxyurides, and eclampsia has been attributed to them, but such a result is exceptional, if indeed the cause be rightly assigned. Although the caecum is the chosen abode of this worm, and here more than elsewhere it exists in its normal state, it is not certain that it produces any appreciable symptoms in this part of the intestinal tract. The symptoms which render this the most annoying of all the intestinal parasites are produced by these oxyurides, chiefly the females, which descend 774 LOCAL DISEASES. into the rectum, where by their active movements they produce intense itch- ing. A small number of worms cause little inconvenience, but when many are present in the folds of the rectum their crawling produces such intense pruritus that the patient can with difficulty remain quiet. Usually this symptom is most marked in the early evening, when the child is warm in bed. It sometimes causes onanism in the girl as well as boy. This symptom may be nearly or quite absent during the day, but it returns so regularly at night as to resemble and be mistaken for a periodical nervous affection. So eminent a physician as Cruveilhier confesses that he has made this mistake of diagnosis. In the female child the oxyuris occasionally passes from the rectum to the vulva, producing leucorrhoea. In many instances tape-worms exist in children as well as adults who thrive and present no symptoms, but in other instances there is more or less disturbance of the digestive function, with an uncomfortable sensation in the abdomen. This sensation is more noticed after fasting or after the use of certain kinds of food, and it is diminished by a full meal. Great hunger and a feeling of faintness are also common, according to authorities, but I have not particularly remarked them in children. Irregular action of the bowels, vomiting and various nervous symptoms, as itching of the nostrils and anus, headache, tinnitus aurium, cardialgia, numbness, deafness, blindness, etc. have with more or less correctness been attributed to the tape-worm. Cer- tainly, such symptoms occasionally arise from this cause, for they cease with the expulsion of the worm. 1 Intermittent colicky pains in the umbilical region were the only marked symptoms in a child with taenia which I recently treated. Since the cysticercus cellulosse is the embryonic form of the taenia solium, it is quite possible that individuals possessing the latter may be infected from its ova with the former, so that symptoms which have been attributed to the intestinal parasite have sometimes been due to the encysted embryo. We are unacquainted with the symptoms of the tricho- cephalus, if any occur, and this worm is very rare in children. Diagnosis. — Bremser long since made the remark — and it has been repeated by most writers on diseases of children — that there is no sign or symptom which affords positive proof of the presence of intestinal worms except the expulsion of one or more. In recent years, however, microscopic investigations have revealed a pathognomonic sign — namely, the presence of ova in the feces, which indicates not only the nature of the disease, but the species of the worm. The symptoms and disorders produced by lumbrici may all occur from other causes. Still, if several of them be present and a careful examina- tion disclose no other cause, the presence of worms should be suspected, provided that the child be over the age of two years. The microscope may then be used for diagnosis. A little tentative treatment, entirely safe to the child, will also determine whether the suspicion be correct. One or two doses of medicine, administered under such circumstances, like the surgeon's exploring needle may reveal the nature of the disease and indicate the means of cure. In the case of the oxyuris vermicularis the itching directs attention to the anus as the place of the disease, and here the offending entozoa may often be discovered by the eye. Prognosis. — Intestinal worms produce a fatal result in only a small pro- portion of cases. Oxyurides never prove fatal, unless in rare instances through convulsions. The manner in which death may be produced by lumbrici has already been pointed out. In general, when the nature of the disease is ascertained the worms are 1 Medico-Chir. Rei\, January, 1868. INTESTINAL WORMS. 775 readily expelled by treatment and the patient restored to health. Therefore, if there be no complicating disease, the prognosis is good. Treatment. — Much injury has been done to children by the use of anthelmintics occasionally employed by physicians, but oftener by parents before the physician is called. Medicines of this kind are usually irritants, and. in many of those diseases which simulate the verminous affection, but are distinct from it. there is already an irritated if not an inflamed state of the intestinal mucous surface. Vermifuges administered under such circumstances obviously do harm, and in all acute diseases in which they are not required, even if their action be harmless, their employment is to be regretted, since it consumes time, which is very precious. It is thus that many lives are lost by the use of anthelmintic nostrums which are extensively advertised and which command a ready sale, inasmuch as the belief in the presence of worms as a frequent cause of disease pervades all classes. A safe rule, followed by many physicians — and it would be much better if it were general — is not to give anthelmintics unless the child have passed one or more worms or their ova be found in the feces, and not then if the symptoms seem to be referable to a coexisting disease. In doubtful cases in which the symptoms resemble those of worms a purgative dose of calomel or calomel and rhubarb may be employed. It will generally bring away one or more lumbrici or a mass of ascaris vermicularis if either species of entozoa be present. This purgative may be safely employed if there be no previous diarrhoea or debility. If after one or two doses and a free purgation no worms be passed, anthelmintic remedies should not be given, for it is almost certain that none exist. A large number of medicines have been employed for the purpose of expelling lumbrici. Santonin, the active principle of the European worm seed, is one of the best, and is much employed in this country and in Europe. It is nearly tasteless ; it may be given in powder spread on bread with butter. It is kept in shops in one or two-grain lozenges, with and without calomel. It has the advantage of easy administration, and is destructive to both the round- and thread-worm. M. Bouchut considers it preferable to all other remedies in the treatment of the round-worm. " To children two years of age he administers it in doses of ten centigrammes (1.54 grains), and in patients above this age the quantity is increased by five centigrammes (0.75 grain) for every additional year." He gives in addition occasional doses of calomel or castor oil. In this country santonin is usually administered in one- to three-grain doses once or twice each day, with an occasional purga- tive. The purgative is required to aid not only in the expulsion of the worm, but also of the ova. In over-doses santonin causes vomiting, diarrhoea, and altered vision, so that objects appear yellow, but in medicinal doses it pro- duces no unpleasant consequences. Other medicines are preferable if there be symptoms of enteritis. Treatment by santonin from two to three days suffices. For many years the anthelmintic most employed in this country was the pinkroot, the root of the Spigelia marilandica, an indigenous plant. It was not only prescribed by physicians, but employed by families as a domestic remedy. It is liable to cause, if the dose be large, cerebral symp- toms, as vertigo, dimness of sight, spasm of the facial muscles, stupor, and even convulsions. These effects less frequently occur if the pinkroot be given with a purgative, and it has been customary to administer it in com- bination with senna in an infusion. A half ounce of spigelia with an equal quantity of senna is macerated for two hours in a point of boiling water and then strained. For a child two or three years old the dose is half an ounce to one ounce. So popular has this vermifuge been in this country that 776 LOCAL DISEASES. probably a majority of the native-born old people in the States recollect the nauseating doses of pinkroot administered by anxious parents. Pharmacy now provides us with the same medicine in a more convenient and acceptable form, that of the fluid extract: R. Fluid ext. spigel., f^j ; Fluid ext. senna?, fgss. — Misce. One teaspoonful to a child from three to five years. The officinal fluid extract of spigelia and senna may be given in the same dose as the above. Professor Proctor recommends the addition of santonin to this extract : R. Fluid ext. spigl. et senna?, 15 j ; Santonin, gr. viij. — Misce. This is probably the best anthelmintic that can be employed for the destruc- tion of the round-worm in uncomplicated cases, and it is also very useful in treating the ascaris vermicularis. Chenopodium is also a good anthelmintic. It is efficient, and at the same time one of the safest in case the mucous membrane be inflamed. If there be abdominal tenderness, with stools too frequent and thin or mucous and tinged with blood, I should prefer the chenopodium to most of the other vermifuges. To a child of three years five drops of the oil may be given three times daily. It may be continued for a longer period than would be safe for most of the other vermifuges. Twice a week, during its use, a mild purgative should be given, as castor oil, rhubarb, or magnesia, unless the bowels are open. It may be given dropped on sugar or in a mucilaginous mixture. Dr. J. F. Meigs says : " I myself rarely give any other remedy than wormseed oil in slight and especially in doubtful cases, unless this has already been tried and failed. From my own experience I believe that this remedy is all-sufficient in a large majority of the cases that occur in this city, as these are almost always of a mild character, and as it not only produces the expul- sion of the parasites when they exist, but also acts beneficially upon the forms of digestive irritation which simulate so closely the symptoms pro- duced by worms. I am persuaded, indeed, that of all the cases that have come under my notice in which it seemed probable that worms might be present, none were expelled in nearly half, and yet the signs of disturbed health have passed away under the use of this remedy." .... -'The follow- ing is a very good formula for the administration of this remedy : " R. 01. chenopodii, gtt. lx vel f^j ; P. g. acacia?, t ^ij ; Syrup simplic, :?j ; Aq. cinnamom., Jij. — Misce. Give a dessertspoonful three times a day for three days, and repeat after several days." In cases of protracted intestinal disease attended by an increased and vitiated secretion from the mucous surface, a state which often gives rise to worms, turpentine is one of the best anthelmintics. In fact, in some of these cases there is no good substitute for it. For example, a boy of about ten years, attended by myself, October, 1864:, had reached or nearly reached the fourth week of typhoid fever, when he passed from his bowels a large quan- tity of blood. He was previously emaciated and weak, and there had been, as is usual in such cases, considerable diarrhoea. The hemorrhage was R. Spts. terebinth, rect, 3y; Ol. limonis, gtt. v ; Mucil. gum. acac.j Syr. simplic, da. gvj ; Aq. anisi, Sii-iij Dose : One teaspoonful every six hours. INTESTINAL WORMS. 777 attended with great prostration, from which, however, he partially rallied by the use of stimulants. On the following day an equally severe hemorrhage occurred, attended with coldness of the face and extremities and great feeble- ness of pulse, so that death appeared imminent. Turpentine was now admin- istered every six hours, a few lumbrici were passed, and the case thenceforth progressed favorably. The mechanical effect of the lumbrici on the ulcerated surface of intestine had probably given rise to the hemorrhage. Turpentine may be given in doses of from five to ten minims three times daily to a child five years old. Sweetened milk or sugar in powder is a good vehicle for it, or it may be given in a mucilaginous mixture : -Misce. The following formula for the employment of this agent is recommended by Dr. Condie : R . Mucil. gum acac. , ^ij ; Sacch. alb., ^x ; Spts. aether, nitr. , ^iij ; Spts. terebinth, rect., ^iij ; Magnes. calcinat., ^j ; Aquse mentha?, ^j. — Misce. It is useless to enumerate the many anthelmintic mixtures which, have been extolled from time to time. Those mentioned above are the least nauseous, and rarely disappoint the practitioner. One other antidote for the round-worm should be mentioned, as it has been much used and is efficient — namely, cowhage. This consists of the bristles which cover the pods of the Mucuna pruriens, a tropical plant. The pods are dipped in plain syrup of the ordinary consistence, and the bristles are scraped off with the syrup. When enough of the medicine is added to render the syrup of the consist- ence of thick honey, it is ready for use. The dose is a teaspoonful every morning for three days, after which a cathartic should be administered. I have never prescribed cowhage, although it is not unfrequently ordered by physicians, and a popular nostrum consists chiefly of it. One affected with tape-worm is obviously cured only when the head of the parasite is expelled ; but in the majority of cases which I have observed the head has not been found in the evacuations, even when the treatment had effected a complete cure, as shown by the subsequent history. The chain of expelled segments commonly terminates very near the head. This, I believe, is the common experience if we trust the friends of the patient with the examination of the stools. The physician himself should search for the worm's head, the evacuations being preserved. The nurse should be directed to add a little carbolic or salicylic acid, and a sufficient quantity of water to nearly fill the vessel. The liquid should not be roughly stirred with a stick, as physicians are in the habit of doing, since this breaks the worm into small portions and renders the inspection more difficult, but it should be shaken frequently, so as to detach the segments and head, if it be present, from the fecal matter. After it has stood at least five or ten minutes, the worm, which has greater specific gravity than water, sinks to the bottom, and the upper part should be poured off. This process must be repeated till the water is nearly colorless, after which search should be made for the fragments, and the head, if present, will be found. 778 LOCAL DISEASES. Since entire expulsion of the tape-worm is effected with difficulty, pre- paratory treatment for about forty-eight hours should be employed before the vermifuge is administered. During this time the patient should take a mild purgative once or twice, and such food, in moderate quantity, should be allowed as leaves little residuum, as beef tea, milk, etc., with some stimu- lant if the patient feel exhausted. There are three articles of food which experience has shown to be especially useful in this preparatory treatment, perhaps from a sickening effect which they produce upon the worm — namely, salt herrings, onions, and garlic. They may therefore be taken as food in the twelve or eighteen hours preceding the employment of the vermifuge, which it is ordinarily most convenient to administer in the morning. The various taenicides recommended in the books are probably all more or less efficient, but the one which has given most satisfaction in the Out- door Department at Bellevue, where probably a larger number of these cases are treated than in any other place in this country, is the oil of male fern \ but it is found necessary to employ a larger dose than is recommended in some of the books. For a child of six years the dose employed is one drachm in any convenient vehicle, as the syrupus aurantii florum. This should be followed in about four hours by a dose of castor oil, which completes the treatment. Heller, a high German authority, recommends koosso, or its active principle koossin, in the use of which I have had no personal experi- ence. The pumpkin-seed has also been employed at Bellevue and elsewhere under my direction, but it seems to be less efficient than the oil of male fern. If the chain of segments break near the head and the head be not seen, it will be necessary to wait two or three months in order to determine whether the cure is complete. The medical journals during the past year have published and extolled the following formula for the treatment of the tape-worm. It is difficult to expel the head, and teenicides employed singly so often fail in accomplish- ing this result that so powerful a combination of tsenicides deserves consid- eration, and perhaps trial. The dose recommended is probably for the adult> but a proportionate dose could be given to a child : R. Granati corticis radicis, jf ss ; Seminarum peponis, Jrj ; Pulveris ergotse, gj ; Aquse bullient, l^iij • — Misce. Fiat infus. R. Extracti filicis maris setheris, f^j ; 01. tiglii. nyj ; Pulveris acacise, ^ij. — Misce. Fiat emulsionem. Mix the emulsion with the infusion and give them at 10 a. m. A full dose of Rochelle salts should be given the previous evening, and no breakfast taken. We should hesitate to administer so powerful a remedy to a child under the age of eight years. Perhaps it might be best to recommend one-quarter or one-third of the above dose to a child of eight years, and half the dose to one of twelve or fifteen years. Since the symptoms produced by the oxyuris vermicularis are referable chiefly to the rectum, and are caused by the active movements of the worm, the prompt and thorough use of enemata, which causes their expulsion, is evidently required. Enemata are more effectual if used cool than if warm ; and since this worm inhabits the caecum as well as rectum, large enemata INTUSSUSCEPTION. 779 given through a long tube or a large catheter are more effectual, causing the expulsion of a larger number of worms than are expelled by small enemata employed in the usual manner. Various substances have been used for this purpose, as lime-water, table salt in water, turpentine in milk, decoction of aloe, decoction of garlic, etc. Heller says : " Simple water would do well for this purpose, for in a short time it causes the worm to swell up and burst ; but it is not altogether without an injurious effect on the intestinal mucous membrane. Hence. Vix recommends a solution of castile soap in distilled water or rain-water of the strength of one to two and a half grains to the ounce. This has no unpleasant action on the intestinal mucous membrane, while at the same time it quickly destroys both the worms and their eggs. .... Yix has tested all the medicine in general use in enemata, and has found the above solution of castile soap to be the most effectual." The use of the enema in the evening, although only a small quantity of liquid be employed, so as to wash out the rectum, ensures relief from the itching and sleeplessness during the night. But it is undeniable that enemata alone do not effect a complete and per- manent cure in a large proportion of cases, and hence those affected with this worm remain sufferers for years, having only a temporary respite, unless medicines be administered by the mouth. Those medicines which produce free watery evacuations appear to be the most effectual in dislodging and expelling oxyurides. whose attachment to the intestinal surface is not strong ; therefore Heller recommends the saline purgatives "joined with copious draughts of water." The solution of magnesium citrate found in the shops is useful for this purpose. CHAPTER XII. INTUSSUSCEPTION. Intussusception, or the passage of one portion of intestine into another, has long been known as an occasional accident. Hippocrates, though debarred from the study of morbid anatomy, appears to have had a pretty clear idea of this displacement, and he suggested a mode of treatment which has been employed till the present time. Intussusception without Symptoms. This is not properly a disease. It consists in a displacement without any other anatomical change. There is, therefore, no obstruction, inflammation, or even congestion present, and no symptoms. This form of invagination might ordinarily be reduced by the normal peristaltic and vermicular move- ments of the intestine. Invagination of a portion of the small intestine into the part immediately below it is often observed at the post-mortem examination of young infants who had presented no symptoms due to the displacement. The invaginated mass is usually from half an inch to two inches in length, and as a rule this accident is multiple. There may be ten or more distinct intussusceptions at distances of a few inches from each other. The simple displacement is believed to occur ordinarily at or a short time prior to the moment of disso- lution. It has been supposed to be most frequent in those who have died of 780 LOCAL DISEASES. cerebral or spasmodic diseases, but its occurrence is not unusual in other pathological states. I have often found it at the post-mortem examination of infants who have had subacute or chronic entero-colitis. Heven states that he has seen it at the Salpetriere more than three hundred times. Billard has seen it especially in infants who have been subject to constipation. Any irritant, mechanical or other, which disturbs the regular movements of the intestines doubtless may produce it. It has been caused in the rabbit by irritating the anus. It is not improbable that simple intussusception occasionally occurs tem- porarily in children whose health remains good when the regular movements of their intestines are disturbed by irritating ingesta or other causes. This form of displacement never takes place in the large intestine. Its usual seat is the lower part of the jejunum and upper part of the ileum. Since it pos- sesses little interest as regards pathology, and none whatever as regards symptomatology and therapeutics, it may be ignored in our description of intussusception. Intussusception with Symptoms. Intussusception, or invagination, is one of the most painful and danger- ous of human maladies, but fortunately it is not very frequent. I have the records of 52 cases occurring in children in addition to the records of sev- eral cases more recently observed. From these the facts contained in this chapter are chiefly derived. The patients were under the age of twelve years. Previous Health. — In 34 of the 52 cases the state of the health pre- viously to the invagination was recorded. From the following table it is seen that one-half, or 17, were previously well, the remaining half suffering from some disease or derangement : Previous Health. Age. Good. Disease or Derangement. One year or under 15 8 Over one year _2 9 17 17 MM. Rilliet and Barthez, whose views in reference to intussusception are derived from the examination of the records of 25 cases, state that the pre- vious health is ordinarily good, and the intussusception is therefore primary. Their remark, according to the above statistics, is seen to be correct as regards patients under the age of one year, but incorrect for those over that age. Most of the 17 who had previous ill-health had diarrhoea, dysentery, or constipation, or diarrhoea alternating with constipation. Of those otherwise affected, 1 had thread-worms, 2 obscure abdominal pains, 1 nausea and vomit- ing, and 1, whose age was four months, had had symptoms of invagination when ten weeks old, which soon passed off. It is seen that the pre-existing affections were ordinarily such as would be likely to accelerate the movements of the intestines and at the same time render them irregular. Causes. — The above statistics, therefore, show that intussusception is often preceded by disease or functional derangement of the intestines. The two opposite conditions — namely, constipation and the diarrhoeal maladies — so often precede the displacement that they must be regarded as common causes. Another probable cause is intestinal worms, which by their mechani- cal action stimulate the intestines. They were present in 3 of the 52 patients, though 2 of the 3 seemed well till the occurrence of the intussusception, but the other patient had complained of irritation at the anus, and ascarides had been found on examination. 3 were 3 months old. 2 " 4 ti a 3 " 5 a u 5 " 6 a (i 1 was 7 u a 1 " 8 n a 3 were 9 a (i IXTUSSUSCEPTION. 781 The use of irritating and indigestible food is an occasional cause. Thus, some who have had intussusception have been in the habit of eating fruits, candies, and pastries freely. Such ingesta may be an immediate cause by their irritating effect, or a remote cause giving rise to diarrhoea, which in turn produces intussusception. Sex is a predisposing cause, since male patients are largely in excess. Of the 25 cases collated by Rilliet and Barthez, all but 3 were boys. In our own collection the sex of 34 of the patients was recorded, and of these 23 were boys. In rare instances external violence is the apparent exciting cause. One patient received a severe contusion of the abdomen two years before death, and from this time continued to complain at intervals of pain in the bowels. One writer also mentions the case of a child nine years old who received a blow from a comrade at school, and from this time had alternately diarrhoea and constipation till the invagination commenced. Rilliet and Barthez also relate the cases of two children who were taken suddenly with invagination when their parents were tossing them in their arms. Age. — Of the 52 cases embraced in our statistics, the ages were as follows : 1 was 10 months old. 1 " 11 " " 1 « 12 " 2 were from 1 to 2 years old. 8 " " 2 " 5 " " 8 " " 5 "12 " " 3 not given. Therefore, no cases occurred under the age of three months ; 23 cases were between the ages of three and six months, or nearly one-half of the entire number ; 8 between the ages of six months and one year ; and only 18 between the ages of one year and twelve. These statistics correspond, in the main, with those of Rilliet and Barthez, in whose collection of 25 cases no one was under the age of four months. Leichtenstern l says : " Half of all invagina- tions, according to my statistics of 473 cases, occur during the first ten years. The first year after the third month is remarkable for a special frequency — one-fourth of all intussusceptions." The great liability to intussusception in infancy is due partly to the ana- tomical character of the intestine in this period of life, and partly, doubtless, to the fact that there are more frequent irregularities in the intestinal move- ments than in older children. In the infant the walls of the intestines are thin, the mucous and muscular coats and the connective tissue being much less developed than in those that are older ; the mesentery and mesocolon have also greater depth as compared with the same in other periods of life, except the mesocolon at the points where it passes over the kidneys, in which places it is very short or even in some cases nearly absent. Moreover, the space occupied by the large intestine, in which part of the digestive tube intussusception commonly occurs, is much shorter relatively to the length of the intestine than in those that are older. In about thirty measurements which I have made of the length of the large intestine and the space occupied by it the latter was found, on the average, about one-third that of the former, which of course necessitates doubling of the intestine on itself. These pecu- liarities of structure in the infant obviously favor the occurrence of intus- susception. Seat and Pathological Anatomy. — While intussusception occurring 1 Ziemsseri's Encyclop. 782 LOCAL DISEASES. without symptoms is usually multiple, that form which occurs with symp- toms is ordinarily single. Two exceptional cases which I observed will be presently related. In one of the cases embraced in the statistics an invag- ination occurred with symptoms, and coexisting with it was another in the small intestines apparently without symptoms and quickly reduced by handling. While intussusception without symptoms occurs in the small intestine, the seat of intussusception with symptoms is, with occasional exceptions, the colon. The colon constitutes the entire invaginated mass, or else and more frequently it forms the exterior, while the incarcerated portion consists wholly or in part of the ileum. Intussusception in the Small Intestines. Bouchut says : " M. Rilliet states in a recent treatise that in infancy the intestinal invagination is always accomplished at the expense of the large intestine, and that there is never invagination of the small intestine. This is incorrect. I have observed the small intestine invaginated in the adjacent inferior part. Taylor has reported a case of this kind in a child twenty months old who died after an attack of acute peritonitis. M. Marage has seen another case in a child thirteen months old, who recovered after having voided the invaginated portion furnished with two of those diverticula so frequent in the small intestine of the foetus." But, from all that appears, the case reported by M. Marage may have been, and probably was, an example of the common form of intussusception — to wit, the prolapse of the ileum into the colon. In Mr. Taylor's case the invagination was really of the ileum into the colon, although a small por- tion of the ileum next to the valve had not been inverted, so that it con- stituted a little of the exterior of the mass. Nevertheless, Bouchut is correct in stating that irreducible and fatal intussusception may occur in the small intestines. Probably the displace- ment is at first of the simple variety, but, continuing and increasing in extent, its return becomes impossible. The positive statement of so great an authority as M. Billiet, that intussusception with symptoms does not occur in the small intestines, justifies the publication of the following cases, which establish the fact that there are instances, though not frequent, in which the displacement does have this location : Case 1. — This patient's health had been uniformly good, and nothing unusual was observed in his condition till the age of four and a half months, when he became restless, as if in almost constant pain, with occasional exacerbations. Castor oil was prescribed, which operated freely, and then the following mixture : R. Magnes. calcinat., £)j ; Tinct. opii camphorat., ^ij ; Tinct. asafoet. , ^ss ; Aq. anisi, ^j. — Misce. Dose : Ten to twenty drops, repeated according to the pain. These remedies failed to give relief, as did also chloroform given in doses of two drops. After two or three days another set of symptoms arose, those cha- racteristic of pneumonia — to wit, hurried respiration, accelerated pulse, short, suppressed cough, and expiratory moan. He was treated with the oiled-silk jacket and mild counter-irritation, and took an expectorant mixture containing ammonium carbonate. In a few days the pulmonary disease was evidently sub- siding, but the pain in the abdomen, with occasional exacerbations, continued. His countenance was pallid and bore an expression of suffering. There was no distention or tenderness of abdomen and no abdominal tumor. He took little nutriment and seldom vomited. In the last part of his sickness the dejections INTUSSUSCEPTION. 783 were scanty, and the last three days his stools consisted mainly of mucus and a little blood. The pain seemed to be growing less when he was seized with con- vulsions, and died the same day, precisely two weeks from the commencement of his sickness. Sectio Cadaver. — Head not examined ; body slightly emaciated ; mucous mem- brane of trachea and bronchial tubes vascular ; posterior portion of the lower lobe of each lung solid, of greater specific gravity than water, and allowing only partial inflation ; it was in the second stage of pneumonia. Stomach, duodenum, jejunum, healthy. In the upper part of the ileum was an intussusception two-thirds of an inch long, presenting no trace of inflammation either within or around it, and its vascularity, when it was examined externally, did not seem notably increased. Above the intussusception the intestine was empty •, below it, and chiefly in the small intestine, was a dark-colored substance, evidently blood, and giving in a few hours the offensive odor of decaying animal matter. There was a passage through the intussusception at least two or three lines in diameter, as shown by a probe. The intussusception sustained the weight of sixteen inches of the intestine, and it would have apparently sustained considerably more. The remaining organs were healthy. Case 2. — F. S , a female infant four months old, was treated at the New York Infant Asylum in June and July, 1865, for entero-colitis, the usual epidemic of the summer season. The following records show the state of the bowels imme- diately before her death : June 29th : Has five or six stools daily. 30th : Two stools in twenty-four hours. July 1st: Had two stools since the last record; no vomiting. 3d: Four stools in Fig. 212. last twenty-four hours. 4th : The diarrhoea continues, as before ; the stools about four daily. On the 6th of July she died. Her pulse during the time in which these records were taken generally num- bered about 128 per minute. She was much emaciated, and the day before death she frequently struck her head with her hand. The medicines employed were mainly alkalies and astringents. Sectio Cadaver. — Parietal bones united ; serous effusion over the convolutions of the brain, under the arachnoid ; occipital bone depressed ; commencing at a point about two feet below the stomach were four intussusceptions two or three inches from each other. The invaginated masses were from one to one and half inches in length, and three of them were found to be very vascular in their interior. Above, between, and immediately below the intussusceptions the intestine was healthy. One of the invaginations was tested by weight, and was found to sustain a foot 784 LOCAL DISEASES. and a half of intestine, and would have sustained more. Water poured above these intussusceptions escaped through them very slowly ; no fibrous exudation - y descending colon vascular and thickened and solitary glands enlarged. The irreducible character of the intussusceptions in the above cases was shown by the fact that they sustained weights which doubtless produced greater traction than that exerted by the intestine in its normal action. That the displacement existed prior to the moment of death was shown by the symptoms in one of the cases and by the anatomical changes in both. In one the capillaries of the incarcerated mass were ruptured during the last days of life, so as to produce sanguineous stools, while in the other there was intense congestion of the invaginated mucous membrane, and that portion of this membrane which was adjacent, but not engaged, was healthy. In both patients the symptoms were less severe than in ordinary cases, and they came on more gradually, for the invaginated intestine was not com- pletely closed, so that it allowed the passage of fecal matter in one till the close of life, and in the other till near its close. At both of the autopsies water poured into the intestines above the invaginations passed slowly through them. Intussusception in the small intestines in the infant, commencing as the simple form, may become irreducible, and yet, remaining pervious, may con- tinue for weeks without giving rise to severe or dangerous symptoms. The following case was an example of this : Case 3. — Male child, died at the age of nineteen months, the last eleven of which he was under observation. The mother states that he had never been well since the age of one month, and that there had been little variation in the symptoms of his disease. During the period in which he was under observation he was ordinarily fretful, and frequently seemed to be in considerable pain. His stomach during this whole time was so irritable that he rarely took more than three or four spoonfuls of nutriment without vomiting. There was usually more or less diarrhoea, but no tenderness or distention of abdomen. He became slowly but gradually more ema- ciated, and finally died in a state of extreme emaciation and exhaustion. He had no convulsions, and was conscious to the last. Sectio Cadaver. — Brain not examined ; lungs healthy, except a circumscribed portion which was inflamed at the summit of the right lung ; liver small and almost destitute of oily matter, as shown by the microscope. In the jejunum, about two feet below the stomach, was an intussusception two inches long, the intestine form- ing which seemed to have undergone no structural change. Above the intussuscep- tion the intestine was of small calibre, and entirely empty and pale; below the intussusception the intestine was somewhat larger than above, but it seemed quite healthy. The invagination was sufficiently pervious to allow water to pass through it, and it readily sustained the weight of two feet of intestine. From eight to ten inches below this intussusception there was another, which was immediately drawn out the moment the intestine was disturbed. The other abdominal viscera were healthy. There is uncertainty as to the duration of the intussusception in the above case, but the symptoms indicated that it existed a considerable time prior to death. There was no strangulation, nor indeed any appreciable anatomical alteration in the coats of the intestine, but the fact that the invaginated mass sustained two feet of intestine and required considerable traction for its reduction shows that it was not a case of simple displace- ment occurring at the moment of death and without symptoms, but was an example of the variety with symptoms. Intussusception in the Large Intestines. In most cases of intussusception occurring in infancy and childhood the ileum is invaginated in the colon or the first part of the colon is invaginated IXTUSS USCEPTION. 785 in the part succeeding it. Intussusception not infrequently begins in the prolapse of the ileum through the ileo-caecal valve, in the same way that pro- lapse of the rectum occurs through the sphincter ani. If death take place early, only a small portion of the ileum may have passed the valve. If the case' be protracted, the tenesmus brings down more and more of the ileum, with its accompanying mesentery. The constriction of the valve, which acts as a ligature, soon prevents the further descent of the ileum ; and, the tenes- mus continuing, the next step in the displacement is the inversion of the caput coli. which is drawn into the colon by the descending mass, and unless the case terminate by sloughing or death, the ascending and transverse portions of the colon are successively invaginated. The records show that intussusception occurs as above stated in a large proportion of cases. In one case among those which I have collated the invagination began a few inches above the valve, so that the ileum constituted a small portion of the exterior of the mass. Occasionally the caecum is the part primarily inverted and invaginated, and, descending along the colon, it draws after it the ileum, which sustains its natural relation to the ileo-caecal valve. When this occurs the caecum is found at the lower end of the mass, and two orifices are observed, one leading through the valve and the other into the appendix vermiformis. These two forms of invagination — that in which the ileum, passing through the ileo-caecal valve, successively inverts and draws after it the caput coli and the divisions of the colon, and that in which the caput coli is primarily invaginated, and, descending along the large intestine, in- verts the latter and draws after it the ileum — constitute the vast majority of cases of this disease in the first years of life. I have notes of 45 fatal cases occurring under the age of twelve years in which the portion of intestine first displaced is recorded. In 4 of these the displacement was entirely in the small intestine, involving in no way the colon ; in 38 cases it commenced either by prolapse of the ileum through the ileo-caecal valve or by the inversion of the caecum into the ascending colon, there being perhaps not much difference in the relative frequency of these two modes ; in one case the invagination was confined to a segment of the transverse colon, in another to a segment of the descending colon, and in the remaining case to the lower part of the descending colon and the upper part of the rectum. In three instances the invaginated mass itself became invag- inated, producing an intussusception of great thickness, and necessarily fatal. Intussusception is sometimes attended by so little constriction of the incarcerated portion that it remains pervious. In such a case life may be protracted for weeks or even months without reduction of the displacement or any material change in it, the passage of fecal matter being sufficiently free for the maintenance of life. Death finally occurs in a state of exhaus- tion. Thus in one instance a child four months old lived six weeks after the symptoms of invagination commenced, and seventeen days " with a portion of the bowel protruding from the anus." It was found at the post-mortem examination that part of the ileum had descended through the entire colon, and had remained pervious. In a case related by Dr. Worthington 1 symp- toms of intussusception were present for seven months before death, and during the last six weeks of life the invaginated intestine protruded fre- quently from the anus, and was replaced by the mother. In this case " the caecum was inverted, and, descending through the colon to the lower portion of the rectum, carried with it the ileum and the entire colon except the last ten or twelve inches." In another case the symptoms indicated a continu- ance of the disease for three, if not eight, months. But such cases are ex- 1 Amer. Journ. of Med. Sci., for January, 1849. 50 786 LOCAL DISEASES. ceptional. Ordinarily, as the intestine becomes invaginated its mesentery or mesocolon is also invaginated and its veins compressed. The pathological state of the incarcerated mass soon becomes that of intense congestion. In infants, usually in a few hours, so great is the distention of the capillaries that they give way, blood escapes into the intestine, and passes from the bowels in scanty motions. On examining the invaginated intestine after death, if gangrene have not occurred, it is found of a uniformly intense red color, sometimes resembling to the naked eye a long and firm clot of blood. In those who die early no traces of inflammation are seen, but in more pro- tracted cases the attrition between the serous surfaces excites local peritonitis. In none of the fifty-two cases which I have collated, in which post-mortem examinations were made, did the inflammation extend more than a few lines beyond the invagination. Usually the intestine forming the exterior of the invaginated mass is much drawn together or puckered. In one case treated by myself the entire large intestine which formed the exterior of the mass was compressed within a space of six inches or less, since about twelve inches of the ileum, doubled on itself, lay within the entire colon and pro- truded from the anus, the only part of the large intestine which was inverted being the caput coli. In one case six or seven inches of the ileum, which formed a portion of the exterior of the mass, were compressed within the space of one inch. The abdomen, at first of natural fulness and soft, usually becomes more and more distended till the close of life ; but in case of much vomiting the distention is moderate. The fulness is due to gas and fecal accumulation above the invagination. The portion of the intestine below the displacement is ordinarily empty, except that in the infant it commonly contains mucus, mixed with more or less blood which has escaped from the capillaries of the strangulated mass. There are few anatomical changes in this disease which do not arise directly from the intussusception, and are therefore located either within the mass or in its immediate vicinity. In those who recover by the process of sloughing the cicatricial contraction may give rise to symptoms and lesions of greater or less gravity. Thus the late Sir James Y. Simpson examined a child aged nine years who recovered with loss of ten inches of intestine, and, at the meeting of the Medical Society ] before which the specimen was presented, he remarked that there was unusual distention of the cutaneous veins of the patient, due probably to such compressions of the ascending vena cava by the cicatrix that the venous circulation was obstructed. Mr. Charles King 2 relates the case of a child aged six years who on the eleventh day of the disease voided the caecum and a part of the colon. Two days subsequently pulsation ceased in the left leg, and all that part below the patella became gangrenous. The patient gradually recovered with loss of the leg. The cause of this unfortunate sequel was doubtless compression from the cicatricial contraction around the artery which supplied the leg, and probably the formation of a thrombus. Dr. F. Bush 3 relates a case in which he was enabled to observe the extent and appearance of the cicatrix. The patient, aged twelve years, discharged from the bowels fifteen to eighteen inches of the ileum on the eighth day of the intussusception, after which convalescence was rapid. Fourteen weeks later the child died from tj'phus fever, and at the autopsy '-traces of the diseased bowels were visible by a contraction and puckering where the slough had taken place and the parts united." But, fortunately, in most instances when the intestine sloughs and the child survives no serious or permanent injury results from the cicatriza- 1 Trans. Medico-Chir. Soc. Edin. 2 London Lancet, for 1854. 3 Load. Med. and Phys. Journ., for December 18, 1823. IXTUSSUSCEPTION. 787 tion. The cicatrix stretches little by little and accommodates itself to the surrounding parts. Symptoms. — The symptoms vary according to the age of the patient and the degree of strangulation. Pain in the abdomen, usually paroxysmal, is among the first and is one of the most conspicuous symptoms. It is often severe, resembling the pain of hernia, and abating only with the failing strength of the child. After the first few days, if inflammation arise, the pain is continuous, though more severe in paroxysms. At first pressure upon the abdomen is tolerated, but afterward there is tenderness. This is due to the inflammation which occurs in and around the invaginated mass, and it is therefore confined to the part of the abdomen in which the tumor lies. At this point also the abdomen is more full than elsewhere, and not infrequently the physician can feel the invaginated mass and detect its exact location and approximately its extent. Sometimes, at an early period as well as late, cerebral symptoms occur, as in a case related by Dr. Cogswell 1 which ter- minated in convulsions and death on the second day. Convulsions are, how- ever, comparatively rare, and the mind is generally clear till the last moment. In infants the countenance in the intervals without pain, in the first stages of the complaint, is often placid and not indicative of any serious disease, but in older patients constant and severe local symptoms, referable to the intus- susception, commence early. At an advanced period, whatever the age, the countenance becomes anxious and haggard, the eyes hollow or sunken, the body loses its plumpness, and, if the case be protracted, becomes emaciated. Vomiting is rarely absent ; in 39 out of 47 cases it is stated to have been present ; in 7 cases there is no record of this symptom, while it is recorded absent in only 1 case ; but in this case, the records of which are very meagre, death occurred on the second day. The vomiting becomes stercoraceous in a few days, and it ordinarily continues with greater or less frequency till the period of collapse. It relieves partially the distention. The appetite is impaired and often entirely lost. Infants at the breast commonly nurse, however, for several days, probably from thirst rather than hunger. In most patients one natural evacuation occurs from the bowels after the intussusception commences, and then obstinate constipation succeeds. This evacuation consists of the excrementitious matter below the invagination. In children under the age of one year scanty motions of blood mixed with mucus begin to occur in a few hours. Of 27 children under this age, I find that 24 had such evacuations, occurring in most of them several times in the course of the day ; in 2 of the 27 there is no record of this symptom, but in the remaining case it is stated to have been absent. Scanty evacuations of blood unmixed with fecal matter have been considered pathognomonic of intussusception in the infant, and we see the ground for such belief ; but in exceptional instances the invaginated mass is partly pervious, and although the dejections may contain blood, they are also excrementitious. In our col- lection of cases are 3 examples of this in infants under the age of one year. One has already been referred to. In this case there was the rare anomaly of so large an opening through the ileo-csecal valve as to allow not only prolapse and descent of the ileum through the entire colon, so as to protrude six inches from the anus, but also fecal passage through it daily. In children above the age of one year the capillaries of the invaginated intestines are not so frequently ruptured as under this age, and sanguineous evacuations are therefore less common. I have records of 19 cases between the age of one year and twelve, in only 6 of which it is stated that there were bloody motions, and in these the blood was not passed frequently, nor even 1 London Lancet, for July, 1853. 788 LOCAL DISEASES. in some cases daily, as in infants, nor in so pure a state, unless in 2 cases, the records of which are not explicit on this point. Two of these 6 patients passed moderate bloody evacuations after protracted periods of constipation, 1 had fecal discharges with the blood through the entire sickness, and in 1 blood was passed at first, but finally the stools were entirely fecal. In those above the age of one year obstinate constipation was ordinarily present, no dejections, either bloody or fecal, occurring for several days ; but there were a few exceptions. In 3 cases the bowels were relaxed. The ileum in these 3 had descended through the entire colon or the larger part of the colon, and, being pervious, the feces escaped from the anus without detention in the large intestine or with detention only in its lower portion, and were therefore liquid. Tenesmus is another symptom. It is not always present, but in a large proportion of cases, even when the invagination is in the upper part of the large intestine, it is a frequent and distressing symptom. It often does not commence till there is a considerable amount of displacement, and it ceases when the strength is much reduced. The temperature of the surface is normal in the commencement of intus- susception ; but finally, as febrile reaction symptomatic of the inflammation comes on, it rises and continues above the healthy standard till the intestine sloughs or till the stage of collapse occurs which ushers in death. The pulse, especially in the infant, is tranquil at first, but, whatever the age, it soon becomes accelerated from the paroxysms of pain, and subsequently from the inflammation which occurs in the invaginated mass. There is no disturbance of respiration, except that it is somewhat hurried from the fever and from the pain felt in advanced cases on full respiration. It will be seen that the symptoms vary in certain particulars under the age of one year from those occurring over that age, but differences in the symptoms depend more on the degree of invagination and constriction than on the age and exact location of the disease. Diagnosis. — The diagnosis of intussusception is not, in general, difficult, except at its commencement. When the inversion has reached that degree at which obstruction occurs, the symptoms are, in most cases, such that the disease can be readily diagnosticated. In the cases whose records I have col- lated a correct diagnosis was made with few exceptions, and at an early period. In the infant the disease for which intussusception is most frequently mis- taken is dysentery, on account of the tenesmus and the muco-sanguineous stools. In certain of the reported cases this mistake was not rectified until it was ascertained that purgatives produced no fecal evacuations. The symptoms which are commonly present, and which indicate the nature of the disease, are obstinate constipation, vomiting, paroxysmal pain referred to the seat of the disease, and tenesmus. In the infant also scanty evacuations from the bowels of mucus and blood or of pure blood are, as we have seen, an important diagnostic sign. It should be borne in mind, how- ever, that in exceptional cases the displaced bowel may remain pervious, and the usual symptoms which possess diagnostic value therefore be absent. There may be no vomiting or tenesmus, and diarrhoea may even occur in place of constipation, as in the cases related above. As an aid to diagnosis it should be stated that, whatever the age of the child affected with intussus- ception, clysters are often administered with difficulty, and are quickly and forcibly returned, on account of the resistance opposed by the invaginated mass. We have stated above that the seat and even extent of displacement can be ascertained in a large proportion of cases by digital examination of the abdominal walls. The tumor can be felt hard, elongated, and tender on pressure, so that the diagnosis is clear. If the invagination have extended IXTUSSUSCEPTIOX. 789 to the lower part of the large intestine, it can usually be discovered by an examination per rectum. Duration. — In the following table the duration of the intussusception in 49 cases is given as nearly as it can be ascertained from the records : 2 died the 1st day. 6 4 c< " 2d " 3d 2 (( " 4th 5 (( " 5th 2 ({ " 6th 2 u " 7th 1 lived over a week. 1 died the 8th day. 1 " " 10th " 1 " " 14th " 1 lived nearly a week, the exact time not being given. 1 lived six weeks. 3, time of death not given. 7 recovered. In 2 of the 3 cases in which the duration is not stated the patient lived much longer than the usual period. One of these 2, a girl of six years, having eaten raw carrots, was seized with pain in the abdomen, which lasted eight months, when she died. During the last three months she passed mucus and blood. In this case the caecum had descended to the anus, drawing with it the ileum, which remained pervious. The symptoms indicated the con- tinuance of the invagination for three months, if not eight. The other patient was a boy aged three years and four months, who complained of pain in the abdomen for many months, and occasionally vomited. During the last six weeks of his life all the phenomena of invagination were present. In this case also the inverted caput coli had descended the entire length of the colon, and at the autopsy it lay in the rectum. In West's Treatise on Diseases of Children (5th ed., 1866, p. 504) it is stated that death in this complaint always occurs within a week. The above statistics, however, show that there are exceptions to this statement, although a large majority do die within the first seven days. In 33 of the cases embraced in my statistics death occurred within the first week, and in no fatal case in which strangulation was complete was life prolonged beyond the eighth day. In these cases of complete strangulation the average duration was 3.7 days, and the largest number of deaths occurred on the third day. Death on the first day is rare, but it occurred in two of the cases embraced in my statistics. Death at so early a period usually takes place in convul- sions and coma. Prognosis. ^Intussusception is in its nature so grave an accident that the physician called to a case should always explain its gravity to the friends. But, while death is the common result, there are three different modes of termination in which life is preserved : First, the reduction of the incarcerated intestine, with immediate relief. There can be no doubt that it is possible for intussusception, when recent, to be reduced by the unaided action of the bowels, in the same way as the common, simple intussusception in the jejunum and ileum or as hernia is reduced, through the vermicular action of the intestines ; for sometimes, as in Dr. Coggswell's l case, the patients at some previous time have experienced the same symptoms as those which accompanied the attack, and which subsiding they remained for a time in perfect health. This termination is probably rare if the symptoms be sufficiently marked to necessitate treatment. Again, the intussusception may be cured by early and well-applied treatment. The physician often succeeds in reducing the displaced intestine, even if the intussusception be in the upper part of the colon, if he be called sufficiently early and employ the proper measures. A second mode of favorable termination is alluded to by certain foreign 1 London Lancet, July, 1853. 790 LOCAL DISEASES. writers. The intussusception continues for a considerable period with the cha- racteristic symptoms, and then, as Bouchut expresses it, " the vomitings grad- ually cease, the intestinal hemorrhage disappears, the strength returns, and the health becomes restored without the expulsion of fragments of the intes- tine/' What changes the displaced intestine undergoes in these protracted cases, which gradually recover without sloughing, have not been clearly ascer- tained, although they have been the subject of conjecture. According to Billiet, a large proportion of favorable cases terminate in this manner. It does not appear, however, from the statistics which I have collected that this is a common mode of recovery. The clinical history of intussusception estab- lishes the fact that in a large majority of protracted cases there is either death or the third mode of favorable termination — namely, by sloughing. But we cannot reasonably expect recovery in young children through sloughing and the expulsion of the intestine, since few have the requisite strength for so tedious and exhaustive a process. The youngest child that recovered in this way, so far as I have been able to ascertain, was an infant thirteen months old, whose case was reported by M. Marage. With the exception of this case the youngest was a boy aged five years. The older the child the greater, of course, the power of endurance and the better the prospect of recovery. Of the 52 cases whose records I have collated, 7 recovered by the sloughing and expulsion of the mass. These children were of the ages of five, six, six, nine, eleven, twelve, and twelve years. The sep- aration of the invaginated mass occurred in six of these between the sixth and twelfth days, with an average of nine and a half days. In the remain- ing case the time is not given. If, then, the patient can be carried through the first week without too much exhaustion, discharge of the slough, reopen- ing of the bowels, and ultimate recovery may possibly be the result. But in those cases in which the intussusception remains open, so as to allow the passage of fecal matter, recovery is improbable unless the displace- ment be diagnosticated early and properly treated. If the intussusception continue, it becomes greater and greater from the absence of strangulation. Without inflammation and with little or no congestion of the displaced por- tion, and without the severe symptoms which occur in ordinary cases, the patient wastes away, having irregular evacuations and more or less abdominal pain, and finally dies in a state of emaciation and weakness. In the early stage of this form of displacement it is not improbable that injections or inflation, employed with sufficient force, will give relief, but if the early period pass without such treatment, cure is impossible by the ordinary methods. It is in such instances especially — to wit, those in which the dis- placement occurs without strangulation or inflammation, and in which fecal matter passes through the displaced mass more or less freely — that laparotomy is justifiable, and is likely to give relief when injections and inflation have been employed in vain. Jonathan Hutchinson's successful performance of this operation in a child of two years who had this kind of displacement is known to most readers. 1 The prognosis is most favorable when the displacement occurs in the lower part of the large intestine, for its reduction is then comparatively easy. An interesting case of this kind was observed and treated by Drs. O'Dwyer, Beid, and myself in the New York Foundling Asylum in 1875. The child was a female aged two years, and had had previous good health. The invaginated mass protruded like a prolapse about four inches outside of the anus. It was cold, considerable hemorrhage had occurred from it, and the infant seemed in collapse. When the mass was returned so far as it could be carried within the pelvis by the index finger, the lower end of it could 1 London Lancet, November 22, 1873. INTUSSUSCEPTION. 791 still be felt like an os uteri. It protruded four or five times within twenty- four hours, but by replacement so far as possible with the fingers and the use of simple water injections, with the hips elevated, it was finally permanently reduced, and. with the use of stimulants, she soon fully recovered. Mode of Death. — This is different in different cases. It sometimes occurs from collapse. At a meeting of the New York Pathological Society, held December 10, 1873, I presented a specimen showing intussusception occurring about one foot above the ileo-csecal valve in an infant aged thirteen months. On the day before its death, its previous health having been good, it seemed ill, and vomited once or twice, but did not appear to be in pain. Ifc had two evacuations from the bowels, of the usual appearance, in the latter part of the day. On the following morning it was unexpectedly in collapse, and died within about twenty-four hours from the commencement of the sick- ness. At the post-mortem examination the cranium was not opened, but all the organs of the trunk were found normal except the intussusception. The mass involved in the displacement measured two and a half inches in length and was slightly crescentic. The mucous membrane above and below it had the normal appearance, as had that of the external or incarcerating portion of the mass, while that of the incarcerated part was deeply injected. Water poured into the intestine above the invagination was wholly arrested by it. 1 But in the majority of instances death occurs from asthenia, which comes on gradually, but increases rapidly in consequence of the pain, vomiting, and imperfect nutrition. Children dying in this way may have convulsive movements more or less marked, but the prevailing characteristic as death approaches is extreme exhaustion. In exceptional instances the life of the sufferer is cut short by convulsions before the stage of exhaustion is reached. Thus a child aged three years, whose case was reported by Dr. Isaac Thomas, 2 and another, aged two years, whose case was reported by Dr. Coggswell, 3 died in convulsions on the second day. Treatment. — It is unfortunate in cases of intussusception that the time in which treatment can be of most service is likely to pass by before the true condition of the intestine is detected. Invagination being comparatively rare, the patient is generally on the first day treated for colic or dysentery or some other common affection of the bowels, and it is often not till the second day, when the intestine has become incarcerated, that the physician accurately diagnosticates the disease. The purgative medicines often given in the commencement injure the patient. In fact, both reason and experience teach us the impropriety of using purgatives in this complaint. Cathartic remedies act as a vis a tergo, and may cause still further descent of the in- verted intestine. Yet such powerful agents of this class as quicksilver have been employed. It was administered in two doses of one ounce each in one of the cases embraced in my statistics, but none of the mineral passed the bowels. At the post-mortem examination a considerable part of it was found in small globules, coated with a black layer consisting of the sulphuret or black oxide of mercury, in the intestine above the intussusception. It need not be added that the case was speedily fatal. The proper treatment of intussusception consists in attempts to reduce the displacement by pressure from below. The pressure may be applied either by liquid injections into the rectum or by inflation of the lower intes- tine by air or gas. Injections should be made with lukewarm water, for cold or hot water may cause contraction of the muscular fibres of the intestine and increase the constriction. The child should be placed in bed or in the nurse's lap. 1 New York Medical Record, April 1, 1874. 2 Amer. Med. Recorder, 1823. 3 London Lancet, July, 1853. 792 LOCAL DISEASES. with the nates elevated 45°. With the common India-rubber — or, better, the fountain syringe — and the aid of an assistant the liquid should be gently thrown into the rectum until the abdomen is fully distended. By carry- ing the fingers, firmly but gently applied upon the abdominal walls, along the direction of the colon, the liquid is made to press against the lower end of the intussusception. The same gentleness and perseverance are required in kneading and pressing the abdominal walls as in the treatment of hernia by taxis. If the invagination be in the descending colon, probably only a small quantity of the liquid can be injected, and it may be forcibly returned, but by repeating the injections a sufficient quantity can ordinarily be introduced to obtain the full effect of the mode of treatment. There is also sometimes an increased irritability of the rectum, even when the intussusception is at the upper extremity of the large intestine, so that tenesmus and expulsive efforts follow the introduction of the instrument. The assistant can aid in overcoming this and in retaining the water by pressing the soft parts of the nates around the instrument. If the injection fail to reduce the displacement, it may be repeated after allowing the patient to rest for a while. In the New York Medical Journal for May, 1875, is the history of an interesting case which was treated by Drs. Church and Warren, and is reported by the latter. The infant was seven months old and had the usual symptoms, such as frequent parox- ysmal pain in the abdomen, vomiting, tenesmus, and scanty muco-sanguineous stools. On the third day injections were twice employed without result, but on the fourth day an injection of ten or twelve ounces reduced the displace- ment and the infant recovered. In a second case treated by Dr. Warren the age was nine months, and a tumor appeared a little above the umbilicus a few hours after the commencement of the symptoms. The following is Dr. War- ren's account of this interesting case, which will give a clear idea of the proper mode of treatment : " The patient was looking very pale and prostrated, the pulse was quick and feeble, and the skin cold. I at once determined to use fluid injections, and, with the little patient placed in a semi-prone position in his mother's lap, with an ordinary Davidson's syringe I commenced injecting tepid soap-and- water, but after perhaps a gill had been thrown into the rectum it was almost immediately rejected, very highly colored with blood, and mixed with it a very small quantity of mucus and fecal matter ; the latter, by the way. not hardened, but of the consistency of soft putty. In a second attempt the fluid was retained longer, but was after a little while discharged, with more blood and mucus, but with much less tenesmus and pain. " When, soon after, I made my third attempt, the child's chest was rested upon the side of its mother's lap, with the lower extremities elevated by an assistant, so that the position was at an angle of about 45°, anus upward. This time I injected the fluid very slowly, in order to avoid, if possible, the irritation caused generally by the frequent emptying and refilling of the syringe (which, by the way, is a very serious hindrance to the successful use of this syringe, and which renders it much inferior to the fountain or hydro- static). In this manner I succeeded in injecting, as I estimated at the time, perhaps ten or twelve ounces, and during the operation the child gradually became more quiet, and had, when I ceased, fallen asleep. Then, with the direction that occasional doses of tinct. opii camph. should be administered during the night, to control, if possible, the peristaltic action of the intes- tines, I left him. " On the following morning, to my surprise, I found the child sleeping quietly and naturally, and I was informed that at about 5 A. M. (six hours after my visit) he had a movement of the bowels, which was saved for my INT USS USCEPTION. 793 inspection, and consisted simply of the enema, slightly colored with fecal matter. From that time he seemed to be entirely free from pain, and six or seven hours later had a natural passage, after which recovery progressed rapidly, and in a few days he was discharged well." The following case is interesting as showing success from the use of injections after the lapse of two days in a severe case which had resisted treatment on the first day. The good result was apparently in great part due to the manipulation, which was made so as to press the water against the course which intussusceptions are known to take. On September 10, 1876, I visited, with Dr. Gillette, a nursing infant aged nine months whose history was as follows : It was habitually constipated, but it continued in its usual health till September 8th, on which day it was carried by its nurse to one of the city parks. After its return it began to be fretful ; it vomited and seemed to be in pain. It continued to vomit frequently, espe- cially after nursing or taking drinks, and in the ensuing night passed two scanty stools of mucus and blood without fecal matter. In the morning of September 9th, Dr. G-. was summoned, who found the pulse 180 and tem- perature 102°, and the matter vomitedgreenish like bile. In the evening the temperature was 102f°. Dr. G. diagnosticated intussusception, and employed injections of water, but they were returned without bringing fecal matter and without apparent result. He also administered opiates by the mouth. September 10th : Temperature 102f° ; features pallid, beginning to have a pinched or sunken appearance, and indicative of much suffering ; no nutri- ment is apparently retained on account of the frequent vomiting, and the bowels are obstinately constipated. As the symptoms indicated rapid sink- ing and collapse, consultation was called at 4 p. m. It was impossible to determine certainly, through the abdominal walls, on account of the disten- tion, whether there was any tumor, but it was my opinion and the opinion of one of the other physicians that a tumor, hard and inelastic, could be felt nearly in the median line between the umbilicus and the symphysis pubis. At about 5 P. M. the shoulders of the little patient were lowered and the nates elevated, so that the trunk formed an angle of perhaps 45° with the horizontal, and a large quantity of tepid water was gently passed into the intestine through Davidson's syringe, with the vaginal nozzle attached. It was impossible to estimate the quantity retained, since a considerable part of it escaped, although the anus was firmly pressed around the instrument. When the abdomen was distended as fully as seemed justifiable, the nates being still elevated, and the liquid retained, so far as possible, by firm pres- sure upon the anus, the abdomen was firmly and deeply kneaded by the hand, the movements being made chiefly from the right lumbar toward the right inguinal, and from the right inguinal toward the hypogastric region. The kneading was continued perhaps eight or ten minutes, and the water, which contained no perceptible amount of fecal matter, blood, or mucus, was allowed to escape. After this operation the child became quiet, slept, and the vomiting ceased. At our next visit, at 7 P. m., although the severe symptoms had in a great part abated and the countenance had lost that pinched and suffer- ing aspect which was so prominent before, it was deemed best, in consulta- tion, to repeat the injection, and this time through a rectal tube, which was introduced farther than the nozzle employed at the preceding visit. The body was placed in the same position as before and the abdomen kneaded in the same manner. The water, when allowed to return, brought no fecal mat- ter, but the last that flowed contained two shreds, the largest about one inch in length by two lines in width, resembling matted and nucleated epithelial cells. It was believed that they were composed of such cells, with perhaps 794 LOCAL DISEASES. some of the mucous membrane to which they were attached, and that they were detached from the invaginated portion. An opiate mixture was now prescribed, to be given sufficiently often to relieve any restlessness and keep the patient quiet, and a flaxseed poultice was applied over the abdomen. On the following day the temperature was 103J°, pulse 158, and the abdo- men somewhat distended ; but the vomiting had ceased, and there had been two fecal evacuations since our last visit. The intussusception had been relieved, the inflammatory symptoms soon abated, and the infant's health was fully restored. Gloodhart reports a case of cure by injecting a boracic-acid solution after the symptoms had continued seventy-six hours. The patient's age was eight months, and the tumor could be felt per rectum. 1 Humphreys relates two cases of recovery by injection of water thirteen and forty hours after the commencement of symptoms in infants of eight months and two years. 2 Butler also succeeded by water injections in reducing intussusception of thirty-six hours' continuance in a child of three years. 3 But injections of water have not always been successful. Chaffey failed to reduce invagination of the caecum and appendix in a " somewhat chronic " case, but inflammatory bands were found in their vicinity, 4 and Cripps ruptured the intestine by injecting water in a girl of eighteen months. The symptoms had continued four or five days and the tumor projected from the anus. Injections, in order to be effectual and give promise of success, should be aided by gravitation. The physician should remember to elevate the nates higher than the shoulders, as in the case related above. Treatment by infla- tion — which indeed ought to occur to any intelligent physician appreciating the anatomical condition of the parts as deserving of trial — was prominently brought to the notice of the profession in modern times by Mr. Samuel Mitchell. 5 " I take the liberty," he writes, " of suggesting to the profession, through the medium of your valuable periodical, the trial of inflating the bowels by means of a glyster-pipe attached to a common pair of bellows ; it has fallen to my lot to witness several of these most distressing cases in chil- dren ; the nature of the obstruction was foretold during life, and unfortu- nately verified by post-mortem examination, The last case of the kind which came under my care, about two years since, presented all the usual symp- toms — intolerable restlessness, the most obstinate sickness, the singularly dis- tressed state of countenance, and shrunken features. The usual remedies were had recourse to — viz. warm baths, glysters, anodyne frictions over the abdomen, etc. — but without avail. As a forlorn hope I made trial of infla- tion by the above means, with the most happy result. The sickness imme- diately ceased ; the child within an hour passed a natural stool, and in the morning was almost without ailment." This mode of treatment is termed novel in the Lancet, but it is really as old as the time of Hippocrates, who speaks of throwing air into the bowels, by which flatulence is imitated (flatus immitatur). 6 Haller 7 also recom- mended the same treatment : " Flatus etiam immissus celerrime susceptionem dispellet." Dr. David Greig 8 relates five cases of successful treatment of intussusception by inflation. The first, an infant six months old, previously in good health, suddenly became very fretful, apparently having severe paroxysmal pain in the abdomen. She had vomiting, and finally tenesmus, 1 London Lancet, Feb. 25, 1888. 2 Ibid., Oct. 27, 1888. 3 Brooklyn Med. Journ., Feb., 1888. 4 London Lancet, Julv 7, 1888. b Ibid., for March 17, 1838. 6 Hippocrates' Works, translated from the Greek by Grimm, 4 Bd. p. 198. 7 Physiologia Corporis Humani, torn. vii. p. 95. 8 Edinburgh Medical Journal, October, 1864. INTUSSUSCEPTION. 795 with bloody evacuations. Warm-water enemata could not be employed, on account, the writer thinks, of the spasmodic action of the intestines, and an abdominal tumor could be felt near the umbilicus. Castor oil and a purga- tive powder and enemata of water having been employed in vain, and the case becoming really critical on the second day, inflation was resorted to. The writer says : " The nozzle of a small pair of bellows was introduced into the anus, and air injected to a considerable extent. Contrary to our expecta- tion, the air passed readily into the bowel, and seemed to give the child great relief. After the injection it lay very quiet, as if asleep, and evidently quite free from pain. In about twenty minutes from the time the air injection was administered a slight rumbling noise was heard in the child's abdomen, fol- lowed by a crack so loud and distinct as to alarm the attendants in the room, who thought something had burst in the child's bowels. The child, however, continued as if asleep and free from pain, and in about half an hour a large feculent stool, slightly mixed with blood and mucus, was passed without pain. During the night the child rested pretty well, had no return of vomiting, took the breast as usual, and in two days was quite well." Another child, nine months old, treated by Dr. Greig, presenting nearly the same symptoms ami the abdominal tumor, also obtained relief by inflation after castor oil and enemata had failed to produce any benefit. An apparatus for the production and injection of carbonic-acid gas has been invented by Schultz & Warker, and is manufactured by them. It consists essentially of two glass chambers, one over the other. In the lower one a bicarbonate is placed, and in the upper an acid in a liquid state. By the gradual admixture of the two carbonic acid is set free. An elastic tube conveys the gas from the lower chamber. This apparatus has been used by physicians of this city for the reduction of intussusception and other purposes, and is a useful invention. Syphons of highly- charged carbonic-acid water, from which, when in- verted, a powerful current of the gas is evolved, may also be used for the purpose of reducing the displacement. Two or three of these bottles, with a portion of the tube from Davidson's syringe, which can be readily at- tached to the stem from which the gas escapes, constitute all that is required for an ordinary case. The following cases, which I have treated with Dr. Biichler in 1871, show what may be achieved by inflation, and also the unfavorable result which must inevitably occur in certain cases. A German infant five months old, nursing, began to be fretful, crying often, on March 7th, and before night passed a scanty motion of blood. The symptoms continuing, I was asked to examine the infant on the 10th, and learned the following facts : It had vomited daily, had had daily scanty but infrequent stools, consisting chiefly of blood, accompanied at first by tenesmus, but not within the last day ; it continued to nurse, but was becoming thinner and weaker, and was evidently in pain. The symptoms indicating the nature of the disease, the abdomen, which was not distended, was examined for the tumor, which was found on the right side in the site of the ascending colon, apparently about one and half to two inches in length ; pulse 124 in sleep ; no cough. An ineffectual attempt was made to reduce the intussusception by a very rude and imperfectly constructed apparatus (the bellows), when from the lateness of the hour further treatment was postponed till early the following morning. 11th. Tumor still detected in the right lumbar region; pulse 120 asleep, 150 awake. By means of Schultz & Warker's apparatus the intestines were inflated so as to produce very decided prominence of the abdomen, and the abdomen was gently kneaded. After some minutes the gas was allowed to escape, when it was seen that the tumor had disappeared. In a few hours 796 LOCAL DISEASES. a natural evacuation occurred from the bowels, and the infant has remained well since. The second case ended unfavorably, although the symptoms were appar- ently no more grave than in the case just related and had continued a shorter time. This infant was also of German parentage. The tumor, firm and elongated, could be distinctly felt in the left lumbar region. In this case the inverted bottles of carbonic-acid water were employed, and when, after considerable delay and kneading of the abdomen, the gas was allowed to escape from the intestine, the tumor had disappeared. A few hours after- ward convulsions occurred, ending fatally. At the autopsy the invaginated mass, which was too firmly strangulated to admit of reduction by inflation, was found in the epigastric region, having been carried up from its former position by the inflation of the intestine below. It consisted of the terminal part of the ileum, which had passed through the ileo-cgecal orifice, and had become incarcerated in the ascending colon, and, as is not unusual in these cases, the movements of the intestines had changed the location of the tumor in the abdomen from the right to the left side. In the London Lancet for Feb. 18, 1888, Cheadle reports a case of successful inflation in an infant of fifteen months, whose symptoms indicated intussusception of fifteen hours' duration, and the tumor could be felt per rectum. Higginson also reduced an intussusception by inflation. The patient, an infant of seven months, had symptoms of intussusception three days, and the tumor could also be felt per rectum. 1 Whether air or carbonic acid be employed, it is necessary to produce distention of the intestine to its fullest extent below the seat of the com- plaint without endangering rupture, and of course the sooner it is used the better the chance of success. In a few days the displaced intestine has, in a large proportion of cases, become so firmly incarcerated, and has descended so far, that attempts to replace it, either by injections or inflation, are unsuc- cessful ; still, even at a late period, a persevering attempt should be made if it have not previously been tried. During the four years which have elapsed since the publication of the sixth edition of this treatise in 1886, I have treated successfully three — I think I may say four — cases of intussusception in infants by frequent rectal injections of warm water as large as could be given, and followed by kneading of the abdomen. The youngest of these infants was Geo. H. Mc , male, aged four months, nursing, to whom I was called on Dec. 24, 1886. He had been very fretful since Dec. 22d, had the last fecal evacuation on the morning of Dec. 23d, and had since passed stools of mucus and blood without the least fecal matter. Enemata of warm water as large as possible were given every hour to two hours with the nates raised, and were followed by kneading the abdomen. The fretfulness was always less after these enemata. On Dec. 26th the temperature fell from 101 J ° to normal, and a fecal evacuation, the first in three days, occurred. From this time the infant was well. The vomiting, which had been frequent since the 22d, ceased on the 26th. The mother stated that the tenesmus, which had been a distressing symptom, was uniformly less after the injec- tions. My experience during the last ten years with cases of intussusception incline me more and more to the belief that copious and frequent warm-water injections, employed in the manner described above, are more likely to give relief than any other mode of treatment. But it is proper that I should state that during this time I have seen cases that were fatal in which this and other modes of treatment, including laparotomy, were employed. If the modes of treatment which I have recommended above fail to give relief when perseveringly and sufficiently employed in a case of acute intus- 1 London Lancet, May 19, 1888. INTUSSUSCEPTION. 797 susception, the patient's state is one of extreme peril and the prognosis is unfavorable. Yet recovery is possible in one of two ways — namely, first, by incision through the abdominal walls (laparotomy), and reduction of the displacement by the fingers within the abdominal cavity ; and secondly, by sloughing of the invaginated mass and union by adhesive inflammation of the ends of the intestine which have preserved their vitality. Cripps relates a remarkable case of spontaneous cure in an infant of seven months. It had been two weeks sick, with vomiting and alvine discharges of blood and mucus, when presented for examination. A portion of the large intestine, gangrenous, protruded from the rectum. This was cut off, and portions of sloughy sub- stance were removed daily for a month afterward, when the child recovered. It died of scarlet fever eight months subsequently, and the autopsy revealed the entire loss of the large intestine, the small intestine being united to the anus. 1 Atrophy of the imprisoned part so seldom occurs in a case which has resisted injections and inflation that it need not be considered in this connection as a mode of recovery. Laparotomy has been successfully performed in a child aged two years, as I have stated above, by Dr. Jonathan Hutchinson of London. The case was one of those exceptional ones in which great displacement had occurred without strangulation. It had continued, as indicated by the symptoms, about one month, and a portion of the intestine terminating in the ileo-caecal valve had protruded several inches from the anus. " The patient was anaes- thetized by chloroform, and the abdomen was opened in the middle line below the umbilicus. The intussusception was then easily found and as easily re- duced. The after-treatment consisted only in the administration of a few mild opiates, and the child made rapid recovery." 2 In a case of this kind there can be no doubt of the propriety and necessity of laparotomy as the last resort, for, there being no strangulation, sloughing could not occur, and death sooner or later from exhaustion must be the result. Cases of this sort have usually been left to perish after the ordinary modes of relief have failed. Thus as far back as 1784, M. Robin published 3 the case of a child aged three and a half years who died after the lapse of three months with a caecum protruding from the anus ; and in the American Journal of Medical Science for 1849, Dr. Worthington published a similar case, in which a child aged three years and four months lived a longer time. In these days of anaesthetics, and with the brilliant success of Hutchinson, a physician would, in my opinion, be reprehensible if he allowed a child aged two years or over with this form of displacement to perish without strongly advising laparotomy when injections with water have failed. But the question arises whether in those more frequent cases of intussus- ception in young children in which, after displacement has continued a few hours, there is such firm constriction of the invaginated mass that the patient suffers much pain and constitutional disturbance, and passes blood and mucus without fecal matter, laparotomy is justifiable. This operation in the case of infants has heretofore been regarded as so dangerous and so likely in itself to prove fatal that the profession have generally considered it unjustifiable, believing that, although death was nearly certain without it, the perform- ance of it did not increase the chances of a favorable result. Dr. J. B. Sands of New York has recently shown that laparotomy is justifiable as a last resort for the relief of this form of intussusception, even in the youngest infants, and in the following case, recorded in the New York Medical Journal, June, 1877, saved the patient, who doubtless would otherwise have perished : On March 11, 1877, an infant of six months suddenly presented the cha- 1 Brit Med. Journ., June 2, 1888. 2 London Lancet, November 22, 1873. 3 Mem. de V Acad, de Chirurg. 798 LOCAL DISEASES. racteristic symptoms of intussusception, such as tenesmus, abdominal pain, vomiting, and bloody stools. A few hours later, when Dr. Sands was called, the pulse was rapid and feeble, with symptoms of collapse. An elongated tumor could be felt in the abdomen, extending from the left iliac region to the left hypochondrium, inelastic, tender on pressure, and dull on percussion. The lower end of the invaginated mass could be readily touched by the finger introduced into the rectum. The usual methods to effect reduction were at once employed with partial success, for the tumor disappeared from the site where it had been discovered, and was reduced to a small and firm mass on a level with the umbilicus, but it resisted any further attempts to effect its reduction. Dr. Sands then, having etherized the patient, made an incision in the median line of the abdomen, extending downward about two inches from a point a little below the umbilicus. Through this opening, proceeding cau- tiously and using as little violence as possible, he was able, after some delay, to reduce the displacement. The invaginated mass, which was only one and a half inches in length, consisted of the terminal portion of the ileum and caecum, which had entered the ascending colon. The wound was closed by five silver sutures, which embraced the peritoneum, and the patient made a good recovery. The operation was performed eighteen hours after the com- mencement of symptoms. Dr. Sands has collected the statistics of 20 cases of laparotomy for intus- susception occurring at different ages in which the result was stated. Of these, 7 recovered, or 1 in 3 ; but he judiciously remarks, considering the gravity of the operation, that it is doubtful whether future statistics will show so favorable a result of laparotomy for this displacement as to justify the frequent use of the knife. For facts and statistics relating to this sub- ject the reader is referred to an able and elaborate paper by Dr. Ashhurst. 1 It is obvious that the earlier the displacement is recognized, the greater the probability of the reduction by the judicious use of injections or infla- tion, and it is seen from cases related above that this treatment may be suc- cessful as late as the second or third day, after previous attempts to reduce the intussusception by the same means have failed, and when there is that degree of strangulation that bloody stools occur. But, as my own experi- ence has shown me, there is also inevitably a large proportion of cases in which the use of injections and inflation, however judiciously and perse ver- ingly made, totally fails, and it seems to me, in the light of present expe- rience, that when pressure from below by water, air, or gas, which is the only efficient mode of treatment short of the knife, has been tried sufficiently long and sufficiently often without result, it is the duty of the physician to seek sur- gical advice in reference to laparotomy, as he would in a case of hernia, espe- cially since, under Lister's antiseptic method, the danger from severe operations appears to be considerably diminished. It may be added that laparotomy performed on the first or second day will be much more likely to save life in ordinary cases than if performed later, since the strangulated intestine is soon badly damaged, and a local peritonitis is likely to be developed any time after the first forty-eight hours. When an intussusception has reached that stage in which active inter- ference by injections, inflation, or laparotomy is no longer proper, the physician can only prescribe opiates with sustaining measures and an emollient poultice over the abdomen, and must await the result. The diet should consist of beef juice and other concentrated nutriment which leaves little residuum. Vomiting, which is so common, is best controlled by bismuth and opiates ; convulsions require the bromide of potassium and an enema of three to five grains of chloral hydrate dissolved in a little water. 1 American Journal of the Medical Sciences, for July, 1874. APPEXDICITIS. 799 CHAPTER XIII. APPENDICITIS AND PEKITONITIS. Appendicitis. Etiology. — The most common cause of this inflammation is the lodge- ment and impaction in the appendix of fecal matter or hard, indigestible foreign bodies which produce inflammation, and sometimes perforation, by their pressure. In 146 cases of perforation of the appendix collated by Mat- terstock, fecal concretions were present in 63 ; foreign bodies different from concretions in 9 ; neither fecal masses nor hard bodies in 8 ; and in the remaining cases the records do not mention the presence of any substance likely to cause inflammation. In 49 cases of fatal appendicitis in children, perforations had occurred in 37. The analysis of 152 cases collated by Fitz gives a very similar result to that obtained from the examination of Matter- stock's records ; but Hagen ascertained the presence of fecal concretions in 69i per cent., and hard bodies not concretions in 30t> per cent., of the cases of perforation of the appendix. We must therefore regard foreign sub- stances, either concretions or other hard bodies which act mechanically by pressure, as the common cause of appendicitis, perforation of the appendix, and consecutive inflammations extending from the appendix. The fecal concretions found in the appendix are single or multiple, and of different degrees of hardness. The hardest masses sometimes exhibit con- centric layers and contain phosphate of calcium. Exceptionally, the concre- tion has a nucleus of some solid substance in the interior. The foreign bodies which lodge in the appendix and cause ulceration are numerous. In a case in my practice an over-baked bean, hard and black, perforated the appendix and caused an abscess, which by rupturing produced fatal peritonitis. Among the substances which have caused perforation and been recovered we may mention hard fecal matter, small buttons, beads, grape-seeds, cherry-stones, orange-seeds, raisin-seeds, apple-seeds, and seeds of other fruits. A perforation occurring in this manner allows fecal, purulent, or gan- grenous matter to escape into the abdominal cavity, causing peritonitis. A perforation occurring in this way is indeed the most common cause of peritonitis in children. Anatomical Characters. — The initial lesions take place in most instances in the appendix. Ulceration or necrosis of its epithelium occurs from pressure of the foreign substance ; then the intestinal microbes invade the exposed subepithelial tissue, causing septic inflammation. This inflam- mation extends through the muscular coat to the subperitoneal connective tissue and peritoneum, causing peritonitis. The extension of the disease and adhesive peritonitis around the ulcerated appendix is common. The extent and gravity of the peritonitis depend on the size of the perforation and the quantity of pus or feculent matter that escapes. If the substance which escapes from the perforation be considerable and highly irritating, the inflammation is of course severe and suppuration results. Its location depends upon the place of perforation. It is stated that in most instances the centre of the abscess is behind or alongside the caecum, and if it extend upward its walls consist of intestine and the posterior and lateral parietes of the abdomen. If the appendix be long and extend to the brim of the pelvis minor, and the perforation be near its distal end, a some- what rare occurrence, the abscess may press upon the rectum or uterus. 800 LOCAL DISEASES. The abscess, left to itself, may open in any direction. It sometimes dis- charges into the intestine, either into the lower end of the ileum, the c^cum, ascending colon, or rectum, through an opening that is quite small in the mucous membrane, but larger in the other intestinal coats. Evacuation of the pus per rectum, sometimes tinged with blood, has been regarded as favor- able from the time of Dupuytren. It occurred in 18 per cent, of the cases collated by Fitz, the pus breaking into the intestine at some point above, and escaping by the rectum. But the result is not always favorable when the abscess breaks into the intestine, for after the pus has been evacuated fecal matter may escape from the intestine through the opening, carrying with it microbes which may poison the system and set up septic fever. Of 6 cases related by Demme in which the abscess broke into the intestine, 3 subse- quently died. In a case treated by the late Dr. F. M. Warner and myself a boy of about eight years recovered in this manner. Henoch states that abdominal abscesses are very prone to escape at the umbilicus, since this is the weakest part of the abdominal wall. Rarely the pus makes a passage into the bladder, and if this occur cystitis, due to the presence of purulent and fecal matter, may result. The inflammation has also, in a case mentioned by Eisenchiitz, extended from the perforated appendix to the right ovary, producing purulent inflammation in this organ. Extension of the inflamma- tion from the perforated appendix to and around the contiguous blood-vessels may produce disastrous results. The superior mesenteric vein, which con- veys blood from the caecum and appendix to the portal vein, sometimes becomes the seat of thrombosis, the circulation in its branches being inter- rupted by the presence and pressure of inflammatory products. Detached particles of the thrombi, conveyed through the portal vein to the liver, pro- duce septic inflammation and abscesses in this organ. Matterstock has the records of eleven cases in which the liver became involved in this manner. Occasionally the abscess ascends along the colon and behind the liver, becom- ing subdiaphragmatic, and cases have been reported in which it entered the right pleural cavity. Tillmann states that in 22 cases of fecal fistula extend- ing into the pleural cavity 6 originated from perforations in the appendix. The abscess penetrating the retro-peritoneal tissue may extend to the kidney, so as to become perinephritic, or it may descend along the psoas and iliac muscles, even under or below Poupart's ligament. Cases are reported in which it burrowed under the gluteus maximus muscle or in the perirectal tissue, occupying the sacral or coccygeal region. Evidently, inasmuch as the appendix is invested by peritoneum, its per- foration and the escape of fecal substance or a foreign body, which produces the abscess described above, cannot occur without a localized peritonitis behind and below the caecum, where the appendix lies. But a more serious and ordinarily fatal result sometimes follows — to wit, the occurrence of acute dif- fuse peritonitis. This may take place immediately after the perforation, but frequently an abscess forms, perhaps of little extent, around the appendix, and it may continue for weeks or months without producing any dangerous symp- toms. Finally it bursts, and its contents escape into the general peritoneal cavity, producing an acute peritonitis, which rapidly extends over the perito- neal surface. A large proportion of the cases of perforation of the appendix if left to themselves terminate, after a time, in this manner, in peritonitis, which from its extent and severity is usually fatal. This was the result, ac- cording to Volz, in 31 of 39 cases, and, according to Cless, in 7 out of 8 cases. Symptoms. — The initial symptom of this form of inflammation is pain, more or less severe, in the region of the appendix, perhaps at first paroxysmal, with intervals of comparative ease, but accompanied by tenderness. The patient is apt to have nausea and even vomiting, constipation or diarrhoea, APPENDICITIS. 801 flatulence, and tenesmus, so that experienced physicians sometimes err in diagnosticating a milder disease, not aware of the serious malady which is impending. These symptoms in the initial period frequently abate for a day or two, and the patient is able to be about, but they return with equal or greater severity. When the disease continues, the pain in the caecal region is so constant that the patient takes to bed, unable to stand upright or to walk. He inclines forward and to the right, and his right thigh is flexed to relieve the tension. Sometimes he refers the pain to the epigastrium or the abdomen, and it is increased by coughing, by full inspiration, and by extension of the right thigh when the peritonitis begins. Vomiting of the- ingesta mixed with mucus and bile is common, and eructations of gas may occur. Occasionally these symptoms are preceded by a chill, but less frequently in children than in adults. The following are the symptoms commonly present : anorexia, thirst, fever with morning remissions (101° to 103° F.), accelerated pulse, features indicative of severe sickness, sometimes icteric hue of skin and con- junctiva, perhaps dysuria, scanty urination or retention of urine, diarrhoea or constipation ; abdomen flat and muscles tense at first, but subsequently abdomen tympanitic ; tenderness on pressure at first in the right iliac region, but subsequently more general; prominence of the ileo-caecal region, at first from gas, subsequently from exudates ; a caecal tumor, tender and immovable ; adjacent loops of intestine distended. Such are the symptoms and phenomena that attend this disease. Pressure of the crural plexus may cause numb- ness, pain, or other abnormal sensation in the right leg and the external genital organs. Pressure on the iliac vein may retard the return circulation from the leg and cause oedema of the limb. The progress of this disease and its gravity vary greatly in different cases. In the mildest forms of the inflammation, the pain, nausea, fever, ileo-caecal tenderness, and fulness gradually abate, and in two or three weeks the health is restored : or the symptoms may continue longer, but finally yield after the discharge per rectum of gas and offensive feces. A deep-seated induration and soreness, gradually abating, may remain at the seat of the disease for months, and the patient may complain of aching or pain after a full meal or active exercise. When the abscess opens into the intestine the dangerous symp- toms abate rapidly, and the patient, as a rule, quickly begins to convalesce. In other cases the symptoms continue, but with some remission due to the fact that the abscess, which does not discharge, becomes surrounded by condensed connective tissues which limit its extension. Then, perhaps after some unusual effort or a blow or pressure upon the inflamed part, an aggra- vation of symptoms occurs. Purulent or septic matter has probably escaped at some point, and peritonitis may have resulted, or burrowing of pus, as has been described above, or septic inflammation in some important organ. The sudden advent of alarming symptoms when the patient has been compara- tively comfortable, severe and general abdominal pain,' prostration, rapid pulse (150 to 160), a high temperature (105° or 106°), or abnormally low for the other symptoms, painful respiration, tenseness of the abdominal mus- cles, followed by tympanites and distention, indicate rupture of the abscess, general peritonitis, and rapidly approaching death, unless early and imme- diate laparotomy be performed and the peritoneal cavity be irrigated by a warm antiseptic lotion. In this alarming state vomiting, gaseous eructa- tions, constipation, more rarely diarrhoea, retention of urine, clammy perspi- rations, hiccough, flexed thighs, pallor, and finally collapse, indicate the fatal progress of the disease. To add to the gravity of the situation, septic inflammations in other parts sometimes start up, as empyema or pericarditis, cystitis, perhaps with per- 51 802 LOCAL DISEASES. foration of the bladder, inflammation around or within the female genital organs or in the retro-peritoneal connective tissue. On the other hand, it must be remembered that in a considerable propor- tion of cases the abscess is so encapsulated that septic poisoning and diffuse peritonitis are prevented, at least for a time. Of the symptoms enumerated above, pain is one of the most constant, and was present in 84 per cent, of the cases collated by Fitz. It is of course less severe if the inflammation is localized in the ileo-caecal region and of little extent than when it occupies a wider area from the extension of peri- tonitis. Vomiting is one of the most common symptoms. It was absent in only 2 of the 72 cases collated by Matterstock, and was present in Pepper's 13 cases. It appears to be more common in children than in adults. Diarrhoea was present in 33.3 per cent, of Matterstock's cases, and constipation in 46.6 per cent., alternating constipation and diarrhoea in 15.5 per cent., and normal stools in 4.5 per cent, of the cases. According to Pott, diarrhoea is more common than constipation in children, 1 and in fatal cases approaching termi- nation severe colliquative diarrhoea sometimes occurs. More or less fulness and induration can usually be detected in the ileo- caecal region at an early as well as late stage of the disease, but a distinct tumor is only occasionally perceptible. According to Pepper, in 19 children with this disease a tumor could be detected in only 3 instances. A dull per- cussion sound in the right ileo-caecal region is common, but occasionally, even when there is considerable inflammatory induration, loops of intestine distended with gas lie over the seat of inflammation, so that the percussion sound is resonant. The temperature usually ranges from 100° to 103° or 104°. It is sometimes remittent, In a case treated by the late Dr. H. B. Sands the temperature fell from 101.6° before laparotomy to 98.5° imme- diately after the operation, and it remained below 100° during convalescence. A sudden rise in temperature indicates extension of inflammation or perhaps the occurrence of septic inflammation in organs not previously involved. A sudden fall of temperature when other symptoms are grave, like cessation of pain, indicates collapse. Diagnosis. — Recurring pain or tenderness in the caecal region at intervals of a few weeks should excite suspicion of the presence of a foreign sub- stance in the appendix. Dr. C. E. With 2 found that such recurring attacks preceded the severe disease for weeks, months, or even years in certain cases, and in the large number of cases which he collated, Matterstock ascertained that these occasional attacks of pain and tenderness preceded the disease in 8 per cent, of the children affected. Sometimes the accumulation of fecal matter in the caecum can be determined by palpation, since it produces a " doughy " feel. The diagnosis of this inflammation from invagination is not difficult, since the latter occurs chiefly in infancy, is attended by a tumor more centrally located in the abdomen than the ileo-caecal induration which we are considering, and is attended often by bloody stools and fecal vomiting. Dr. V. P. Gibney 3 states that four children with perityphlitis had been brought to his orthopaedic hospital in the belief that they had hip disease, and had been treated for it ; but a more careful examination of such cases, especially under ether, shows that the hip-joint is not affected. The swelling in hip-joint disease is lower down than the perityphlitic induration. Besides, perityphlitis does not produce the change in the appearance of the hip when examined from behind, or in the position of the foot, which we observe in 1 Jakrbuch fiir Kinderheilk., N. F. xiv. 2 Peritonitis Appendicularis, etc., Kjobenhavn, 1879. 3 Ainer. Journ. of Med. Sci., 1881. APPENDICITIS. 803 hip disease. N. Senn l recommends rectal injection of hydrogen gas as a means of determining the presence of perforation of the caecum or appendix, since in case of perforation the gas enters the peritoneal cavity, and lapa- rotomy without delay is indicated. The diagnosis from a psoas abscess may be made by attention to the following facts : This abscess occurs gradually, without symptoms referable to the intestines or peritoneum, and without the ileo-caecal induration of perityphlitis. Moreover, the abscess usually descends along the psoas muscle and forms a swelling under Poupart's ligament, or it extends along the thigh under the fascia. Prognosis. — This varies greatly in different cases. If the inflammation be of little extent and encapsulated, and sepsis do not occur, the prognosis is good. On the other hand, if the perforation of the caecum or appendix be of considerable size, with considerable escape of feculent matter, loaded as it is with microbes, the severe inflammation which results in the peritoneum or retro-peritoneal tissue, with perhaps consecutive septic inflammation in adja- cent organs or tissues, to which septic matter has been conveyed by the lymphatics or blood-vessels, a fatal termination is almost certain. It is evi- dent that the statistics relating to the result, as ascertained by different writers, vary according to the average severity of the cases whose records they consult. The following statistics have been published, showing the mode of termination of appendicitis, extending in many of the cases which ended fatally so as to cause more or less typhlitis, perityphlitis, and perito- nitis : Authors. Deaths. Recoveries. Volz 39 10 Bamberger 18 ........ 55 W. T. Bull 33 34 Matterstock 49 21 With 12 18 Demme 27 9 According to Matterstock, age influences the result in a measure, since of 12 patients under the age of six years, 11 died ; of 24 patients between the ages of six and ten years, 15 died ; and of 34 patients between the ages of ten and fifteen years, 23 died. A diffuse peritonitis, whether resulting immediately from the perforation or from rupture of an abscess which has been previously encapsulated and indolent, is usually fatal. Evacuation of the abscess into the caecum or rectum justifies a favorable prognosis, though some die in which this occurs. Evacuation of pus through the abdominal walls, if it takes place at an early date, is also regarded as favorable. Lapa- rotomy, as this operation is designated, if performed at the proper time and with antiseptic precautions, greatly increases the chances of recovery. According to Noyes. 2 in 100 such operations the mortality was only 15. But according to Bull, the result is not so favorable if the abscesses burrow their way to the surface and open without surgical assistance, for of 28 such abscesses, 11 were fatal. How long patients may live in fatal cases after the occurrence of severe symptoms has been investigated by Fitz, who found that in 176 cases 34 per cent, died in the first five days, more than half in the first week, 31 per cent, in the second week, and 4 per cent, in the third week. In those mild cases in which the inflammation in the caecal region is of slight extent and the patient is soon convalescent, a sudden aggravation of symptoms sometimes occurs from breaking loose of the inflammatory products of septic absorp- tion, and the case ends fatally. 1 Journ. of the Amer. Med. Assoc, June 23, 1888. 2 Trans. Rhode Island Med. Soc., 1882. 804 LOCAL DISEASES. Treatment. — Prophylactic. — Children should have plain and easily- digested diet, from which seeds or other indigestible substances are removed as much as possible. They should be instructed to reject the seeds of the ordinary fruits which they are allowed to eat, since seeds are the offending substances which cause appendicitis and perforation in so large a proportion of cases. Daily fecal evacuations should be procured, so as to prevent fecal accumulation in the caecum. If there be complaint of colicky pain in the abdomen while the bowels move regularly, or if there be occasional pain or aching in the caecal region, a careful examination should be made in order to ascertain if there be tenderness or induration at the point complained of, and if so, a quiet life with open bowels should be enjoined. By such measures the threatening symptoms may pass off. Curative. — The late Prof. Henoch of the University of Berlin, whose opinions relating to the diseases of children always claim attention, if not acceptance, on account of his large experience, says that whether the inflam- mation occurs from over-distention of the caecum by fecal masses or from concretions in the appendix, the symptoms are the same as in later life — to wit, pain in the caecal region, which is likely to extend over " a large part of the peritoneum ; the frequent formation of a tumor by the exudation, which not infrequently terminates in suppuration ; the repeated relapses, etc." Henoch states that he keeps the intestines perfectly quiet by opium, and only gives castor oil or calomel when prolonged constipation and palpation indicate the presence of a large fecal accumulation in the caecum ; otherwise, he ab- stains from purgatives, applies a few leeches, without after-bleeding if there be much tenderness, gives an emulsion of oil (emulsio oleosa), with the aqueous extract of opium every two hours, and uses constantly the ice-bag over the caecum. When with this treatment the pain and tenderness cease, he states that defecation usually occurs spontaneously or is produced by a simple enema or a dose of oil. The following remark might be thought to be an exaggeration were it not for the well-known accuracy and high profes- sional standing of Prof. Henoch : " When this treatment was begun early enough, recovery ensued in almost all cases, and if a swelling had been formed by the exudation, its transition into suppuration was prevented even in chil- dren who in the course of a few years had been repeatedly admitted to the hospital on account of relapses." The treatment detailed above, employed and recommended by Prof. Henoch, is in my opinion the best that can be prescribed for typhlitis, appendicitis, and perityphlitis before suppuration has occurred. The use of laxatives, unless sometimes laxative enemata, should be postponed until the tenderness and other inflammatory symptoms have to a considerable extent abated by the use of a warm flaxseed poultice, or, if the temperature be above 103°, the ice-bag, and opium in sufficient doses to allay restlessness and procure sleep should be employed. If, when the inflammation has been subdued, we ascertain by palpation the presence of fecal masses in the caecum, a large clyster of warm water, containing one ounce of glycerin and one of sweet oil, may be prescribed, or perhaps, as recommended by Henoch, a dose per orem of castor oil or calomel may be given. Even in the commencement of the treatment, if there be the history of constipation, and on palpation the caecum appears to be distended with fecal matter, it is proper to employ a large clyster of warm water, containing one ounce of glycerin and one of sweet oil, in order to remove a chief cause of irrita- tion. The diet should consist of liquids that leave little residuum, as the beef peptones and peptonized milk. Carbonized water may be allowed to relieve the thirst or nausea. If the case result favorably, the child should lead a quiet life, avoiding violent exercise during and after convalescence, for relapse is not infrequent. PEEITOXITIS. 805 But in appendicitis, with the contiguous inflammations, typhlitis and peri- typhlitis, or without them when the inflammation persists, an abscess results ; and in recent years many lives have been saved by the incision and drainage of the abscess. In America the advantages of early liberation of the pus in ileo-cascal abscesses was brought to the notice of the profession by the late Prof. Wil- lard Parker, whose first case of successful operation occurred in 1843. Since this time the treatment of perityphilitic abscesses by incision has been prac- tised in numerous instances, so that Dr. B. F. Noyes was able to collate the records of 119 cases, only about 16 per cent, of which were fatal. 1 Dr. Sands strongly objected to the use of the exploring needle at an early stage of the inflammation, employed for the purpose of determining the presence or absence of pus, since it might penetrate the healthy peritoneal cavity and pierce the intestine or pus-cavity, and when withdrawn the foul substance adherent to it would probably infect the peritoneum and cause a diffuse peritonitis. G. Buck, Wier, and Bull advise, if the presence of pus be determined by the needle, to leave it in situ, that it may serve as a guide in making the incision. Morton states that the aspirator needle should never be used, and Bansohoff also objects to it. Dr. Lange 2 in making the incision and entering the peritoneal cavity, finding that the tumor was covered by omentum, closed the opening and made the cut farther to the right, where the peritoneum was adherent to the tumor, and the patient recovered. Sands recommends making a vertical incision over the tumor, as affording the readiest approach to the diseased parts. Noyes, Parker, Hancock, and others make the incision, four inches in length and even longer, in a line parallel with the outer half of Poupart's ligament. Hadden and Bontecou make a curved incision along the crest of the ileum, and others, as Gibney and Parker, make the incision at the most prominent part of the tumor and nearer the median line than most other operators. Laparotomy, or the opening of the abdominal cavity for the purpose of evacuating the abscess, has been performed a considerable number of times during the last ten years, and cases have been published showing very favor- able results. Peritonitis. The peritoneum is very extensive. It is a serous membrane and a closed sac, except in the female at the extremities of the Fallopian tubes. It covers all the viscera in the abdominal and pelvic cavities, and is reflected over their parietal surfaces, forming by its extension the greater and lesser omentum. Its free surface is moist, smooth, and covered by a layer of thin squamous epithelium, while its under surface connects with the underlying viscera, and fascia, in which the muscles, blood-vessels, lymphatics, and nerves lie. The great extent of the peritoneum and the large number of lymphatics in it render its inflammation dangerous, and, if it be general, likely to be fatal. Etiology. — The earliest form of peritonitis occurs in the foetus, rendering it non-viable. This form ordinarily originates from syphilis. Septicaemia is also a common cause of peritonitis in the newly-born in filthy and degraded families. If sanitary precautions are neglected and the habits of the house- hold are filthy and degraded, germs from sources of uncleanliness are liable to enter the umbilical fossa. We have shown elsewhere how pathogenic germs derived from the decaying cord not infrequently enter the umbilical vessels and lymphatics, and are conveyed to different and distant parts, setting up inflammation in the peritoneum as well as elsewhere. Prudden and Delafield state that peritonitis may occur without apparent 1 Trans, of Rhode Island Med. Soc, 1882. 2 N. Y. Med. Journ., Mar. 3, 1888. 806 LOCAL DISEASES. cause, but it is more frequently produced by appreciable agencies. We have mentioned syphilis and septicaemia as causes, but the distinguished pathol- ogists named above enumerate, among the causes, abdominal wounds, con- tusions, ulcers, new growths, intussusceptions, ruptures, perforations, inflam- mations of the stomach and intestines and of the vermiform appendix. If the inflammation of any organ or tissue covered by peritoneum reach the peri- toneum, peritonitis occurs by extension of the inflammation, or by rupture of the peritoneum and the escape of irritating matter into the peritoneal cavity, which produces a general and usually fatal peritonitis. If we exclude peritonitis due to tubercles and that from septicaemia and syphilis, it may, in my opinion, be truthfully said that a majority of the cases of peritonitis in the young originate from appendicitis. From an anatomical point of view we recognize two forms of acute peritonitis, designated the cellular and exudative. As described by Prudden and Delafield, the former is produced by an irritant of moderate activity. After death in this form of peritonitis the entire peritoneal surface is of a bright-red color, but with no visible fibrinous, serous, or purulent exudate. The endothelial cells have increased in number and size, so as to project outward more than in health. The second form of peritonitis, designated exudative, was studied experimentally by Prudden and Delafield. In one to two hours after the injection of an active irritant into the peritoneal cavity of the dog they found a little serum in the cavity, congestion of the peritoneum, and points of exuded serum upon the inflamed surface. No marked changes occurred in the connective tissue or endothelial cells, but pus-cells collected in the stroma under the endothelium, and white blood- cells increased in the vessels. Twenty-four hours later the peritoneal con- gestion was greater, as well as an increase of serum, fibrin, and pus, and an increase and swelling of the endothelial cells. In the human being, if death occurs by the third day, which is the common result in experiments on dogs, the same anatomical results are observed — to wit, general congestion in the peritoneal surface, along with an increase in pus, fibrin, serum, in the number and size of the epithelial cells. Death commonly results between the sixth and fourteenth days, and the anatomical changes which have occurred vary in different cases. Congestion of blood-vessels may be very intense, with extravasation of blood, or the latter may be absent. Pus and fibrin in a thick or thin layer may cover the adjacent surfaces, or pus may infiltrate the entire thickness of the peritoneum and subjacent connective tissue. Sometimes the pus is sacculated by adhesions, so as to appear like an abscess ; it may have a dirty color from the presence of bacteria ; and it is thick or thin according to the relative proportion of serum and pus-cells. Acute peritonitis, if it be not fatal or the symptoms are not aggravated by the close of the second week, may become chronic. Local peritonitis often results from an underlying inflammation commencing in one of the viscera and extending to the peritoneal covering. The inflammation may be circumscribed by adhesions or may extend so as to be fatal. The most important and interesting instances of this kind have only in recent years been correctly understood. It is now known beyond doubt, from surgical experience and observations in the dead-house, that the peritonitis occurring in children previously supposed to be healthy, and ending ordinarily in death, results in a large proportion of cases from appendicitis. The lodgement of a foreign substance, often fetid and highly irritating, in the appendix causes inflammation, ulceration, and not infrequently perforation, with the escape of the putrefying matter, which causes a general peritonitis. The subject of appendicitis as a cause of peritonitis will be considered hereafter. PERITONITIS. 807 Delafield and Prudden describe the following varieties of chronic perito- nitis : 1. Cellular peritonitis ; 2. Peritonitis with adhesions ; 3. Chronic peritonitis with thickening of the peritoneum ; 4. Chronic peritonitis with the production of fibrin, serum, and pus ; 5. Hemorrhagic peritonitis ; 6. Tubercular peritonitis : («) Tubercular ascites ; (6) Tubercular peritonitis with the production of a large amount of fibrin ; (c) Tubercular peritonitis with adhesions. Symptoms. — Obviously, since peritonitis in many instances results from some anterior disease, the symptoms of this disease precede it. Frequently, especially during childhood, abdominal pains, often intermittent and vague, precede the severe symptoms indicating peritonitis. An appendicitis has probably pre-existed. Sometimes an empyema has occurred, more or less filling the affected side of the chest with pus, and pus-cells traversing the lymph-spaces of the diaphragm appear on its under surface and excite a peritonitis, which, commencing in the upper part of the abdominal cavity, extends downward. A suppurating mesenteric gland, an ulcerating Peyerian patch, scarlatinous uraemia, and a local inflammation, whatever the cause, extending to the peritoneum, inevitably give rise to inflammation of this membrane. Typical peritonitis begins with severe pain, vomiting, and tenderness, in- creased by pressure, followed by distention with gas. Sometimes there is initial chilliness, followed by a quick pulse and heat of surface ; constipation is common ; the countenance is anxious and expressive of suffering ; and the legs are flexed. As the disease continues the intestines become distended by gas, which increases the pain, and the food is ejected. The loss of appetite and loss of food by vomiting, by which, after a time, even bile is ejected, cause progressive emaciation and weakness. Hiccoughs, sometimes present, greatly aggravate the pain. The eyes become sunken. While the abdomen is distended, other portions of the system emaciate. The pulse in the beginning of peritonitis is usually accelerated, being perhaps from 110 to 150, and the temperature from 101° to 104° F., though these symptoms are variable. The pain is usually severe or griping, and is increased by pressure or motion, as by a deep breath or a cough. The pain is also increased by peristaltic or vermicular movements of the intestines. Exceptionally, the pain may be slight. It is usually most severe in perfora- tive or traumatic cases before adhesions have occurred. As peritonitis is usually local at first, the pain is at first localized, and it extends and becomes more severe as the inflammation increases until it is general. Nausea is likely to occur when there is no vomiting, accompanied with belching. The distention may become such that the abdomen is not only markedly dis- tended, so that the skin is smooth and shining, but the diaphragm is carried up — the apex of the heart upward and backward ; the liver is carried upward and turned on its axis in extreme cases. In severe peritonitis, espe- cially from perforation, collapse may soon follow. The pulse is rapid and weak, the voice feeble. In severe cases, approaching a fatal termination, the temperature may be very high — as high as 108° or even 110° F. It is often higher in the latter part of the day than at other times. On the other hand, it may be subnormal. The tongue at first is moist, but afterward it becomes dry and furred ; in cases of septicaemia or other grave constitutional diseases it may be dry and covered by a brown fur from the first. 808 LOCAL DISEASES. The appetite and digestion are greatly impaired, and the food is regurgi- tated to a greater or less degree ; constipation is also common, due to paraly- sis of the muscular coat of the intestines and fibrinous adhesions. Urination may be frequent or of natural frequency, but it is likely to be painful and scanty when the inflammation extends to the bladder. At a later stage the catheter is often required if, as is usual, the inflammation has extended over the bladder and the patient is fully under the influence of opium. In certain grave forms of peritonitis a trace of albumen appears in the urine. Diagnosis. — It is very important that the diagnosis be made early, for correct treatment and the life of the child depend on it. On palpation in the beginning of peritonitis the abdominal walls are commonly tense and resist- ing. Occasionally the friction between the inflamed surfaces can be detected, and the fluctuation is noticed if there be considerable increase of serous exu- dation. A clear history of the case, a careful examination of the abdomen by palpation, percussion, and change of position, with proper appreciation of the history and symptoms, generally will lead to a correct diagnosis. If there be general peritonitis, there is general tenderness, fulness, and hardness. If the inflammation be limited to one part, that part exhibits hardness, fulness, and tenderness, or tympanitic resonance may occur, due to distended intestine underneath. The acuteness, pain, vomiting, tympanism, fever, and the continuance of these symptoms, with the aspect of severe sickness, justify or render probable the diagnosis of peritonitis. If by de- cided measures to relieve the patient, which will be mentioned hereafter, he do not on the following day express considerable relief from the suffering, the case is probably one of peritonitis. No physician summoned to a case of abdominal tenderness or pain should neglect to examine the region of the appendix vermiformis, located in most cases midway between the umbilicus and the anterior superior angle of the ileum. From the fact that peritonitis, occurring in those who have previously been free from ailment and robust, ordinarily begins in the appendix, this region should in such instances be carefully examined by deep pressure with the tips of the fingers. The space between the right iliac bone and the um- bilicus should be thoroughly explored in order to ascertain if there is any tenderness, fulness, or hardness in the site of the appendix. The examina- tion can be facilitated by pressing at the same time posteriorly with the thumb of the same hand or the fingers of the other hand applied against the right lumbar region. By this manner the site of the appendix is grasped anteriorly and posteriorly. Prominent surgeons of Xew York with whom I have examined cases have sometimes been able by rectal examination with the finger to refer the localized peritonitis to an abscess in the appendix. Prognosis. — In acute general peritonitis a fatal result should be predicted if the diagnosis is clear. I have not yet seen a patient recover who had general peritonitis, manifested by intense redness of the entire visceral and parietal surfaces, with purulent and commencing fibrinous exudation, as shown by a subsequent autopsy. Of course septic or tubercular peritonitis is fatal from the primary disease. There can be no doubt that many more children with local peritonitis are now cured than formerly, and this improve- ment in the result of treatment has occurred chiefly from the surgical meas- ures employed in the treatment of the peritonitis caused by and extending from an appendicitis. This is treated of elsewhere. The most favorable forms of peritonitis are evidently the local, and especially those occurring in parts which are susceptible of removal. Treatment. — Evidently the most urgent indication is to relieve pain, and the measures employed for this purpose fortunately have a tendency to check the inflammation. Many remedies will relieve pain, but an opiate is HEBXIA OF THE ABDOMEN. 809 preferable, because it is best, at least after one or two evacuations, to keep the bowels checked, and this an opiate accomplishes. A child of eight years may take one-fourth of a grain of opium or 5 drops of deodorized tincture of opium every two hours until the pain ceases or the physiological effects of the drug begin to be manifested by contracted pupil, stupor, and slow respiration. The opiate appears to be absorbed slowly, and it is the common belief that ab- sorption is slower in a case of peritonitis than in one not affected by this dis- ease. It is better, as a rule, to avoid subcutaneous injections of an opiate in children, since a dangerous stupor may suddenly occur from this treatment. Given by the mouth and its effects carefully observed, if the pain becomes less the intervals between the doses should be lengthened. If the vomiting be persistent, it may be necessary to employ rectal sup- positories. In all cases local treatment over the site of inflammation is required. A light poultice of one part of ground mustard and twenty of flax- seed, between two pieces of muslin so moist as to wet the hand in holding it, and as thin as the pasteboard covers of a book, may be employed, or a flax- seed poultice may be applied with the following on its under surface : 01. caryophylli, sjij ; 01. camphoratee, ,§iij. — Misce. Or hot water in a rubber bag may be used. Some physicians recommend cold applications over the abdomen in cases of acute peritonitis. Broken ice should be mixed with bran in about equal quantity, and applied over the abdomen if it give most relief. Generally, according to my experience, if the temperature of the patient reach or exceed 103° F., the cool applications give most relief and should be preferred. If it be below 103°, the warm applications best satisfy the patient and should be used. Vomiting, flatulence, and eructations of gas are often symptoms which cause considerable distress. In such cases the most success attends the fol- lowing mode of treatment: A flexible No. 12 catheter is introduced six, per- haps eight, inches through the rectum, and half a pint of predigested milk, with half a pint of hot water to which two teaspoonfuls of Rudisch's predi- gested extract of beef are added, should be cautiously injected. The expul- sion of gas and undigested matter will be useful in relieving the distention, and what remains will be useful in sustaining the strength, especially if one or two teaspoonfuls of brandy be added to it. CHAPTEE XIV. HEKNIA OF THE ABDOMEN. Inguinal hernia consists in the protrusion of the abdominal viscera cov- ered by the peritoneum in the course of the inguinal canal, the channel by which the spermatic cord passes through the abdominal muscles to the testis. Several forms are recognized, which depend chiefly upon the varying rela- tions of the peritoneum. They have been explained as follows (T. Holmes) : (a) In congenital inguinal hernia the process of peritoneum which passes down with the cord, funicular process, remains freely open ; the general cavity of the 810 LOCAL DISEASES. peritoneum is therefore identical with that of the tunica vaginalis testis forming the hernial sac, the bowel contained in which is in direct contact with the testicle (Fig. 213). (6) The condition of the parts in an infantile hernia are as follows : The tunica vaginalis, 1 (Fig. 214), is closed above, at or near the external inguinal ring, but Fig. 213. Fig. 214. Congenital inguinal hernia. Infantile hernia. its funicular portion is open : the bowel in the hernial sac lies behind this funicular portion, and is represented in the diagram as having made its way between the funicular process and the cord ; the relation of the sac to the cord seems, however, to be variable ; the bowel is covered in cutting down from the skin by three layers of peritoneum — viz. 1 and 2, the opposite surfaces of the funicular process, and 3, the anterior layer of the peritoneal hernial sac. (c) In the encysted form (Fig. 215) of infantile hernia the bowel, instead of passing behind the closed funicular process, has distended the membrane which closes its upper end, and has pushed itself into the funicular process, the upper or back wall of which envelops it ; in this case, therefore, the hernial sac is furnished by the funicular process itself, and only two layers of peritoneum cover the intes- tine. (d) In the common scrotal hernia (Fig. 216) the tunica vaginalis is seen behind Fig. 211 Fig. 216. Encysted form of infantile hernia. Common scrotal hernia. and below, and is represented as distended with a certain amount of hydrocele fluid, but quite distinct from the hernial sac. (e) Partial obliteration of the funicular process illustrates the formation of cysts in the cord, encysted hydrocele of the cord (Fig. 217) : the cavity of the tunica vaginalis testis is closed at c : the funicular process is also separated from the peri- toneal cavity at a, the situation of the abdominal ring ; there is also another septum at 6. When one or more of these septa are absent or imperfect various conditions occur. HERNIA OF THE ABDOMEN. 811 (f) In the formation of the hernia into the funicular process of the peritoneum (Fig. 218) the septum or obliteration at c is absent, so that the tunica vaginalis is Fig. 217. Fig. 218. Cysts of the cord ; encysted hydrocele. Hernia into the funicular process. open as high as the septum, b, which is imperfect or has given way from some acci- dental cause ; in the diagram the septum at the external abdominal ring, a, is drawn as being widely open, but strangulation may occur either in the septum at b, some- what lower down, or at both. The symptoms and appearances of inguinal hernia are generally suffi- ciently characteristic, but even in the most marked case it is important, by a formal inquiry and the recognized tests, to distinguish it from differ- ent affections which occur in these organs and tissues. The more noticeable are hydrocele ; inflammatory affections and other diseases of the testis, cord, and their coverings ; of inguinal and lymphatic glands ; malpositions of the testis. Femoral hernia is so rare in children as not to require notice. Femoral must be distinguished from inguinal hernia by its position below Poupart's ligament ; from abscess ; from an enlarged gland and an enlargement of the femoral vein ; from tumors at this point. Umbilical hernia occurs at the point where the umbilical vessels pass through the abdominal wall ; it exists anterior to the period when cicatrization is complete, which varies in different infants, but in general requires several months. When the parts which fill the aperture are firmly cicatrized, this point of the wall is firmer than surrounding parts, owing to the condensation of the cicatrix and the Fig. 219. peculiar arrangement of the fibres of the trans- versalis fascia (Fig. 219). In infants the protruding viscus pushes before it that portion of the parietal peritoneum lying imme- diately behind the aperture in the linea alba, through which the umbilical vessels enter the abdominal cavity ; the hernial sac thus formed, before the closure of the ring is effected, may pass into the connective tissue of the cord itself before that struc- ture has separated ; after the separation of the cord the hernial sac may be protruded in consequence of the umbilical aperture remaining imperfectly closed, when it is covered only by the integuments ; in the youth the hernia may escape through a partially closed ring, which it dilates by continual pressure ; in the adult the fibres of the linea alba may become separated by stretching, owing to the pressure within, and the hernia escape at the site of the once-closed ring or in its vicinity (Fig. 219). Fascia at umbilicus. 812 LOCAL DISEASES. The hernia begins by forming a soft, projecting ovoid tumor at the navel ; at first it may be reduced by pressure, when a small hole is felt with very sharp and rigid edges ; if the finger is removed, the skin either remains re- laxed in the fossa of the navel or it is slowly projected forward; as the dis- ease progresses the protruding viscus descends lower and lower, so that the broadest part lies below the mouth of the sac ; the tumor varies much in form, the transverse diameter being sometimes greater than the vertical ; occasionally it is pyriform, and seems suspended or spread out like a mush- room (Fig. 220) ; again, its base is nearly as large as its body ; in infants the Point of attachment of cord. Congenital umbilical hernia. hernia usually contains intestines, but in the adult omentum is generally added, and sometimes the stomach ; the coverings, usually very thin and often inseparably united, are the integument, some fat, the internal abdominal fascia, the sac ; the body of the sac is usually very delicate, but stronger near and at its orifice, around which the tissues form a firm, resisting, unyield- ing band ; the mouth of the sac is often large in proportion to the bulk of the protrusion. This hernia has been overlooked in very corpulent persons, and proved fatal by strangulation. The treatment of hernia should first be palliative. The truss is the first appliance to be resorted to in reducible hernia ; it should be applied immediately that the disposition to the formation of rupture is detected, with a view to procure adhesions of the serous surfaces : the rule applies to both sexes and all ages, the only exception being a misplaced testis. The effect of such pressure is to approximate the sides of the mouth of the sac, prevent the descent of the bowel, and lead to contraction and final obliteration of the hernial sac. As the commencement of a radical cure by truss-pressure dates from the last time the bowel or omentum came into the sac, it is of the first importance to prevent the hernia from ever coming down. About 15 to 20 per cent, may be cured by judicious and persistent truss-pressure. DeGrarmo reported a cure of one-fourth of his cases by the truss in a total of 1000 treated ; he believes a large percentage of cases under middle life curable by mechanical means. Inguinal hernia requires a truss-pad that does not press upon or interfere with the circulation or other functions of the spermatic cord. Not uncom- monly the cord becomes jammed by the downward pressure of the truss-pad upon the crest of the pubic bone below, causing pain and uneasiness along the cord and in the testicle ; the latter slowly enlarges if the pressure be con- tinued, effusion takes place in the tunica vaginalis, and a hydrocele or a HERXIA OF THE ABDOMEN. 813 hydro-sarcocele is gradually formed, or the pressure upon the spermatic origin of the cord gives rise to varicocele. It is of great importance to pro- tect those who, from hereditary tendency or weakness of the abdominal walls, are predisposed to rupture. For this purpose a broad band with a suitable pad (Fig. 221) may be worn (Fig. 222). It should consist of stout elastic web, which passes round the body, Fig. 221. Fig. 222. Band and pad applied. and it is attached to the pad in front by metallic loops engaging studs on the pad ; elastic bands pass from the body-band, under the limbs, to studs upon the rupture- pads. The bearing of the surface of the pad should be flat, the edge rounded off, the shape being an oblique oval. The best substance for the pad is vulcanite, and it should be maintained in position by a side-spring which encircles the body midway between the trochanter and the anterior superior iliac spine 5 sometimes it is neces- sary to wear a perineal band which buttons in front, but this may be dispensed with when the truss has accommodated itself to the shape of the body. A great variety of trusses may be found, but unless they conform in construction to the principles given they will fail to meet the indications. Femoral hernia requires that the truss-pad protect the crural ring by pressure over Poupart's ligament, and also press upon and fill the saphenous opening without pressing downward so as to obstruct the saphenous vein. Umbilical hernia, if congenital, should at first be treated with a piece of lint wrapped around a penny piece and kept on with a light flannel bandage, lightly swathing the infant's body, and kept from chafing by powdered starch. This form of hernia in the infant requires persistent efforts to close the opening by the following dressing : Apply a flat pad of any soft and tolerably firm material, moulded to the shape of the parietes and extending beyond the margin of the opening (Fig. 223) ; maintain it in position by Fig. 223. adhesive strips or by a broad elastic band properly padded ; remove the apparatus frequently to preserve cleanliness and prevent chafing, the finger being applied meantime to the open- ing. Radical cures have been effected by the truss. In the Umbilical adult this hernia is best retained by a truss with a wooden block slightly convex on its abdominal surface and secured to an elastic spring encircling the body ; if the hernia has become irreducible, apply a hollow, cup- shaped, well-padded truss. Obstruction from accumulation of stercoraceous matters frequently occurs in irreducible umbilical hernia, with severe constitutional dis- turbance, but without positive strangulation ; this condition is best overcome by the free administration of aperient enemata. The radical treatment of hernia should be undertaken when palliative treatment has failed, Of the many different operations devised, few are absolutely free from danger, and none are always ultimately successful. In determining the question of the propriety of an operation every case must be studied by itself, and the decision should depend upon the condition of the hernia, the health of the patient, and the risk incurred. 814 LOCAL DISEASES. The following method of operation for inguinal hernia is advised : The external surfaces having been made aseptically clean, make an incision the centre of which is over the external abdominal ring ; the dissection is con- tinued until the sac is exposed. While it is important to be careful, owing to the peculiar delicacy of the structures in children, the operator may be so cautious as to tear and bruise tissues needlessly. The sac must now be care- fully separated from the cord and freed from all connections to a point within the internal ring, this latter being effected by the end of the index finger. The sac, being empty, is drawn down so as to be quite tense, and then firmly tied with strong carbolized silk as high up as possible within the internal ring. The fundus is next cut off about half an inch below the ligature, and the stump is pushed into the abdomen. Ball twists the sac with strong for- ceps, making four or five complete revolutions, then ligates the highest part of the twisted pedicle with catgut ligature and cuts away the mass. The next step in the operation is to raise the cord, and close by firm suture the internal ring from below upward. This should be done with carbolized silk and in such manner as to bring the conjoined tendon in contact with Pou- part's ligament. In order to bring these margins in firm contact, so as to secure a complete closure of the canal and internal ring, the best suture is that of the shoemaker, which gives the support of a double suture. The old canal and the internal ring having been closed, the cord is placed in posi- tion and the external wound closed. No drainage is required, and the exter- nal dressings must be antiseptic. Owing to the difficulty of keeping the wound of a child clean, Grerster of New York closes the neck of the sac and packs the wound with iodoform gauze, and thus treats it as an open wound. The radical operation for femoral hernia in children has rarely been required. Umbilical hernia is so generally relieved by a very simple pad as to have attracted little attention. Xota (Marcy) reduces the hernia and closes the ring with the finger ; while the sac is held firmly by an assistant, the operator winds a rubber tubing, one-eighth of an inch thick, three or four times around the neck of the sac tightly, and then ties the ends secure with a silk ligature. The whole is covered with cotton. In ten or twelve days the mass sloughs off, and the surface is dressed with iodoform and car- bolized cotton. The wound closes in four or five days. Xota has operated successfully on 18 cases. A strangulated hernia in a child does not differ from that in an adult in its management. The practitioner must first examine to determine the kind and variety ; its duration ; the hour at Fig. 224. which vomiting commenced ; the varia- Distended and ^t/\ Collapsed and tions in the composition of the fluid congested wk%]\ bloodless ejected: the usual size of the tumor; its bulk before vomiting; the changes during this stage ; the pain, whether local or extending into the abdomen with or without manipulation; the condition i\ eck of sac. Amk ' Jlk\ of its coverings: its probable contents: the treatment already pursued. The first step in the treatment is to endeavor to displace the hernia from its abnormal A strangulated hernia. position and pass it through the orifice of the sac into the peritoneal cavity. Before vomiting occurs abstain from manipulation of the tumor until other remedial measures have been tried ; place the patient on the back, with knees flexed and pelvis raised, and apply warm fomentations over the region of the mouth and neck of the sac ; if urgent symptoms do not arise, a few HEX XI A OF THE ABDOMEN. 815 Fig. 225. hours may be allowed to elapse to afford time for this treatment to take effect. Other measures have been employed to assist in reduction, with occasional benefit, as cold to the hernia ; reversing the trunk by keeping the head nearest the ground and the pelvis upward. Anaesthetics exert a power- ful influence over the causes preventing reduction. During the administra- tion of the anaesthetic taxis should be employed. This is a method of manip- ulation, and must be practised as follows : Place the patient in a position to relax all abdominal muscles which contract around the mouth of the sac ; fix as far as it is possible the mouth and neck of the sac with the fingers of one hand, whilst the fundus of the tumor is held in the palm of the other, the object being to dilate the mouth of the sac and diminish the bulk of the protrusion, the fact being borne in mind that irreparable injury is frequently inflicted upon the herniated bowel by violence, and that the danger of mis- chief by the use of the taxis increases in proportion to the length of time the bowel has been strangulated. As soon as the voluntary muscular con- traction ceases, make gentle and well-preconcerted pressure, and, if the taxis succeed, the tumor will gradually become softer or less elastic, smaller, and of different shape, until it escapes from the embrace of the mouth of the sac ; taxis, if not already abandoned, must always be discontinued altogether when it is certain from the vomited fluids that there is regurgitation of the contents of the duodenum and jejunum. The failure of the taxis necessitates the liberation of the hernia by the operation of herniotomy. An inguinal hernia which has resisted well-directed taxis must be at once liberated by division of the stricture. This operation should be performed with careful attention to all of the details required in the use of antiseptic dressings. Provide an ordinary hernia-knife, a common scalpel, probe-pointed bistoury (Fig. 225), forceps, di- rector, carbolized sponges, carbolic water 1 to 20, bichloride solution for irrigation, and carbolized gauze. Place the patient on a firm, low table ; shave the parts and wash them with bi- chloride solution ; give the anaesthetic fully. If the hernia is an oblique inguinal, raise the shoulders and slightly flex the thigh of the affected side, and make an incision through the skin over the neck and body of the tumor, its upper ex- tremity being nearly midway between the anterier superior spinous process of the ilium and the tuberosity of the pubes, about one inch and a half above the level of Poupart's ligament, and its lower about the middle of the scrotum. This incision exposes the intercolumnar fascia which forms the first and thickest covering of the sac ; divide this fascia after raising with forceps or on a director, when the cre- master muscle will be exposed, which must be cut in a similar man- ner, and this incision lays bare the sac. The division of these layers often causes great embarrassment and delay, for the operator, expect- ing to see the sac itself when he has divided the integuments, mis- takes the thickened covering and the cremaster muscle for the hernial sac, and cuts the fascia with extreme caution, fibre by fibre. Open the sac with exceedingly great care to avoid including the walls of the bowel, either seizing the sac with forceps (Fig. 22G) or raising it between the thumb and fingers. Make an opening sufficiently large to admit a grooved director with the scalpel, the sharp edge of which is directed laterally, the side of the blade being placed nearly flat on the tumor ; divide the sac on the director, pressed firmly against its inside (Fig. 227). Make slight pressure upon the sac to return its contents into the abdomen : if reduction be impracticable, open the sac sufficiently to reach its orifice easilv : pass the index finger along the anterior surface of the protrusion upward toward the mouth of the sac, when the stricture will be encountered : the palm being- upward, pass the hernia-knife flatwise along the finger (Fig. 228) or on a grooved Probe-pointed bistoury. 816 LOCAL DISEASES. director through the mouth of the sac ; turn the knife so as to cut parallel with the linea alba, and divide the structures in contact with it sufficiently to allow Fig. 226. Fig. 227. Dissection of hernia. Introduction of director. Finger as director in operation for hernia. Fig. 229. the ungual phalanx to pass freely into the abdominal cavity. Carefully examine the protruded intestine to determine whether the brown color which it assumes under strangulation lessens or disappears, the proof of a return of circulation ; the intestine should also be pulled down a little to examine the part immediately compressed by the stricture ; the veins on the surface may be emptied by pressure and their sudden filling noted ; if the intestine appears to have free cir- culation, relax the parts by posi- tion, and directly but gradually return it, replacing about an inch at a time, and securing each part with the fingers until the whole is returned into the abdomen. The contents of the hernial sac should now be returned : all violence and improper haste should be guarded against, for the intestine is tender and will easily tear at the strictured part. Clear the parts of blood, irrigate with bichloride solu- tion 1 : 5000, nicely adjust the sac and its coverings, introduce a drainage-tube at the upper angle, and stitch all opposing tissues together with a continuous suture, in such manner as to firmly close the would. Bring the edges of the wound together with in- terrupted sutures (Fig. 229). Dust the sur- face with iodoform, and apply iodoform dressings with the spica bandage to retain them in position. The important feature of the after- treatment is the diet, which should be farinaceous, with milk ; opium should be used when required ; the bowels are often relieved spontaneously, but if they remain inactive and any discomfort arises, give an enema of warm water or gruel with common salt or a little castor oil ; if thirst is distressing, give ice ; stimulants are often required soon after the operation, but should be given in small quantities, and the addition of opiates is frequently very useful. Incision for inguinal hernia, stitched, show- ing the position of the drainage-tube at the outer angle of the wound. HEBXIA OF THE ABDOMEN. 817 Fig. 230. Umbilical hernia, strangulated, differs from other hernias in this, that too much stress cannot be laid upon the protracted and judicious employment of taxis, owing to the great fatality of operations upon this hernia. Place the patient on the back ; give an anaesthetic : as the tumor has descended, if at all bulky, draw it away from the ring, press its contents directly upward and backward in a direction opposite to that of the displacement. Should the taxis fail and the symptoms not be urgent, try the effects of a full anodyne and cold or warm applications. These efforts having failed, proceed to ope- rate antiseptically : Select a scalpel and director ; bearing in mind the thinness of the external coverings, particularly in recent cases, make a J_-shaped incision (Fig. 230), the vertical limb being carried nearly an inch above the upper extremity of the tumor, directly in the line of the linea alba ; raise successive layers on the director down to the sac, which must, if possible, be left intact, owing to the great danger of fatal peritonitis if it is divided. Seek the seat of stricture, which is generally found at the upper margin of the ring ; carry the knife upward upon the finger, and divide the stricture to the requisite extent : draw the protruded parts somewhat downward to liberate them from their confinement, and gently replace them in the abdomen — first bowel and then omentum. If the constriction is within the sac. the latter must be opened, the incision being as small as possible. When the hernia is irreducible leave the protruded structures, after the division of the stricture, in their extra-abdominal situation. 52 Incision in operation for umbilical hernia. SECTION IV. DISEASES OF THE RESPIRATORY SYSTEM. CHAPTEE I. CORYZA. The term " coryza " is applied to inflammation of the Schneiderian mem- brane. It is acute or chronic. The acute form is primary or secondary. Acute primary coryza is common in infancy and childhood. Its usual cause is exposure to currents of air, to cold, and especially to sudden changes of tem- perature, from warm to cold. The cause is the same as that in the ordinary forms of bronchitis. The two diseases frequently indeed coexist, occurring from the same exposure. The inflammation in such cases commences upon the Schneiderian membrane immediately upon the operation of the cause, and soon after extends to the bronchial tubes. Acute coryza may also be produced by the inhalation of irritating vapors, hot air, or dust, and also by the presence of a foreign body, as a button or bean, in the nostril. Secondary coryza is commonly due to a specific cause. The diseases in connection with which it occurs are influenza, whooping cough, measles, scarlet fever, diphtheria, and constitutional syphilis. In the infant coryza is one of the first manifestations of inherited syphilitic taint. Acute primary coryza ordinarily abates in from one to two weeks. The secondary form gradually declines, in most cases, when the primary affection on which it depends is cured. Syphilitic coryza is more protracted than the primary form or than that accompanying the eruptive fevers. Some children are so liable to coryza that it occurs whenever they take cold. Occasionally it is so frequently renewed in the winter months that it resembles the chronic form of the disease. Acute coryza is commonly dependent on a dyscrasia, usually the syphilitic or strumous. The dyscrasia is indicated by pallor, flabbiness of the flesh, and liability to glandular swellings. Certain cases take their origin in the nasal catarrh of the exanthematic fevers, the local affection continuing after the constitutional disease has declined. Chronic coryza sometimes occurs in chil- dren who appear otherwise in good health. It is probable that in such cases there is a dyscrasia of which the coryza happens to be the sole manifestation. If the coryza appear on one side, be persistent, and the discharge be muco- purulent and offensive, probably a foreign substance, as a button, has been pushed into the nostril. Obviously, if present, the coryza will continue until the substance is removed by the forceps or otherwise. Anatomical Characters. — The alterations which the nasal mucous membrane undergoes when inflamed vary considerably in different cases. In the simplest and most common form of coryza this membrane is sometimes in patches, sometimes generally reddened, thickened, and softened. Its papillae are prominent, producing an inequality of the surface. Ulcerations are not common in simple acute coryza, but they sometimes occur in the chronic form. In diphtheria, and sometimes in scarlet fever and variola of severe type, the coryza is pseudo-membranous, and when it presents this form it is com- 818 CORYZA. 819 monly. but not always, associated with pseudo-membranous angina or laryn- gitis. It is commonly diphtheritic wherever diphtheria prevails, and is very prone to end in systemic infection unless promptly and properly treated. Symptoms. — The constitutional symptoms are mild or severe according to the gravity of the inflammation. If the coryza be acute and pretty general, there is febrile movement, with thirst and loss of appetite. Frontal headache is common, from the proximity of the inflammation to the head or its exten- sion to the frontal sinuses. Sneezing is the first symptom in many cases of acute coryza. As the inflamed membrane swells more or less obstruction occurs to respiration. The breathing is noisy, especially during sleep, and in severe cases the patient is compelled to breathe through the mouth. If there be much obstruction to respiration, the suffering of the patient is con- siderable, from the sensation of fulness in the nostrils, the headache, and the muscular effort required in each respiratory act. In the commencement of coryza the patient experiences a sensation of dryness in the nostrils, which is soon succeeded by a thin discharge of a serous appearance. In the course of a few hours the secretion becomes thicker. It is muco-purulent, and remains such till the disease begins to decline. Inspissated mucus and crusts are liable to collect within the nos- trils and around their orifice in chronic coryza, and sometimes also in the acute disease if the discharge be not abundant. These crusts increase the difficulty of breathing. Often the acridity of the discharge is such that the skin of the upper lip and around the nostrils is excoriated. Prognosis. — Uncomplicated catarrhal coryza rarely terminates fatally. It is only dangerous in young nursing infants, in whom it may prevent proper traction of the nipples. Coryza accompanying the eruptive fevers, although it may increase the suffering, does not materially increase the danger. Syphilitic coryza subsides when the system is sufficiently affected by antisyphilitic remedies. Chronic coryza is sometimes very obstinate. It may continue for months or years, giving rise to a constant though not abundant discharge. Treatment. — Common mild attacks of coryza require little treatment. The bowels should be kept open and the body should be warmly clothed. Inunction of the nostrils is a popular remedy, and it seems to give some relief. The most successful mode of treating simple catarrhal coryza, as well as ulcerative or membranous, is by nasal irrigation by means of a hand-atomizer or syringe, used hourly or every two hours, with one of the following remedies: Squibb's peroxide of hydrogen (11 vol.) rendered alkaline and reduced by water at the time of use. The mother or nurse should first employ it upon herself, and dilute it still more if necessary (see art. Diphtheria). Another good nasal wash is Seller's tablet, one tablet to six tablespoonfuls of water. A 5 per cent, solution of common salt in warm water injected into the nostrils with a small syringe aids materially in removing the muco-pus which obstructs the respiration and in establishing a healthier state of the inflamed surface. The following formula will be found useful in most cases of this form of coryza : R. Acidi borici, 35; Sodii biborat., 3ij ; Aquae, 5 vii J' R. Sodii chloridi, £j ; Sodii biborat., £ij ; A quae, Oj. — Misce. Half a teaspoonful, used warm, should be injected into each nostril several times daily, with the head thrown backward. 820 LOCAL DISEASES. The treatment proper for pseudo-membranous or diphtheritic coryza is detailed in our remarks on the therapeutics of diphtheria. Chronic coryza, since it depends upon a dyscrasia of which it is one of the local manifesta- tions, requires remedies appropriate for the blood disease. Scrofula needs the syrup of the iodide of iron and cod-liver oil. The various ferruginous preparations, as wine of iron, tincture of the chloride of iron, iron lozenges, and the vegetable tonics are also more or less useful. The diet should be nutritious and plain, and out-door exercise and, if possible, country life should be enjoined. If the dyscrasia be syphilitic, similar invigorating measures are required, and mild mercurial inunctions to the nasal surface are especially useful. The following, which has been largely employed in the Out-door Department at Bellevue, is one of the best ointments for such cases, and its alterative effect renders it also useful for strumous coryza : R. Ung. hydrarg. nitratis, ^ij ; ITng. zinci oxid., ^ij. — Misce. To be thoroughly applied to the Schneiderian membrane by a swab or camel's- hair pencil three or four times daily. Recently it has been modified by the substitution of Squibb's 5 per cent, oleate of mercury in place of the citrine ointment. If the coryza have a distinctly syphilitic origin, the application of a 2 or 3 per cent, oleate of mercury will fully meet the indication and be followed by improvement. Meigs and Pepper recommend the following ointment in chronic coryza, to be applied at night after the use of injections through the day : R. Unguenti hydrargyri nitratis, gss ; Extracti belladonna, gr. x ; Axungiae, ^ss. — Misce. Astringent injections into the nostrils are not often required in the treat- ment of the various forms of coryza ; but occasionally, if the discharge be protracted and abundant, weak astringent applications may be beneficial, as two or three grains of nitrate of silver or of alum or tannin to the ounce of water. It should be borne in mind that washes for the nasal surface should,, as a rule, be employed tepid. CHAPTER II. LAKYXGITIS. Catarrhal Laryngitis. Acute catarrhal laryngitis occurs at all ages, but it is so common in infancy and childhood that it is proper to treat of it in a work relating to the diseases of these periods. Like other inflammatory affections of the air- passages, it is most common in the cold months or when the weather is changeable. Its usual cause is, therefore, exposure to cold. Protracted and violent crying and the inhalation of acrid vapors are occasional causes. Catarrhal — or, as it is sometimes designated, simple — laryngitis also occurs in connection with certain constitutional diseases, among which may be men- tioned measles, scarlatina, and variola. Laryngitis is also a common accom- LARYNGITIS. 821 paniment of bronchitis and broncho-pneumonia, though its symptoms are liable to be obscured by those of the graver disease. It often likewise accom- panies pharyngitis, due to extension of the inflammation. Symptoms. — Catarrhal laryngitis produced by the impression of cold is commonly preceded and accompanied by coryza. The initial symptom is chilliness, followed by sneezing and the discharge of thin mucus from the nostrils in consequence of irritation of the Schneiderian membrane. The commencement of laryngitis is indicated by hoarseness, which is apparent when the child cries or, if old enough, when it attempts to speak. There is often in severe cases complete loss of voice, so that speech above a whisper is impossible. I have noticed this most frequently in the laryngitis which accompanies measles. A cough occurs which is at first dry and husky, but becomes loose in the course of a few days. Expectoration is scanty, unless the inflammation have extended to the trachea and bronchial tubes. This disease is often accompanied by soreness of the throat, noticed in the act of coughing or when the larynx is pressed with the finger. In laryn- geal catarrh, when uncomplicated, the respiration remains nearly natural and the pulse is but little accelerated. In mild cases the nature of the disease is often not apparent, as long as the child remains quiet, in consequence of the absence of symptoms, but the character of the voice when it cries or speaks, or of the cough, reveals at once the nature of the affection. Acute laryngeal catarrh subsides in from one to two weeks. Occasionally it lasts three or four weeks before the symptoms entirely disappear. Death, which is rare, is due to some complication. Chronic laryngitis is much less frequent than the acute form. Its ana- tomical characters are similar to those in other chronic inflammations affect- ing mucous surfaces — to wit, thickening and more or less infiltration of the mucous membrane, increased proliferation and exfoliation of the epithelial cells, and increased functional activity of the muciparous follicles. In the adult, chronic laryngitis is common as one of the lesions of the syphilitic or tubercular disease. In the child, syphilitic and tubercular laryn- gitis is more rare, but the latter sometimes occurs in connection with pulmo- nary or bronchial tuberculosis. Such patients are emaciated and have the ordinary symptoms of the tubercular disease. Chronic laryngitis also occurs in young children, usually infants, as one of the manifestations of the stru- mous diathesis. I have records of several such cases, mostly nursing infants. Some of these patients had mild bronchitis, but it was obviously subordinate to the laryngitis. Their respiration was noisy and harsh, continuing of this character several weeks and even months. The cough was also harsh and loud, conveying the idea of thickening and relaxation of the mucous mem- brane covering the vocal cords. Their respiration was not notably accelerated and the blood was apparently fully oxygenated, though the friends were often alarmed by the noisy breathing and cough. In this form of chronic laryngitis expectoration is scanty, the fever slight or absent, the appetite remains unimpaired, and the general condition of the child is good. From time to time exacerbations occur, and occasionally improvement is such as to encourage the hope of speedy cure ; but in the cases which I have seen there has not been complete intermission in the dis- ease till the final recovery. Those patients whom I have been able to follow through the disease have recovered in from three to four months or one year. Chronic laryngitis is to be distinguished from frequent attacks of acute laryngitis which are due to fresh exposures, and also from the laryngitis which is associated with bronchial phthisis. It is to be distinguished from protracted acute laryngitis, which sometimes does not entirely subside in less 822 LOCAL DISEASES. than a month or six weeks, by its longer duration, the greater thickening of the inflamed membrane, and more noisy respiration. Often chronic laryngitis results from the acute disease, the inflammation being perpetuated by the struma or dyscrasia of the patients. Anatomical Characters. — In acute catarrhal laryngitis the mucous membrane of the larynx presents the usual appearances of mucous surfaces when inflamed — namely, redness and thickening. It is also more or less soft- ened. Ulcerations rarely, perhaps never, occur in acute primary laryngitis. When present in chronic laryngitis the ulcers are small and situated upon or near the vocal cords. Tubercular and syphilitic ulcers of the larynx are much more rare in children than in adults. The inflammation in simple acute laryn- gitis usually extends over the whole surface of the larynx and also to the upper part of the trachea. It may be pretty uniform or more intense in one place than another, and, like other mucous inflammations, it is accompanied by more or less proliferation and exfoliation of epithelial cells. In most cases of simple laryngitis, whether acute or chronic, the inflammation extends to the pharynx, producing redness and thickening, though generally moderate, of the mucous membrane which covers it. Examination of the fauces there- fore aids in diagnosis. In the adult cedema glottidis occasionally results from laryngitis. In the child there is little danger that this will occur, in consequence of the anatom- ical character of the larynx, since in early life the larynx contains but little submucous connective tissue, and therefore less submucous infiltration or exudation occurs during the inflammation. The structural changes occurring in catarrhal laryngitis of infancy and childhood relate almost exclusively to the mucous membrane. Treatment. — Primary and uncomplicated catarrhal laryngitis requires little treatment. Most cases do well by the employment of suitable hygienic measures, without medicine. Benefit is, however, derived from the use of demulcent drinks and an occasional laxative. A mixture of paregoric and syrup of ipecacuanha or the mist, glycyr. comp. or a small Dover's powder will relieve the cough. For restlessness a warm foot-bath is also useful. Inhalation of the spray of glycerin and water from the atomizer, or of steam, plain or rendered alkaline by the use of lime-water and a little bicarbonate of sodium, is also useful. In the N. Y. Foundling Asylum great benefit appears to be derived from the constant inhalation from a croup-kettle of the vapor of one ounce of turpentine to two quarts of water. Chronic laryngitis dependent on syphilis or tuberculosis requires the constitutional treatment which is appropriate for that disease. The chronic laryngitis which I have described as occurring chiefly in infancy, and which appears to be of a strumous character, is in most cases obstinate. The patient should be warmly clothed, and constant care should be taken that there be no exposure which would endanger taking cold, as this would produce an exacerbation of the disease and tend to counteract what had been gained by remedial measures. This form of chronic laryngitis is most satisfactorily treated by the application of the following ointment upon the neck directly over the larynx, and the internal use of cod-liver oil and the syrup of the iodide of iron : R • Plumbi iodidi, £j ; Ext. belladonna, 3j ; Lanolini, Jj. — Misce. Spasmodic Laryngitis. This is a common disease. It is also called false croup, in contradistinc- tion to true or pseudo-membranous croup, and by some Continental writers LARYNGITIS. 823 stridulous angina or stridulous laryngitis. It should not be confounded with spasm of the glottis, which is a form of internal convulsions and is not inflammatory. It occurs ordinarily between the ages of two and five years. It is commonly a sporadic affection, but Rilliet and Barthez state that " it is incontestable that it may prevail epidemically." They express this opinion, not from their own observations, but chiefly from those of Jurine, made in the commencement of the present century. - Causes. — Children in some families are more liable to false croup than in others, so that an hereditary tendency to it must be admitted. The exciting cause in most cases is exposure to cold. False croup is not uncommon in the commencement of measles. Narrowness of the rima glottidis and an excita- ble state of the nervous system, both of which are common in early childhood, are predisposing causes. Symptoms. — Spasmodic laryngitis is ordinarily preceded for a day or two by a slight cough and fever, by symptoms of mild nasal catarrh, such as all children are liable to on taking cold. In exceptional cases these symptoms are absent and the disease begins abruptly. Singularly, it commences in most patients at night after the first sleep, between ten and twelve o'clock. The sleep is usually quiet and natural, but the child awakens with a loud barking cough. There is great dyspnoea, and the respiration is harsh or whistling, on account of the narrowing of the chink of the glottis from the swelling and tension of the vocal cords. The face is flushed and expressive of suffering. The child cries, moves from one position to another, wishes to be held or carried, seeking in vain for relief. The skin is hot, pulse acceler- ated, the voice hoarse or even whispering. After a variable period, usually from half an hour to two or three — not more than half an hour with proper treatment— these symptoms abate. The patient is then somewhat exhausted and falls asleep. The face is less flushed or even pallid, the heat abates, and the pulse is less accelerated. The cough, though less frequent, remains for a time barking or sonorous, and respiration, though greatly relieved, is not at once entirely natural, but it gradually becomes so. In many cases the spas- modic respiration and cough do not recur, but sometimes the attack is repeated once or more, especially during the subsequent nights. The symptoms vary greatly in intensity in different patients. As the attack declines the disease, losing its spasmodic character, becomes a simple inflammation. In some patients the abatement of the cough and restoration of health are rapid, but oftener the inflammation extends not only into the trachea, but also into the larger bronchial tubes, and a tracheo-bron- chitis remains, which gradually declines. The termination is not always so favorable. Spasmodic laryngitis is, in exceptional instances, the precursor of other serious affections, which may prove fatal. It has been stated that measles often begins with spasmodic laryngitis. Bronchitis, becoming capillary, may occur in connection with it, as may also pneumonia, and by either of these severe inflammations the prognosis may be rendered doubtful. A few cases have been recorded in which it was believed that spasmodic laryngitis was of itself fatal. In some of these the dyspnoea was extreme and persistent and was the cause of death. In a case reported by Rogery, on the other hand, the respiration became easy before death and the pulse more and more frequent and feeble. Death apparently occurred from exhaustion. It is not improbable that had careful post-mortem examinations been made in those cases of spasmodic laryngitis which have ended fatally, other lesions would have been discovered besides those located in the larynx, perhaps tracheo-bronchitis, with an accumulation of mucus in the larynx, producing suffocation, or perhaps in some of the cases congestion of the brain or lungs and serous effusion. 824 LOCAL DISEASES. Anatomical Characters ; Pathology. — The opportunity does not often occur of determining the anatomical characters of spasmodic laryngitis. I have witnessed but one post-mortem examination. A little girl nine years old was taken on Friday night with cough and dyspnoea, indicating a pretty severe attack. The mother, acting through the advice of a friend, gave kerosene oil to her in considerable quantity. This was succeeded by obstinate vomiting and purging, which continued during Saturday and Sunday, and terminated fatally on Monday. At the autopsy we found uniform and intense hyperemia throughout the whole extent of the larynx and trachea and in the bronchial tubes, but there was no pseudo-membrane on the inflamed surface and but little mucus and pus. The solitary follicles of the intestines and Peyer's patches were tumefied, and the gastro-intestinal surface was injected in places. The cause of death was obviously the diarrhoea, appar- ently of an inflammatory character, and probably produced by the kerosene oil. The condition of the mucous membrane of the larynx was that which is ordinarily present in spasmodic laryngitis, though in some cases in which post-mortem examinations have been made the evidences of laryngeal inflam- mation were slight. Guersant relates a case in which the surface of the larynx seemed to be nearly in its normal state. Death in cases of slight laryngitis is due to causes which are independent of the larynx. In Guer- sant's case tuberculosis was present. There is, as has already been intimated, another and a more important ele- ment besides the inflammation in the pathology of spasmodic laryngitis — an element producing those phenomena which render it a disease distinct from simple laryngitis. I refer to spasm of the laryngeal muscles. This element pertains to the nervous system, so that spasmodic laryngitis is allied both to the neuroses and to inflammation. Diagnosis. — The disease for which spasmodic laryngitis is most fre- quently mistaken is pseudo-membranous croup. The friends, indeed, usually make this mistake in forming their opinion of the case before the physician arrives ; and there can be no doubt that many of the cases which have been published in medical journals as true croup were examples of this affection. The points of differential diagnosis are the following : True croup begins with symptoms which at first are slight, so as scarcely to arrest attention, but which gradually increase in intensity. The cough becomes more harsh and the respiration more difficult by degrees. This increase in the gravity of the symptoms occurs by day as well as by night. On the other hand, false croup, though preceded by symptoms of nasal catarrh, commences abruptly. The symptoms have from the first their maximum intensity, and the time at which it commences is at night. Again, the cough in spasmodic laryngitis possesses a loud, sonorous character, while in true croup it is harsh or rough from the presence of the membrane, and having, therefore, less fulness. The voice in spasmodic laryngitis may be hoarse, but it is not lost or is lost only for a short time. It afterward becomes natural or is slightly hoarse. On the other hand, in true croup the voice, from being natural at first, is gradually extinguished. In fatal cases it soon becomes whispering, and con- tinues such till the close of life ; in those that recover the voice remains hoarse several days. These differences are important, and if fully appre- ciated are in most instances sufficient to establish the diagnosis. Besides, in a large proportion of cases of true croup portions of the pseudo-membrane may be discovered on inspecting the fauces, and the faucial surface is deeply injected, while in spasmodic laryngitis there is, with rare exceptions, no false membrane upon the surface of the fauces and but a moderate amount of congestion. LARYNGITIS. 825 Laryngismus stridulus or internal convulsions must not be confounded with this disease. It is not inflammatory, but purely spasmodic, suddenly commencing and abating — identical, it is believed, in character with tonic convulsions of the external muscles, but affecting the internal muscles of respiration. This disease has already been fully described. Prognosis. — Little need be added, as regards prognosis, to what has already been stated. While a favorable opinion in reference to the result may ordinarily be expressed, the physician should not forget the fact that death may occur. Symptoms indicating an unfavorable termination are — great and continued dyspnoea, not diminished by the proper remedial mea- sures : stridulous expiration as well as inspiration ; lividity of the prolabia and lingers : pallor and coldness of surface ; pulse progressively more frequent and feeble. Convulsions and coma may also occur near the close of life. Treatment. — The indications of treatment are twofold : first, to relieve the spasmodic action of the laryngeal muscles ; secondly, to cure the laryn- gitis. To meet the first indication a warm bath of the temperature of about 100° should be employed as soon as possible after the commencement of the attack. The patient should be kept in it ten or fifteen minutes, in order to obtain its full relaxing effect. In mild cases a warm foot-bath may be suf- ficient. A second means is the use of an emetic, which should be simulta- neous with the bath. To children under the age of three years syrup of ipecacuanha should be given, in doses of one teaspoonful repeated in twenty minutes, till vomiting occurs. Children over the age of three years, unless of feeble constitution, are best treated by the compound syrup of squills in teaspoonful doses, or a mixture of this with syrup of ipecacuanha. It is not often necessary to give more than three or four doses, and sometimes one or two are sufficient to produce vomiting. In most cases by the use of the warm bath and the emetic the symptoms are rendered milder, and convalescence soon commences. Dr. R. R. Livingstone 1 reports a case of laryngitis treated by Squibb's ether. It is stated that portions of pseudo-membrane from one-eighth to three-fourths of an inch in length were expectorated ; but the symptoms certainly indicated a spasmodic element as decided as in spasmodic croup, and the benefit from the ether was apparently due to the relaxation of the laryngeal muscles which it produced. The treatment of the patient, who was two years old, was commenced by the administration by the mouth of half a teaspoonful of the ether, and followed by its inhalation. " In pre- cisely eight minutes from the time the patient commenced the inhalation the abnormal muscular exertion ceased ; a general relaxation took place ; the pulse (which had numbered 150) fell to 100." Ether, judiciously employed, will probably prove to be a useful remedial agent in spasmodic forms of laryngitis, whether or not it have any effect on pseudo-membranous forma- tions. A large majority of cases, however, recover speedily without its em- ployment or by the other measures recommended. Attention should always be given to the state of the bowels in spasmodic laryngitis ; if they are not well open a purgative should be administered. For those that are robust and with considerable febrile movement the saline cathartics are ordinarily preferable, as Rochelle salts, or a purgative dose of calomel may be administered. The cathartic should not be prescribed till the nausea from the emetic has subsided. By its derivative effect it tends to diminish the laryngitis, and in severe cases it may obviate the need of depletion by leeches. Inhalation of the vapor of hot water and the application of a sinapism 1 American Journal of the Medical Sciences, April, 1867. 826 LOCAL DISEASES. over the neck and upper part of the sternum, followed by an emollient poul- tice, are useful adjuvants to treatment. The most convenient and effectual way of employing vapor is, however, by the atomizer, and as the chief danger is that the inflammation may become pseudo-membranous, I am in the habit of using in the atomizer the officinal lime-water, its solvent action being increased by the addition of the sodium bicarbonate, two drachms to the pint. When the spasmodic element in the disease is relieved the case becomes one of simple laryngitis, and the general plan of treatment recommended for that malady is proper for this. Small doses of ipecacuanha or of one of the antimonial preparations, as the compound syrup of squills, not sufficient to cause nausea, should now be given at regular intervals. Phenacetin, given every third hour in doses of half a grain, one grain, or one and a half grains, is a useful remedy if the temperature reach 103°. Its effect should be watched, and it should be discontinued when its sedative influence on the circulation begins to be apparent. If, however, the disease do not speedily terminate by recovery, or more rarely by death, there is nearly always tracheo-bronchitis or a more serious affection coexisting with the laryngitis or following it, so that depressing measures should not be long continued. Expectorants of a stimulating cha- racter, as carbonate of ammonium, are required in the course of a few days, and in young and feeble children they should be given at an early period. The mode of treatment recommended above is appropriate for that large class in whom the inflammatory element predominates. In a smaller number of cases the nervous element predominates over the inflammatory, and the treatment should be in some respects different. Such children are usually pallid and of spare habit, having, indeed, the nervous temperament. They are liable to attacks of this disease, though generally of a mild form, on slight exposure to cold, and with a very moderate amount of inflammation. The treatment in these cases should be directed more to the nervous system. My plan has been in the treatment of such patients, after perhaps the use of a mild emetic, to give quinine, one grain three or four times daily to a child from three to five years old, prescribing at the same time a simple expector- ant and a mildly irritating application to the throat. The symptoms in these cases are not severe, and active measures are not required, though the peculiar cough continues longer than in the more inflammatory forms of the malady. The patient with spasmodic laryngitis should be kept in a warm room during the paroxysms, and should inhale an atmosphere loaded with moisture. Trousseau recommends a mode of treatment of spasmodic laryngitis which was first suggested by Graves of Dublin. It consists in the application underneath the chin, so as to cover the larynx, of a sponge soaked in water as hot as can be borne ; in ten or fifteen minutes it is repeated. This red- dens the skin, producing revulsion from the larynx. The hoarseness, dyspnoea, and cough diminish with this treatment, and some recover without other measures. In rare cases of spasmodic laryngitis the dyspnoea becomes so great, not- withstanding active treatment, that the life of the patient is in danger whether oedema glottidis or thickening and infiltration of the laryngeal mucous membrane be present. In these cases intubation with O'Dwyer's tubes will give prompt relief. Spasmodic contraction of the laryngeal mus- cles probably also occurs in these cases, increasing the dyspnoea. Recently, in the case of a child of about three years, the dyspnoea was so great in about three hours from the commencement that intubation was performed with immediate relief. LABYXGITIS. 827 Guersant and others speak of the importance of prophylactic management of children who are liable to this disease. Attention should be given to the dress, so that there may be sufficient protection from atmospheric changes, and there should be an equable temperature of the apartments in which they reside. Children of a decidedly nervous temperament, in whom the slightest laryngitis is liable to be spasmodic, require additional prophylactic measures. They are pallid and in a more or less cachectic state. Such children are benefited by chalybeate and vegetable tonics and by exercise in suitable weather in the open air. Imperforate nose may be congenital ; it is then caused by a membrane stretched across the nostrils, or by firm fibrous tissue, or by simple continuity of the integument. In congenital closure the interference with respiration and sucking often requires an early operation. In most cases a simple in- cision carefully made through the obstructing membrane, and the opening maintained by strips of lint or a short elastic cannula, is sufficient. Some- times it may be desirable to excise a portion of the obstructing tissue. When there is no indication of the opening of the nostril, the adherent parts must be gradually and cautiously divided until the nasal canal is restored. Hemorrhage from the nose, epistaxis, is of very common occurrence in children, owing to the immense distribution of blood-vessels throughout the cavities, and the existence of cavernous bodies between the periosteum and mucous membrane of the turbinated bones. Bleeding may be spontaneous or result from injury, and when severe there is a rupture of vessels. The following are some of the more useful remedies : Place the patient in the sitting posture, the head inclined slightly forward ; re- move all articles from the neck which prevent the free flow of blood ; secure the most perfect possible state of rest of mind and body, and encourage quiet respi- ration without speaking or blowing the nose. The simple means are cold to the nose and forehead or to the back of the neck, elevation of the arms above the head, astringent injection or spray, as of alum, tannin, zinci sulph., mustard foot- baths. As, in a large number of cases, the bleeding spot is near the anterior and lower border of the septum, the bleeding may often be arrested by pressing the ala of the affected side against the septum in such a manner as to close the nostril and the front and upper part of the nose ; or the finger may be applied directly in the nostril ; or a compress of lint, tied with a string with which to remove it, may be introduced into the nostril ; wicks or strips of linen may be introduced through the nose to the pharynx, and they may be sprinkled with tannin or dipped in persul- phate of iron to increase their styptic qualities. Antipyrine in aqueous solution, 1 : 30, is a safe and powerful haemostatic applied on lint ; insert as far as possible, and then compress the nose so as to bring the solution in contact with a large sur- face of mucous membrane. Cocaine applied in a 4 per cent, solution relieves con- gestion. Not unfrequently a careful examination will reveal a small ulcer just within the ala, from which the hemorrhage occurs. The application of the solid nitrate of silver will cause rapid cicatrization. If the child becomes anaemic from frequent losses of blood, the liq. ferri persulphatis in 3- to 5-drop doses in water is very useful. Foreign bodies are often introduced into the nasal cavities by children. The substances may remain long in the nasal cavities without causing any trouble, but, in general, their immediate effect is circumscribed inflammation, with purulent, bloody, and often fetid secretions. The diagnosis is made out from the history and exploration. If the history is doubtful, inspect the cavities, remembering that the foreign body may be covered with secretions; finally, explore with the probe, distinguishing, by the sensation, sound, and mobility, between the movable body and the bone. Early removal must follow detection of the body. Sneezing and the douche are sometimes effective. The most convenient instruments are thin, short, straight dressing- 828 LOCAL DISEASES. forceps and small scoops. Care is requisite in seizing the body, lest it be pushed more deeply into the cavity. First apply a 4 per cent, solution of cocaine with a spray apparatus. CHAPTER III DISEASES OF THE LARYNX. Foreign bodies entering the larynx are arrested in its interior, or descend, according to their size, form, and weight. When arrested in the larynx, they may lodge in one of the ventricles or become fixed between the vocal cords. Occasionally they are arrested at the junction of the larynx and trachea. The first symptoms of the entrance of the body into the air-passages are usually severe and characteristic : the patient gasps for breath, coughs vio- lently, the face becomes livid, the eyes protrude, the body is contorted, and he is like one choked by the hand. If the body is lodged in the larynx, the symptoms will vary with its size and peculiarities. It may be so large as to prove fatal by suffocation, or so small, hard, and smooth as to cause but slight symptoms. Ordinarily there is aphonia, with pain and soreness, and uneasi- ness in that region ensues, with dyspnoea and a whistling sound in respiration ; at the same time there is absence of tracheal and bronchial disturbance. If the symptoms are not so urgent as to require immediate tracheotomy, apply a 4 per cent, solution of cocaine to the palate and pharynx preparatory to laryngoscopic examination. In fifteen minutes examine the larynx. If the body is lodged above or within the larynx, with properly curved forceps it may be seized and removed without pain. As a general rule, the trachea should be opened with as little delay as possible in every case in which a foreign body is certainly known to be retained in any part of the air-passages, for by this means the immediate safety of the patient is secured and subse- quent expulsion or removal aided. An anaesthetic should always be given when the symptoms admit of delay, but in many cases there is not a moment to lose, and the trachea must be opened at once ; even if the patient cease to breathe before this is accomplished, the operation should be completed and artificial respiration instituted and perseveringly main- tained. In those cases where the symptoms are so slight as to cause hesitation before adopting such severe treatment delay is dangerous, for an interval of calm constantly precedes the recurrence of urgent symptoms, and temporary freedom from distress, instead of contraindicating the operation, affords the best opportunity for its performance. In deciding as to the particular form of operation in any case, it must be borne in mind that while laryngotomy is simple, easy, and free from risk, it is not as applicable to early childhood as tracheotomy, on account of the very limited dimensions of the crico-thyroid space. Laryngotomy is performed as follows (Fig. 231) : Place the patient on a table with the head and shoulders properly elevated and firmly fixed (Fig. 232) ; feel for the thyroid cartilage at the lower border of which it is to be opened ; make an incision with a narrow scalpel along the centre of the larynx, from the top of the thyroid to the base of the cricoid cartilage ; this incision should be one and a half inches in length ; if the crico-thyroid artery bleed, it must be twisted or tied ; divide the crico-thyroid membrane in the same direction in its whole extent ; if the open- ing is not sufficiently large, prolong the incision into the contiguous cartilages or transversely. If expulsion should not immediately take place, introduce the double cannula (Fig. 333), which secures freedom of respiration and stops hemor- rhage ; the contracted muscles of the larynx may become relaxed, and the DISEASES OF THE LARYNX. 829 foreign body, set at liberty, be expelled. When the patient has recovered from the immediate effects of the operation, the cannula may be removed, Fig. 231. Fig. 232. Incision in laryngotomy. Position of patient in laryngotomy. and the larynx explored by means of a probe ; if the body is not detected, use a larger instrument, as an elastic catheter ; the laryngoscope may also be used, and if the foreign body is detected it may be extracted with curved forceps (Fig. 234). If not extracted, the patient may now be safely inverted Fig. 233. Fig. 234. Double tracheal tube, movable plate, silver. Laryngeal forceps. and the back struck repeated blows, which often dislodges smooth, rounded bodies, as shot, bullets, or pieces of money ; if these means all fail, the larynx must be fully exposed. T hyrotomy , incision of the thyroid cartilage, is not a difficult operation, and does not involve much risk. Place the patient in the position already given (Fig. 232) ; make the incision through the cartilage perpendicularly upward from the opening in the crico-thyroid membrane previously made, and exactly in the middle line. Make the same search as before, and when the foreign body is removed bring the edges of the incision through the thyroid body together, and secure them by suture ; the laryngeal tube may be retained a few days, until all indications of local mischief have passed away. Burns and Scalds result from inhalation of flames, hot vapors, and attempts to swallow boiling liquids. Violent inflammation follows, with great pain in attempting to swallow, hoarseness, dyspnoea, and croupy symptoms, which gradually become extreme. In a fair proportion of cases little other treatment is required than a warm bed, the application of a hot sponge to the larynx, and the inhalation of warm, moist air. In more severe cases blisters or leeches are useful ; but if the symptoms rapidly progress and laryngeal spasm occurs, tracheotomy must be promptly performed, chloroform being given without fear. If there is immediate danger, proceed as follows : 830 LOCAL DISEASES. The patient being anaesthetized or not, as may be deemed best, and firmly held, the shoulders elevated and the head extended, stand at his right side and place the fore finger of the left hand on the left side of the trachea, and the thumb on the right side, and make uniform, steady, deep pressure until the pulsation of both carotid arteries is felt ; now slightly approximate the finger and thumb until the trachea is firmly and securely held between them, and maintain this grasp until by repeated cuts in the median line the trachea is exposed ; the fore finger of the right hand should be used from time to time to determine the relation of parts ; when the trachea is exposed it may be opened at once, or seized by a sharp hook and held while it is opened ; make the opening by thrusting the point of the knife, the edge directed upward, into the tube, and carrying it upward to a sufficient extent. It is important to keep strictly in the median line, otherwise the cannula will stand away in the wound, and its extremity will be turned sharply against the membrane of the trachea, and will not only cause irritation, but will quickly become blocked with mucus. The point of the knife must certainly penetrate the mucous membrane, which, if swollen, may be pushed before it; but it must not be thrust too deeply, lest it penetrate the posterior wall and the oesophagus ; if the first opening is too small, it must be enlarged. If there is not immediate danger, proceed as follows : The patient being in position, carefully examine the region and determine the precise point of opening the tube ; make a straight incision exactly in the median line, extending from just above the cricoid cartilage, nearly as low as the sternum ; if the patient has a short, fat neck, make the first incision long enough ; the subcu- taneous fat and connective tissue being divided, the sterno-hyoid muscles are ex- posed, divided by a faint line, along which make an incision dividing the fascia ; continue the dissection cautiously through the fascia and connective tissue, layer by layer, the separated tissues being held aside, and every bleeding vessel secured until the trachea is exposed and opened. In every case, however apparently hopeless it may have become, the operation should be completed and the tube introduced, even though the patient has ceased to breathe before this can be accomplished ; the most persevering effort should be made to effect resuscitation by aid of artificial respiration, and by sucking out the blood that may have entered the trachea, for recovery has repeatedly been effected in cases apparently the most hopeless. The last stage of the operation varies with the object in view ; if it has been undertaken on account of the presence of a foreign body, the edges of the opening should be held well apart by means of blunt hooks or dressing-forceps, or silk or wire ligatures may be passed through each edge of the wound, and tied behind the neck of the patient ; if the body is comparatively large and im- Fig. 235. pacted in the upper part of the trachea, it is better to introduce a cannula into the tracheal wound, and wait until all spasm has had time to sub- side ; if, however, the body is comparatively small and is sit- uated in the lower part of the trachea, it is better to lose no time in attempting to extract it by means of forceps, lest it Broad-beaked forceps. find its way into the bronchi. The forceps best adapted to seize the body has a peculiar curve (Fig. 235), with broad beaks. Or it may have a pliable shaft which can be bent at any curve, and will retain that position (Fig. 236) ; when introduced it may be closed and then acts as a probe ; if the foreign body is felt, the blades can be gently protruded, and PSEUBO-JIEMBBANOUS CBOUP. 831 when they enclose the body be closed upon it, and removal is readily effected. If the operation is undertaken for disease, a cannula should be selected which Fig. 236. Flexible forceps. can be worn with comfort, and which will be least liable to obstruction. It should always be double, and so curved as not to press upon the anterior wall of the trachea. CHAPTER IV. PSEUDO-MEMBEANOUS CEOUP (TEUE CEOUP). The term pseudo-membranous laryngitis or laryngo-tracheitis, or true croup, is applied to a common and fatal disease, the essential anatomical character of which is inflammation of the larynx, or larnyx and trachea, with the formation of a pseudo-membrane upon its surface. It occurs most fre- quently between the ages of two and twelve years, but infancy after the age of six months and early manhood are not exempt from it. Etiology. — Wherever diphtheria or pseudo-diphtheria prevails as an endemic or epidemic it is well known that a large majority of the cases of membranous croup are local manifestations of one or the other of these diseases or of the two combined (mixed infection). Whenever the laryngeal or laryngotracheal inflammation reaches a certain grade of severity it may be attended by the exudation of fibrin and the formation of a pseudo- membrane ; but such a result more frequently occurs in the inflammation caused by diphtheria or pseudo-diphtheria than in that produced by other agencies. The percentage of cases of diphtheria and pseudo-diphtheria in which the larynx becomes implicated and croup occurs varies in different epidemics and in different seasons and localities. In epidemics of a mild type the cases appear to be fewer in which the larynx and trachea are involved than in epidemics of a severe form. In New York the percentage is large. From December 1, 1875, to July, 1878, I preserved records of all the cases of diphtheritic diseases which came under my notice. The number was 104, and in 25 of these, or about 1 in 4, croup occurred, producing the usual obstructive symptoms and constituting the chief source of danger. During the two and a half years embraced in these statistics the disease was usually severe. Subsequently amelioration occurred in the type, and the proportion of croup cases has not been so large. Since the differentiation of diphtheria and pseudo-diphtheria has been recent, the term " diphtheria " in the follow- ing statistics necessarily embraces also cases of pseudo-diphtheria. So commonly is membranous croup, when occurring in a locality where diphtheria is endemic or epidemic, a local manifestation of diphtheria that physicians in such localities come to regard most cases of this disease of the larynx as produced by the diphtheritic poison. In New York physicians 832 LOCAL DISEASES. scarcely recognize any other form of membranous croup. It is well, there- fore, briefly to recall the evidences that croup in a certain proportion of cases results from other causes than diphtheria. The occurrence of croup in localities where diphtheria is unknown of course indicates the operation of some other agency than the diphtheritic poison. Thus, in 1842, before diphtheria was established in this country, Dr. John Ware of Boston pub- lished his well-known paper on croup, and in 74 of the 75 cases embraced in his statistics the membranous exudation was present upon the faucial surface. The statistics relating to the introduction of diphtheria into New York City and the recorded death-statistics of this city were annually published, and each year more or fewer deaths from croup were reported. The first death from diphtheria in this century within the city limits, certified by a physician, was that of a German woman at 638 Hudson street on February 15, 1852. Two other fatal cases occurred in 1857, and since then the deaths from croup and diphtheria have been as presented in the following table : Year. 1858 . 1859 . 1860 - 1861 . 1862 . 1863 . 1864. 1865 . 1866 . Croup. Diphtheria. .478 . 622 . 599 .460 . 685 754 449 o 53 422 453 594 981 781 534 435 Year. 1867 1868 1869 1870 1871 1872 1873 1874 1875 Croup. Diphtheria. 338 251 342 276 483 328 421 308 466 238 675 446 732 1151 594 1665 758 2329 Since 1875 weekly bulletins have been issued instead of the annual reports. Thus, in the first years after the introduction of diphtheria the deaths assigned to croup so greatly outnumbered those of diphtheria, as in 1858, when 5 died of diphtheria and 478 of croup, that it is evident that most of the cases of croup in those years were attributable to other causes than diphtheria. Since, as we have stated, any inflammation of the surface of the larynx and trachea, if sufficiently intense, may produce a pseudo-membrane, croup may occur as a primary disease and as a complication of various mal- adies. From the fact that croup was prevalent and fatal in the first half of the present century, before the occurrence of diphtheria, it is evident that we must look for some other cause for it. I cannot resist the conviction that it's cause prior to 1850 was pseudo-diphtheria ; in other words, the presence and action of the streptococcus and staphylococcus. According to my obser- vations in New York City, the chief causes of croup, arranged in the order of frequency, would be about as follows : Diphtheria, pseudo-diphtheria, or the inflammation caused by streptococci and staphylococci, " taking cold," measles, pertussis, scarlatina, typhoid fever, irritating inhalations. Did space permit, other cases might be cited showing the causal relation between the other diseases mentioned above and croup. Scarlatina is so often complicated by diphtheria that there seems to be a close affinity between the two diseases. It is a very common observation in New York City that scarlet fever continues two or three days in its usual form, when the symptoms become suddenly aggravated and the aspect of the disease more severe. On inspecting the fauces a pseudo-membrane is dis- covered covering this region, and it probably appears also upon the nasal surface. Although severe scarlatinous inflammation may cause a fibrinous exudation, yet that diphtheria or pseudo-diphtheria has supervened upon scarlet fever in a considerable proportion of cases which have the above history has been demonstrated by the microscope. In a few instances in my practice the fact that scarlet fever was complicated by true diphtheria, and PSEUD0-2IE1IBRAX0US CROUP. 833 the scarlatinous inflammations first in order were intensified by the presence and influence of the diphtheritic virus, was shown by the occurrence of diph- theria without scarlet fever in other members of the family. In accordance with the above law we may assume that a child who has larvngo-tracheitis, so common from taking cold and manifested by cough and hoarseness, is more prone to have diphtheritic croup than is one whose air- passages are in their normal state when diphtheria commences. A supposed error of diagnosis is often made by physicians, always to their discredit, who diagnosticate catarrhal laryngitis, but find after two or three days that their patients really have membranous croup. A considerable number of such instances have come to my notice, always with the ill-will of families toward their physicians. Now, it cannot be doubted that in many of these cases the physicians have been right in their first diagnosis, and membranous croup supervened on the catarrhal inflammation. Anatomical Characters. — It is important to acquaint ourselves with the anatomical characters of croup, especially with the nature of the pseudo- membrane, that we may know what measures to employ in order to remove it and prevent, so far as possible, the laryngeal stenosis from which so many perish. The surface of the larynx, trachea, and in severe cases that of the bronchial tubes, is hyperasrnic and swollen, and the inflammatory action involves more or less the submucous connective tissue, causing infiltration or oedema. The relation of the exudation to the mucous surface varies according to the kind of epithelium present. Where the epithelium is of the flat or squamous variety the fibrinous exudation from the blood-vessels is poured out around the epithelial cells, which perish. If the inflammation extend more deeply, the underlying connective tissue is also embraced in the coagulation and perishes. Prof. Ziegler of Tubingen, who has made repeated microscopic examinations of the pseudo-membrane, says : " It sometimes hap- pens that the dead epithelial cells become saturated with the exuded liquid and then pass into a peculiar condition of rigidity akin to coagulation. The seat of this change appears to the naked eye as a dull, raised, grayish patch surrounded by red and swollen mucous membrane. The exudation is rich in albumen, and the transformed cells take on the appearance of a kind of coarse meshwork almost or altogether devoid of nuclei." This is superficial inflammation, and Prof. Ziegler next describes deep or parenchymatous inflammation, as follows : " It is characterized by the coagulation not merely of the epithelium, but also of the underlying connective tissue. The affected patch is swollen and assumes a whitish or grayish tint, the discoloration extending through the epithelium to the connective-tissue structures. The epithelium in some cases is lost altogether, and then the diphtheritic patch consists of dead connective tissue only The dead tissue is separated from the living by a zone of cellular inflammation. Fibrinous filaments are seen here and there through the mass. The lymphatics in the neighborhood contain coagula and leucocytes." Squamous epithelium covers the nostrils, buccal cavity, fauces, and larynx upon and above the superior vocal cord, with the exception of its anterior aspect. The pseudo-membrane, therefore, upon all these surfaces lined with this form of epithelium consists of the exudate from the blood which surrounds and permeates the epithelium or epithelium and subjacent connective tissue. These two distinct elements, that poured out from the blood-vessels, and the normal tissue of the mucous surface now dead, incor- porated in one mass, constitute the pseudo-membrane. Its intimate relation with the surrounding living tissue is such that we cannot detach it without lacerating the latter and causing hemorrhage. The anterior aspect of the larynx from the middle of the epiglottis down- 53 834 LOCAL DLSEASES. ward, all that part of the larynx below the superior vocal cord, the entire trachea, and the bronchial tubes, are lined by columnar epithelium. When- ever this variety of epithelium is present the exudate from the blood does not become incorporated with the mucous membrane, but escapes to the sur- face and coagulates in a layer over it. It is, therefore, loosely adherent to the underlying tissues, being attached to it by some fibrinous threads, and when it is peeled off the hyperaemic and swollen mucous membrane is seen under- neath in its entirety, unless, as is commonly the case, a considerable part of its epithelium has been shed and been expectorated. The loose attachment of the pseudo-membrane in the trachea and bronchial tubes is of the greatest significance in its relation to intubation and tracheotomy. The epithelial cells embraced in the pseudo-membrane undergo a change. Cornil and Ranvier say : " Wagner admits the fibrinous degeneration of the cells We have verified the description given by Wagner, but we would conclude that the cells are filled with a material which approaches mucin rather than fibrin." At the same time a fibrinous exudation occurs, binding together the cells. In the first week the pseudo-membrane forms more rapidly, and is usually thicker and more extended, producing dyspnoea more quickly than when it forms in the declining stage of the disease. If the membrane be detached by the forcible coughing of the patient, it is usually quickly reproduced, unless the diphtheria be in its advanced stage and abating. If the croup continue from four to six days, the pseudo-mem- brane begins to soften from commencing decomposition and to disintegrate. The minute fibres which attach it to the membrane give way, and in favor- able cases by the effort of coughing or vomiting it is thrown off. Separation is aided by the muco-pus which collects underneath. Symptoms. — Whenever croup is a local manifestation of another disease, such general or constitutional symptoms are present as commonly pertain to this disease, such as fever, anorexia, thirst, and progressive loss of flesh and strength. The temperature in the commencement in croup from this cause is often higher than at an advanced period, unless some complication occur, as pneumonia, which increases the heat of the system. The temperature is not, however, in the beginning ordinarily above 103° or 104°. Most patients also have those inflammations which commonly attend croup — i. e. pharyngi- tis and more or less coryza, but they are relatively unimportant in compari- son with the croup, for, unlike the croup, they do not in themselves involve immediate danger to life. Croup commonly begins gradually and insidiously, revealed at first to the physician by hoarseness or huskiness of the voice and a hoarse or harsh cough. Both voice and cough are feeble, lacking the fulness and sonorousness present in spasmodic laryngitis. In grave cases approaching a fatal termination the voice becomes more and more indistinct, and finally is suppressed. The cough also, which in the beginning of the croup was strong and expulsive, becomes feeble and ineffectual, and less frequent as the fatal result draws near. The amount of sputum varies considerably in different cases. If the inflammation extend no farther downward than the trachea, it is scanty, but if there be coexisting bronchitis, it is more abundant, consisting of muco-pus with occasional flakes of pseudo-membrane. By vomiting a larger quantity is expelled than by the cough. Occasionally masses of pseudo-membrane of considerable size are expectorated, even moulds of some part of the respira- tory passage, always with great temporary relief to the patient. A pseudo- membrane of considerable thickness and extent obstructs the expectoration of muco-pus, which, collecting in the lower part of the trachea and in the bronchial tubes, greatly increases the dyspnoea. The respiration is somewhat PSEUB0-ME3TBRAX0US CROUP. 835 more frequent than in health, bnt it is not notably increased except when bronchitis or broncho-pneumonia is present. At an advanced stage, when stupor supervenes from non-oxygenation of the blood, the respiration may be slower than in health. Croup in its commencement and in the active period of diphtheria without treatment almost never remains stationary or abates. Little by little, or often quite rapidly, the laryngeal stenosis increases, and soon the patient begins to experience the want of air. He becomes restless, has an anxious expression of the face, seeks change of position, reaching out his arms to the nurse or mother to obtain relief. In some patients only a few hours elapse, and in others a day or more of gradual increase in the obstruction, when it becomes evident that death must soon occur unless relief be afforded. In this stage the post-clavicular, infraclavicular, suprasternal, and inframammary regions are depressed during inspiration, and the larynx is drawn with each inspira- tory act toward the sternum. While there is constant suffering, there are also occasionally most distressing attacks of dyspnoea, attended by an increase in the lividity of the features and extremities, which now have an habitual dusky palor. Sometimes these attacks are perhaps due to the doubling of a de- tached end of the pseudo-membrane on itself, or perhaps to a movement of the muco-pus by which bronchial tubes are occluded. With the ear applied over the larynx or upper part of the sternum, a loud rhonchus is heard both on inspiration and expiration, produced by the passage of the air over the obstruction, and obscuring to a great extent other sounds. Moist bronchial rales are also common. Those who recover from membranous croup without intubation or trache- otomy and by the use of inhalations — and thus far they are a minority — usually improve gradually, the obstruction diminishing by the softening and detaching of portions of the pseudo-membrane. After the detach- ment of the pseudo-membrane several days elapse before the thickening and infiltration of the mucous membrane disappear and the epithelial cells are restored. Diagnosis. — Catarrhal laryngitis with an unusual amount of thickening and infiltration of the mucous membrane and of the underlying connective tissue, so as to produce stenosis and obstruct respiration, may be mistaken for pseudo-membranous laryngitis. In the New York Foundling Asylum two children have at different times died with the symptoms of membranous laryngitis, and the obstruction was found to be due entirely to the thicken- ing and infiltration of the mucous and submucous tissues of the larynx by newly-formed corpuscular elements. Of course, death from catarrhal laryn- gitis is rare, but that this disease may produce such an amount of laryngeal stenosis as to cause even fatal dyspnoea, like that from the presence of pseudo- membrane, these two cases show. In most instances the diagnosis of mem- branous laryngitis from catarrhal laryngitis is easy by the presence of patches of pseudo-membrane on the fauces or by the history of the case, which evi- dently points to diphtheria as the cause. In the case alluded to above a child in my practice died with the symptoms of acute laryngeal stenosis, without any pseudo-membrane upon visible parts and with only a moderate phar- yngitis. This case, which might have passed as one of catarrhal laryngitis accompanied by an unusual amount of cellular and serous infiltration, as there was no known diphtheria in the vicinity, was really due to diphtheria, and was a local manifestation of that disease, for immediately after the death of the patient the two nurses had unequivocal symptoms of diphtheria. The difficulty in using the laryngoscope in young children is such when their fauces are swollen that it has not heretofore afforded much aid in the differ- ential diagnosis of the various forms of acute laryngeal stenosis, at least 836 LOCAL DISEASES. when employed by the general practitioner. By microscopic examination the character of the croup can be ascertained as stated elsewhere. Prognosis. — In New York City, during the fifteen years ending with 1878, the percentage of recoveries was very small, both under medicinal treatment and tracheotomy. During this long period, surgeons, not saving more than 3 to 5 per cent, of their cases by tracheotomy, performed this operation reluctantly. But since 1878 the percentage of deaths after tracheotomy has been reduced, and still further reduced by intubation. The mortality from croup is greater the younger the patients, for the younger the child the less the diameter of the air-passages and the more quickly laryngeal stenosis results. The younger the child, also, the more difficult is the use of the proper remedies, and the less the time for their use before fatal dyspnoea occurs. The result also largely depends upon whether the physician is summoned at the beginning of croup and appropriate remedies are early and persistently employed. In many instances the friends do not take alarm and the physician is not summoned till the disease is well under headway, and there is not the requisite time for efficient treatment. Ob- viously, also, croup, beyond all other diseases, requires faithful and intelligent nurses, for without the co-operation of such nurses night and day in the care of the patient the most judicious measures are often inefficient. Treatment. — Preventive. — In attending a case of inflammation of the upper air-passages the physician should notice at each visit whether the patient have any hoarseness or other signs indicating implication of the larynx, since if the danger be recognized at its inception it may perchance be averted. Ineffectual as inhalations may be for fully-declared croup, expe- rience fully justifies the belief that they are sufficient in a large propor- tion of cases to relieve that degree of laryngitis which is indicated by simple hoarseness, and which if it continue might eventuate in serious obstructive disease. If the physician observe such symptoms, he should immediately recommend that the air in the apartment be kept moist by the croup-kettle or pans of hot water, rendered alkaline by lime-water or sodium bicarbonate. The efficiency of this treatment is increased by employing a tent. I prefer, however, in most instances, to employ the steam-atomizer either with or without the croup-kettle. It should throw a heavy and con- tinuous spray as long as the premonitory symptoms of croup continue. It obviates the necessity of heating the apartment, which in hot weather is very uncomfortable. It is proper, in this connection, to consider which is the most efficient and the best agent for inhalation in croup. Have we an agent that can be safely used, which will prevent, when inhaled, the formation of the pseudo-mem- brane, or which will dissolve it when it has already formed ? The agents which have been most employed for this purpose are lime-water, lactic acid, pepsin, and trypsin. In selecting the one that is safest and most efficient the important fact should be borne in mind that anything which irritates, so as to increase the inflammation of the mucous surface, is injurious. Whatever intensifies the inflammation evidently augments the thickening and infiltration of the mucous membrane and increases the area as well as thickness of the pseudo-mem- brane. It is therefore harmful instead of beneficial. The teachings of Bre- tonneau and Trousseau did immense harm in the fact that they brought into use agents far too irritating to the sensitive mucous surface. Since the pressing danger in croup arises from the obstruction produced by the pseudo- membrane and by the thickening and infiltration of the mucous membrane underneath, that agent is indicated, if it can be found, which loosens and dissolves the pseudo-membrane, and at the same time tends to diminish, or BSEUBO-MBMBBAXOUS CBOUP. 837 at least does not increase, the inflammation of the underlying tissues by its irritating action. Alkalies exert a solvent action on fibrin and mucin, and as the pseudo-membrane consists of the exudate from the blood largely fibrin- ous, and of epithelium and connective tissue which have undergone degenera- tion into a substance resembling fibrin (Wagner) or perhaps mucin (Cornil and Eanvier). their employment seems to rest on a sound therapeutic basis. Lime-water slightly turbid, but not so turbid as to clog the point of the steam-atomizer, with its alkalinity increased by the addition of an unirritat- ing alkali, as sodium bicarbonate, may be used almost continuously by inhala- tion. Dr. E. M. Moore 1 of Rochester recommends insufflation of sodium bicarbonate as an active solvent of the pseudo-membrane. It possesses this advantage — that it is but slightly irritating, so that it can be used in sub- stance or with but little dilution. For this reason it should be preferred to lime-water, which is in more common use. Recently I have employed in the steam-atomizer the following formula, with o;ood results: Trypsin, 3ij; Sodii bicarbonat., 3*j; Aqua; calcis, Oj. — Misce. Trypsin may be advantageously used with this liquid, but trypsin in powder is very likely to clog the atomizer. The liquid trypsin, as prepared by Fair- child, should therefore be employed with the lime-water. The following for- mula may also be used in the hand atomizer : Trypsin, 3J ; Sodii bicarbonat. , gr. xx ; Aquae destillat., ^ij. — Misce. In some instances insufflation of the following powder, as stated in our remarks on diphtheria, has been useful as a solvent of pseudo-membrane in the air-passages : R. Papoid, ) Trypsin, >- da. ^ss ; Sodii bicarbonat., J Sulphur sublimat., £j. For insufflation. By the persistent and timely use of such inhalations as soon as hoarse- ness appears croup can be often prevented. But we all know how fre- quently, notwithstanding our best endeavors, croup occurring in the first week of diphtheria grows hourly worse. In these acute and rapid cases inhalations of the best agents which physicians have hitherto used act too slowly to prevent the growth of the pseudo-membrane, and in a few hours it becomes painfully evident that something more must be done or the life of the child is lost. In those many cases in which diphtheria is ushered in with croupous symptoms, and in which within a few hours laryngeal stenosis begins to occur, the experienced physician sees at a glance, often at his first visit, that inhalations, however faithfully employed, will be inadequate, and that suffocation, the most painful of all modes of death, will be inevitable unless other and energetic measures are used. On the other hand, in the milder forms of croup, in which the exudation has but moderate thickness and forms slowly, inhalations are of the greatest service, and aided by internal remedies they not infrequently arrest the dis- ease and save life. Calomel has long been used in the treatment of croup, and has done 1 Transactions of the N. Y. Medical Association, 1885. 838 LOCAL DISEASES. much harm in this as well as many other diseases. But, properly employed, it is one of the most efficient and useful remedies in croup, though the nurse and attendants incur the risk of severe and prolonged salivation. Calomel has long been employed in the treatment of croup in small and repeated doses, so as to keep up a daily purgation with an increase of the weakness. This effect has been pernicious, and it is believed has increased the mortality. The following method can be recommended from ample experience with it in Brooklyn, where it originated, and in New York, as probably the most effectual of the medicinal remedies to arrest the formation of the pseudo- membrane and aid in its detachment. A tent about five feet in height is erected over the bed in which the child lies, and the sublimation of 10 to 15 grains of calomel is produced upon a tin plate over an alcohol lamp alongside the bed, and the fumes are received within the tent. The vapor is very pun- gent and irritating, and under a closed tent cannot be used without danger of salivation longer than twenty minutes, and oftener than three or four hours. In the New York Foundling Asylum, although this treatment has apparently saved the lives of foundlings having croup, the adults outside the tent were so severely salivated in a succession of cases that this remedy is no longer used in this institution. A physician of New York was so severely salivated by holding his head under the tent some hours, though his patient lived, that he was an invalid for some months afterward. The children, so far as I am aware, have not suffered from the deleterious effects of this medi- cine, but if it be employed the adults should make use of precautionary measures for their own safety. Emetics. — These have been largely used in all forms of croup, and in catarrhal or spasmodic croup they usually produce some relief. Formerly, emetics were much employed in the treatment of membranous croup, but now that diphtheria has spread throughout the country, and most cases of this form of croup occur in patients suffering from diphtheritic blood-poison- ing, depressing emetics, as ipecacuanha and antimony, have fallen into disuse. In my practice a child of ten years with severe diphtheria and with com- mencing croupy symptoms sank rapidly and died between two of my visits from exhaustion produced by a single large dose of ipecacuanha administered by anxious parents without my advice. An emetic may give partial relief to the dyspnoea in certain cases, since it assists in expelling the muco-pus which blocks up the tubes below the pseudo- membrane, and sometimes portions of pseudo-membrane, which are easily detached. But although there may be occasional advantages from an emetic, they are in most instances more than counterbalanced by the disadvantages, especially the prostration which results. If an emetic be employed, one should be selected which acts promptly with but little depression, and as a rule it should only be used at the commencement of croup. Surgical Treatment. — Although the best possible treatment by inhala- tions and internal medication be early employed and without intermission, yet it is the common experience in all countries that such treatment is in a large proportion of cases inadequate, and that many perish from suffocation unless relieved by surgical interference. We have stated above that if croup occur at the commencement of diphtheria, when the exudative process is active and the pseudo-membranes form rapidly and abundantly, death is the common result if the medicinal treatment only be employed. But if the inflammation be less intense or subacute, as in the second week in diph- theria, so that there is more time for the action of medicines and inhalations, and if, as is sometimes the case, the stenosis appears to be at a standstill, without any marked suffering from want of air, resort to surgical measures may be judiciously postponed. INTUBATION. 839 The indications for surgical interference are a gradual increase of the stenosis and consequent dyspnoea, notwithstanding the constant and judicious use of remedial agents, and a manifest suffering from want of air, as shown by restlessness of the child and the expression of suffering in his features, with or without lividity of the surface. We adults may have some faint conception of the suffering which children with acute laryngeal stenosis undergo when we hare severe nasal catarrh and attempt to breathe with the mouth closed ; and the paramount duty of the physician to relieve suffer- ing should prompt a resort to other measures when medicines prove inade- quate, even if we leave out of account the important object of saving life. When, therefore, membranous croup is found to be progressive after having been observed and properly treated from six to twenty-four hours, and the child begins to suffer from want of air, the propriety of surgical measures should be considered. CHAPTER Y INTUBATION. The most important improvement made in recent years in the treatment of croup is intubation, for which the profession is indebted entirely to the genius and perseverance of Dr. Joseph O'Dwyer. Intubation is destined in the future to prevent an immense amount of suffering in the various forms of laryngeal stenosis. It has rescued, and will rescue, multitudes of chil- dren from a most painful death by suffocation. It is an operation of remark- able simplicity, quickly performed, without the use of anaesthetics and with- out pain to the patient. In this respect it contrasts strikingly with laryn- gotomy or tracheotomy, which is a painful and bloody operation, and which, for its proper performance, requires more or less delay. Those who have witnessed the slow suffocation of children in membranous croup and catarrhal croup when accompanied by cedema and infiltration can best appreciate the value of intubation. In 1858, Bouchut published a paper on the treatment of croup by intu- bation of the larynx. He employed a straight cylindrical tube nearly an inch long. The tube was introduced by means of a male catheter open at its two ends. Intubation excited some attention and discussion at the time in the Parisian capital, and M. Gross related a case of its successful employment. But, performed with such rude instruments, it met, as might be expected, with strong opposition from the first by such men as Barthez and Trousseau, who were bringing forward tracheotomy, and it soon fell into disuse and was forgotten. It was reserved for American surgery to achieve the honor of its successful employment. Dr. O'Dwyer, wholly ignorant of the previous his- tory of intubation, after many measurements of the larynx of the cadaver, many discouragements, and many modifications in the tubes to facilitate their introduction and retention, has so improved them that the objection to their use strongly urged by Trousseau thirty years ago, that they caused ulcera- tion, is inapplicable to the tubes now in use. Dr. O'Dwyer has kindly con- tributed the following paper descriptive of this operation : Intubation. By Joseph O' Dwyer, M. D. In the following pages I will confine myself to the practical details of this operation as applicable to those forms of stenosis of the larynx that occur 840 LOCAL DISEASES. almost exclusively in children. The reader is referred to the appropriate sec- tions of this book for information in regard to the diagnosis, medical treat- ment, etc. of croup and kindred diseases. A very serious impediment to the success of intubation, and one for which there is no remedy, arises from the large number of grossly-imperfect instru- ments that are constantly being made and sold as the latest improvements. I will therefore first endeavor to point out some of the grosser defects referred to, in order that every one who uses these tubes may be able to distinguish the good from the bad. The most common defect, and at the same time the one attended with the most serious consequences, is apparently so insignificant that it is often over- looked by the manufacturers, even after their attention has been repeatedly called to it. It results from filing the metal so thin on the anterior surface of the distal extremity as to produce a cutting edge at this point. It should be remembered that this part of the tube is not only in contact with the ante- rior wall of the trachea, but that it also moves up and down over a space of about half an inch during every act of swallowing. This position is pro- duced by the backward pressure of the base of the tongue, which pushes the epiglottis and the upper extremity of the tube before it with considerable force, tilting the lower extremity forward, which glides upward as the larynx is raised and the trachea stretched, to fall back to what may be called its res- piratory position as soon as the act of swallowing is completed. If sharp, or even in the slightest degree rough, at the point indicated, a proportionate degree of injury will be inflicted on the mucous membrane, sometimes amounting to a deep ulcer, which adds to the danger of systemic infection and gives rise to painful deglutition and bloody expectoration. In the perfect tube the metal on the anterior surface is left quite thick and smoothly rounded off like the runner of a sled, so that it will glide up and down over the tissues without injuring them. As the distal extremity of the tube seldom impinges on the posterior wall of the trachea, and never touches the sides, the metal at these points should be comparatively thin, to avoid increasing the size, but the whole should form a perfectly smooth probe- point when the obturator is in position. If the obturator do not project far enough beyond the end of the tube or if it fit imperfectly, the sharp edges will be left unprotected, which will injure the tissues while passing through the narrowed glottis. The metal is also left thick on the anterior surface of the upper extrem- ity, in order to prevent the formation of a cutting edge under the epiglottis. The head or shoulder of the tube which rests in the vestibule of the larynx, and which is compressed by the action of the constrictor muscles in every act of swallowing, should be absolutely free from any roughness or projecting angles or edges. This portion of the tube, about a quarter of an inch in length, has a backward curve to carry it away from the base of the epiglottis, where a perfectly straight tube would be liable to produce ulceration. Another very common defect is the imperfect fitting of the obturator, which allows the tube to wabble when attached to the introducer, and causes it to slip off if the operator fail to place it in the larynx on the first attempt. The instrument-makers find it very difficult to overcome this defect, owing to the joint in the shank of the obturator and the backward curve that exists in the upper portion of the tube. If properly made, the tube when attached to the introducer and ready for use should be as free from motion as if constructed of one piece. I have also noticed in many of the sets of instruments otherwise perfect that the lines indicating the years on the scales do not correspond to the length of the tubes, which renders it difficult for a beginner to select the IXTUJBATIOK 841 proper size. By observing the following rule the scale can be dispensed with : The smallest size is suitable for the first year of life, the second for the second year, the third size for from two to four years, and the others for two years each. A set of intubation instruments suitable for children up to the age of puberty consists of six tubes, an introducer (1) and extractor (3), a mouth-gag (2), and a scale of years (4) ; 6, introducer and tube ; 7, a large Fig. 237. Intubation instruments. round tube used for the expulsion of membrane. Each tube is supplied with a separate obturator, one end of which screws on to the introducer, while the other extends sufficiently beyond the distal extremity of the tube to convert the whole into a probe-point. The numbers on the scale represent years, and indicate approximately the ages for which the corresponding tubes are suitable. For example, the smallest size when applied to the scale, in- cluding the head or shoulder, will reach the line marked 1, and is suitable 842 LOCAL DISEASES. for the first year of life, but may be used up to fifteen or eighteen months if the child is small for its age. The next size, which reaches the line marked 2, is intended for children between one and two years, but may be used up to three years, the only objection being that it is liable to be coughed out. The third size, marked 3-4 on the scale, should be used between the ages of two and four years ; and so on. The largest tube in the set may be used in the early years of adolescence by having a string attached, but is of no use in the adult larynx, as it would either be expelled immediately or pass through into the trachea. When the proper tube for the age is coughed out, there is always room for the next larger size. In one case, of an infant aged twenty months, in which the two-year-old tube was twice expelled, I was obliged to insert the 3—4 size. Indications for Intubation. — As the indications for this operation are the same as for tracheotomy, the reader is referred to the proper section of this work for information on this subject. Method of Operating. — A tube of proper size for the age is first selected, and strong silk or linen thread passed through the eyelet intended for this purpose. In case the tube is placed in the oesophagus instead of the larynx, it quickly passes into the stomach, drawing the string with it, unless the latter be held. To guard against this accident, therefore, the thread should be left long enough to reach the stomach and still protrude from the mouth. The obturator is then screwed tightly to the introducer and passed into the tube when it is ready for use. The antero-posterior or long diameter of the tube should then be in a line with the handle of the introducer. If the obturator be found to turn too far to bring it in this position, which usually occurs after having been used for some time, a washer of writing-paper of one or more thicknesses can be added. It is always advisable to push the tube off once or twice before inserting it, to be certain that it works easily. The person who holds the child should be seated on a solid chair with low back, and the patient placed on the lap with its head resting on the left shoulder of the nurse to avoid interference with the gag. The hands may either be held or secured by the sides by passing a towel or napkin around the body, and retained in that position until the tube is inserted and the string removed. Failure to pay particular atten- tion to this precaution is often the cause of much annoyance to the operator, for if the child gets its hands free for an instant, it seizes the thread and removes the tube. Fastening the hands in front of the chest or thick gar- ments in the same location are objectionable, as they render it difficult to depress the handle of the introducer sufficiently to carry the tube over the dorsum of the tongue. The gag should be inserted in the left angle of the mouth, well back, between or behind the teeth if practicable, and opened as widely as possible without using too much force. In children who have not at least one double tooth on the left side the gag should not be used, as it slides forward on the gums, and, besides being in the way, is likely to injure the incisor teeth. There is little difficulty in keeping the mouth sufficiently open with the finger, and no danger of being bitten if it be kept well to the patient's right. The necessity of using force is obviated by allowing the child to compress the finger for a few seconds until the jaws relax before carrying back into the pharynx. The Denhard gag, which is shown in the cut, holds better than the one originally devised by the author, and seldom slips if properly placed. An assistant, standing behind, holds the head firmly by placing one hand INTUBATION. 843 on either side. and. if without experience, should be requested not to touch the gag. The operator, either standing or sitting in front of the patient, the former position being preferable, holds the introducer lightly between the thumb and lingers of the right hand, with the thumb resting just behind the button that serves to detach the tube, and the index finger in front of the trigger-support underneath. Held in this position, it is impossible to use force enough to make a false passage, while if firmly grasped in the hand the beginner is very liable to lacerate the tissues. Intubation of the larynx. The index finger of the left hand is now quickly passed well down in the pharynx or beginning of the oesophagus, and then brought forward in the median line, raising and fixing the epiglottis, while the tube is guided beside the finger into the larynx. If any difficulty be experienced in feeling the epiglottis, it is better to seek the cavity of the larynx, a cul-de-sac into which the tip of the finger readily enters, and which cannot be mistaken for anything else. Once in this cavity, the epiglottis must be in front of the finger, and the latter is then raised and carried to the patient's right in order to leave room for the tube to pass beside it. As the larynx contracts when touched, thereby diminish- ing its aperture, it is necessary to keep the distal extremity of the tube close to the finger, or even directing it a little obliquely to the right in order to get inside the left aryepiglottic fold. This is particularly important in very young children, in whom the tip of the finger completely covers the larynx. In the beginning of the operation the handle of the introducer is held close to the patient's chest, and rapidly raised as the lower end of the tube passes behind the epiglottis ; otherwise, it slips over the larynx into the oesophagus. When the tube is inserted, it is slipped off by pressing forward the button on the upper surface of the handle with the thumb, while counter-pressure 844 LOCAL DISEASES. is made by the index finger underneath. In removing the obturator the tube must be held down by placing the finger either on the side or posterior por- tion of the shoulder. The tube should be carried well down before being- detached, otherwise it is liable to become occluded with false membrane when subsequently pushed home with the finger. When the tube is in place the gag is removed, but the string is allowed to remain for about ten minutes, or until it is ascertained with certainty that the dyspnoea is relieved and that no loose membrane is present in the lower portion of the trachea. In removing the thread the finger must be reinserted to hold the tube down, but the reinsertion of the gag is rarely necessary for this purpose. The extraction of the tube is much the more difficult operation, and at the same time the more dangerous as far as injury to the larynx is concerned. The patient is held in the same position as for insertion, and the extractor is guided along beside the finger, which is first brought in contact with the head of the tube, and then carried to the right in order to uncover the aperture and leave room for the instrument to enter beside it. Before inserting the extractor it should be ascertained with certainty that the tube is still in the larynx. This can be determined by the tubal charac- ter of the cough, which is characteristic, the difficulty of swallowing, and, lastly, by the sense of touch if necessary. Difficulties of the Operation. — Few who have not practised intubation recognize the fact that it is a difficult operation to perform, and that it is difficult simply because it must be done quickly and at the same time gently. Sufficient dexterity to fulfil both of these requirements can only be acquired by a great deal of practice, and if this be gained on the living subject it must be at the expense of a great deal of unnecessary suffering and the sacrifice of many lives as well. It is the sense of touch alone that is to be relied upon, and that requires to be educated ; consequently, the accomplished laryngologist who has only educated his sense of sight is no more competent to perform the operation than one who has never seen the larynx in its nor- mal position. The operator has so many movements to make, involving both hands, in such a brief space of time that unless he have had sufficient practice to make some of these movements to a certain extent automatic, he cannot operate with safety to his patient nor with credit to himself. The epiglottis must be found, raised, and held in this position as the tube is glided down in contact with the finger, otherwise the operator does not know where it is ; it has to be slipped off at the right moment, and held down while the obturator is being removed ; and to be safe all these movements must be completed in less than ten seconds. Intubation should therefore never be attempted, except in case of emer- gency, without some preliminary practice, either on the cadaver, on one of the smaller animals, or on a larynx removed from the body. Let the beginner who has never performed either operation choose tracheotomy rather than intubation, as being the safer, because in the former he can see what he is doing and his patient can breathe during the progress of the operation. Prac- tice on a child's cadaver is within the reach of comparatively few, but it can be done on that of one of the smaller animals, such as a cat or dog, with prac- tically the same result — viz. education of the sense of touch and automatism in some of the movements. In addition to a moderate amount of this kind of practice, every young operator should keep a small larynx in preservative fluid on which he can continue to practise at frequent intervals by placing it upright in the neck of a bottle or other receptacle in the same relative position which it occupies in the body. IXTUBATION. 845 There is no doubt that dexterity in the use of these instruments can be acquired in this manner ; and this is particularly important in extracting the tube, which is so difficult to do without injuring the larynx. The difficulty sometimes experienced in intubating older children who offer resistance is to a great extent obviated by placing their legs between the knees of the person acting as nurse and holding them firmly in that position. Accidents and Dangers of Intubation. — The most serious of the avoidable accidents attending this operation is asphyxia, from holding the finger too long in the throat. It should be remembered that when intubation is called for the patient is getting very little air, and can afford to dispense with this little only for a very short time without danger to life. After the insertion of the gag an expert can, as a rule, place a tube in the larynx in five seconds or less, and without any shock worth considering. The novice, on the con- trary, having so many other things to occupy his attention, is very liable to forget how long his finger has been in the throat, and that during this time respiration is practically suspended. A fatal issue under these circum- stances is almost invariably attributed to pushing down membrane, which is not a common accident, and has never proved immediately fatal in my hands. There is seldom any danger from repeated failures to intubate, provided the finger be not retained in the pharynx longer than ten seconds at a time, and the child be given a chance to get its breath between the attempts. It is well for the beginner always to have another physician present, who while holding the head will watch the patient closely and be prepared to give some prearranged signal to stop when he thinks there is danger of asphyxia. The ventricles of the larynx seldom offer any obstruction to the entrance of the tube, as they are usually obliterated by the swollen mucous mem- brane and covered over by the fibrinous deposit in croup ; but this should be remembered if any resistance be encountered, as it does not require much force to make, a false passage at these points. Pushing down a mass of pseudo-membrane before the tube is the most serious of the unavoidable accidents attending intubation in croup. In the majority of cases the offending membrane is expelled on the withdrawal of the tube, if the latter be inserted quickly and as quickly removed when the respiration is found to be suspended ; and even if none be expelled, the patient is in no worse condition than he was in before the operation. I have devised and tried various instruments for the removal of pseudo- membrane from the trachea, but I have found short cylindrical tubes of large calibre the most successful. Being short, they do not accumulate masses of membrane before them, and, while overcoming the obstruction in the glottis, afford relief to the dyspnoea where the long tubes fail. They are only intended for temporary use, as, owing to their large size, extensive ulcera- tion would result if long retained. The string should be left attached and secured behind the ear, by which the tube can be removed at the end of four or five hours whether any false membrane be expelled or not. The amount of dilatation from the pressure accomplished in this time will usually secure several hours of relief from dyspnoea and give ample time for the physician to reach the patient and reintubate, if necessary. Should the offending membrane still be retained, it is better to use the same tube on the recur- rence of dyspnoea than to again run the risk of producing apnoea by insert- ing the long one ; otherwise the latter is preferable. These tubes (Fig. 237, 7) have no retaining swell, the size alone being sufficient to retain them. The metal of which they are constructed is made 846 LOCAL DISEASES. very thin, in order to have as large a lumen as possible, and they can also be used to facilitate the expulsion of foreign bodies from the lower air-passages. Under these circumstances they can be left in position for a much longer time without danger from pressure, because the mucous membrane of the larynx is in the normal condition. A separate introducer with long curve is necessary for these tubes in order to carry them well through the subglottic division of the larynx before removing the obturator. Danger of Asphyxia from Loose Membrane below the Tube. — The ex- istence of loose membrane below the tube — that is, in the lower portion of the trachea — usually gives rise to the following signs : A napping sound with the respiratory movements, a hoarse or croupy character of the cough, and obstructed expiration, especially when forced, as in the act of coughing. In some cases there is no difficulty while the breathing is quiet, but the egress of air is completely cut off with the first attempt at coughing. The vis d tergo thus developed is often sufficient to cause the expulsion of both tube and pseudo-membrane, but this does not always occur, and precautions should be taken to avoid the danger of sudden death from this cause. The safest plan is to leave a string attached, by which any one who is present can remove the tube in case of threatened asphyxia. Should this not be practicable, owing to the age or from other causes, a smaller tube than that indicated by the scale of years should be used, which would be more likely to be coughed out in the event of its sudden occlusion. Either of these methods should be resorted to if the symptoms of loose membrane in the lower part of the trachea, absent at the time of operation, subsequently show themselves. Premature expulsion of the tube seldom occurs when the proper size has been used, and is rarely attended with danger, provided the patient be within easy reach. Dangers of Extraction. — Cases have been reported in which the tubes as now made, with large heads, have passed through into the trachea. This accident can only occur when the tissues of the larynx, cartilages included, have been extensively lacerated by the extractor by passing it down on the outside of the tube and withdrawing it with force. This danger has been minimized to a great extent by the addition of a regulating screw to the extractor, which prevents the blades from opening any wider than is necessary to hold the tube firmly. No force is necessary to remove a tube from the larynx, and if any appreciable resistance be encountered, it is pretty certain that the instrument is caught in the tissues. Severe hemorrhage often results from a very moder- ate laceration produced in this manner. When the Tube should be Removed. — In a large number of recoveries following intubation in croup the average time the tube was retained amounted to five days. The longest time in my own practice was twenty- nine days. The older the child, as a rule, the sooner it can be dispensed with. In very young children, when progressing favorably or if the patient be not within easy reach, it is better to leave it in position for seven or eight days. The frequent removal of the tube, unless specially indicated by a recurrence of the dyspnoea or for other cause, is bad practice, principally because of the irritation produced on each occasion. In protracted cases, in which the dyspnoea returns soon after the second or third removal at regular intervals of four or five days, it is safer to leave it in position continuously for two or three weeks, unless some special indication for its removal arises in the interim. If the tube be properly constructed and well plated, it will do no harm when retained for this length of time. INTUBATION. 847 Management after Intubation. — One of the greatest advantages of intuba- tion over tracheotomy is the fact that no skilled nursing is required after the operation. The most important part of the after-treatment consists in getting the patient to take a sufficient amount of nourishment. The difficulty here- tofore experienced in this matter has been greatly reduced by the method suggested by Dr. W. E. Casselberry of Chicago. It consists in feeding while the patient's head is lower than the body. By this means advantage is taken of gravitation, thus allowing any fluid that may have entered the tube to escape without the act of coughing. The little patient soon learns this, and ceases to object to the uncomfortable position. For very young children at least the best position is lying on the back across the lap, with the head hanging well below the level of the body, and feeding from a spoon or bottle. Older children may be allowed to assume any position they wish, provided the head be lower than the chest. Fig. 239. Feeding in the upright position should always be by spoon, at least for the first two or three days, and the patient be given time and encouraged to cough between the acts of swallowing. By this means any danger from the entrance of food is obviated. Nourishment in the solid and semi-solid forms — which are swallowed better than liquids — should be given the preference when children can be induced to take them. Rectal feeding is rarely necessary, but when resorted to the food should be given in small quantities — not over two ounces — and at intervals of three or four hours. No food or medicine should be given for two or three hours after intuba- tion, unless the presence of the tube fail to excite sufficient cough to get rid of accumulated secretions. It is principally by the act of coughing that the tube is kept clear, and, if this does not occur voluntarily, it may be excited by 848 LOCAL DISEASES. giving some irritating substance, such as carbonate of ammonia, brandy strong or slightly diluted, etc. If this plan be adopted and the air of the room be kept well saturated with warm vapor, it will rarely be found necessary to remove a tube for the purpose of cleaning it. The presence of a tube in the larynx does not contraindicate the use of an emetic, which is sometimes necessary when the bronchi are loaded with secretions. CHAPTEE VI. TRACHEOTOMY. Prior to the employment of intubation by O'Dwyer tracheotomy was one of the most important operations in surgery. Properly performed and at the proper time, with judicious after-treatment, it has rescued many children from a most painful death. The details of this operation are given in surgi- cal treatises, but some general remarks relating to it will not be inappropriate here. Lange says that the operator should have three assistants, at least one of them a physician. One should administer chloroform, one use the sponge, and the third, a physician, should be ready to assist in handing instruments, ligating vessels, etc. The operation is simple and devoid of danger, or difficult and dangerous, according to circumstances. The younger the child, the greater the danger, other things being equal. The greatest difficulty and risk attending tracheotomy is in fleshy infants with thick and short necks, and in patients who have extreme dyspnoea and are nearly mori- bund, so that the operator is compelled to hurry in the operation through fear that death will occur before the trachea is opened. The operator should have time for slow and cautious dissection, that he may avoid wounding vessels and other important parts. Tracheotomy may be performed above, through, or below the thyroid isthmus ; the latter place gives more room for the cannula and is to be preferred. Provide a firm table covered with several folds of blankets ; bichloride solution 1 : 1000 ; iodoform and iodoform gauze ; carbolized sponges ; hot and cold water. The fol- lowing instruments are useful : A scalpel ; two blunt hooks with bulbous ends ; catch forceps ; two tenacula for holding the wound apart ; two tenacula with hooks at right angles with the shaft to transfix and hold the trachea when it is opened ; two grooved directors ; artery forceps ; forceps with fine teeth ; the oculist's spring hook to open the wound ; tracheotomy-tube with two cylinders ; pigeon's quills. Place the patient on the table ; elevate the shoulders with a pillow, and support the neck with a firm compress or covered block of wood, so as to throw the head well backward. Wrap the child in a sheet, enclosing the arms and legs to control its movements. One assistant gives the chloroform or holds the head ; a second takes charge of the instruments, and a third of the sponges. Standing on the right side, the surgeon gently compresses the trachea between the thumb and finger of the left hand and defines the median line. Commencing at the cricoid cartilage, he makes an incision through the skin within a third of an inch of the sternum. With hooks the wound is kept open, and he proceeds to cut the tissues down to the trachea, or with the blunt hooks inserted into them in the median line he may, by traction in the axis of the trachea, tear through these tissues without hemorrhage. The wound should be frequently wet by sponges moistened in the bichloride solu- tion. Care should be taken not to make lateral traction, in order not to draw the trachea to one side. All bleeding vessels should be secured before the trachea is opened. The dissection may be made on a director introduced under the tissues in the median line, or the operator may seize the tissues on one side with toothed TRACHEOTOMY. 849 forceps and an assistant do the same on the other side, and, making the parts tense, the tissues are divided in the median line. The isthmus of the thyroid will be met with, and must be drawn upward or downward according as the opening is made above or below this body. If it is found necessary for any reason to divide it, ligatures should first be passed around it on either side and tightened to prevent hemorrhage Avhen the incision is made through it. The trachea is recognized by its white appearance and its rings. When exposed the connective tissue should be removed from the anterior surface where the opening is to be made so as to prevent emphysema. In opening, steady the trachea with the thumb and fingers, or insert a hook into the upper part and make traction upward in the median line sufficiently strong to steady the tube. The point of the bistoury or narrow-bladed knife should be introduced between two rings of the trachea, the cutting edge upward, and three or four rin'gs be divided. Air escapes with a loud hissing sound, and mucus with blood, perhaps membrane, is ex- pelled. The wound should be drawn apart with hooks or toothed forceps, and the operator should be prepared to seize any protruding membrane which may be loose. The first inspirations may be difficult, but very soon the mucus and shreds are dislodged and the breathing becomes more tranquil. If there are evidences of the presence of the loosened exudation, curved forceps may be introduced cautiously and search made. It is frequently useful to have the patient inhale hot vapor, and sponges moistened with hot water may be held with forceps over the opening. Everything being in readiness, the double cannula is gently inserted, and a tape fastened to the rings is tied behind the neck. Much of the success in tracheotomy for croup and diphtheria depends on the efficiency of the treatment after the operation and subsequent manifesta- tions are completed. The patient should be put to bed in a room at a tem- perature of not less than 70° F., for a certain amount of chilliness usually ensues, proportionate to the amount of hemorrhage during the operation and to the intensity of dyspnoea before it ; the external opening should be covered with a fold of woollen gauze or scarf, straddled upon a tape or strip of plaster applied above the wound, which protects the trachea from dust and warms the air a little as it is inhaled ; the risk of pneumonia is thereby lessened, and the liability diminished to clogging of the tube by the accumulation of desiccated crusts and fragments of false membrane. The atmosphere of the room should be kept moist as well as warm by means of steam escaping in the immediate vicinity of the patient, or, if this means be lacking, flat sec- tions of sponge wrung out of hot water should be kept over the tube ; if the reaction from the chill be tardy, warm aromatic drinks should be administered, and flying; sinapisms should be applied to the trunk and limbs, which will cause restlessness to subside and sleep ensue. Sleep, indeed, often comes on before the dressings are completed, and occasionally on the operating table as soon as the cannula has been inserted. The membrane will probably be coughed through the unobstructed orifice. The removal of the cannula, especially during the first twenty-four hours, necessitates a skilled hand for its reintroduction. When it cannot be replaced, or its presence prevents expulsion of obstructing products, some other method of keeping the orifice open must be employed, and the dilating retractor, if retractors are employed, will be of great use ; hooks may be improvised from hair-pins, and may be held in position by tapes passed around the neck. Skilled judgment is necessary for the recognition of these important points and for their proper management ; an officious nurse may interfere unneces- sarily on the one hand and do injury on the other. The obstructed character of the respiration is a guide for interference: under all circumstances the condition of the inner cannula should be observed every two or three hours, to clear it of any viscid secretions that may have adhered to it ; these should be carefully examined in water, so as to detect membranes, which will float out in flat pieces, their amount indicating how the case is progressing. At 54 850 LOCAL DISEASES. the end of twenty-four hours or thereabouts the cannula, soiled as it is with blood and sputum, should be removed for -cleansing, and be replaced by a clean one ; it is best to do this by daylight, and with the child in the same position as when it was inserted ; this removal is followed by cough and dis- charge of morbid products ; the tube being removed, the parts are to be care- fully inspected and carefully cleansed. If everything has gone on well, the tube, if of silver, though soiled by mucus, pus, and blood, will not be tar- nished. If blackened, mortification is indicated at the corresponding point of the wound ; if the tissues are healthy, the parts will be normal in color and soft, and the edges of the wound will be everted. Sometimes the parts will be so pliable as to turn inward and occlude the tracheal incision ; then a dilator should be introduced to keep the wound open until a tube is inserted ; meanwhile, if indicated, search may be made for false membrane. The can- nula should be changed once a day, and the wound dressed if need be ; when air begins to pass by the natural passage, as tested by covering the external wound with the finger-tip, the tube may be left out for a few minutes after each dressing, to be replaced immediately should respiration become embar- rassed ; from day to day the tube may be dispensed with for increasing inter- vals, until it is finally put aside. One of the most favorable indications for this procedure is expectoration by the mouth. As the cannula exposes the patient to the risk of bronchitis and broncho- pneumonia, it should be removed at the earliest possible period ; to determine how necessary the instrument is, close the external opening from time to time and watch the effects ; it should not be withdrawn unless the patient can breathe for some hours with the orifice plugged. The wound usually closes rapidly after the cannula is removed. Foreign bodies passing through the larynx and trachea generally enter the right bronchus, owing to the peculiar anatomical arrangement at the bifurcation ; the symptoms produced and the obstruction to respiration depend upon whether the substance is fixed or movable, its size, nature, and precise position : if impacted in one of the bronchi, the entrance of air into the corresponding lung is more or less impeded, or the obstruction may be complete, with entire loss of respiratory murmur on the affected side. The body may not occupy the whole calibre of the bronchus, when the vesicular murmur will be diminished, or it may be lodged in one of the primary or secondary divisions, causing an entire absence of the murmur over a certain limited space ; natural resonance on percussion is usually preserved ; but as a rule the chest rises less, during inspiration, on the affected than on the sound side, and the respiration is puerile in the obstructed lung ; fixed pain referred to the upper part of the chest when the body is immovable, or con- stant pain with a sense of weight on one side, sometimes indicates the posi- tion of the foreign body ; the voice may be hoarse, the respiration wheezing, the cough aggravated by deep inspiration ; inflammation adds to these symp- toms a copious and offensive expectoration, paroxysms of fever, night-sweats, and exhaustion. When the symptoms indicate that the foreign body is in one of the bronchi, tracheotomy should be performed, and the opening should be of considerable extent and as low down as possible. The removal may sometimes be effected, if the foreign body is globular, by inversion of the patient and giving the posterior wall of the chest a blow, but care must be taken that the substance does not lodge in the larynx and cause suffocation. If it is not dislodged, it must be extracted by instruments : first explore with a long probe in order to learn the exact position of the body, then introduce suitably curved forceps and seize and remove it. BROXCHITIS. 851 CHAPTER VII. BKONCHITIS. Inflammation of the bronchial tubes, or bronchitis, is probably the most frequent disease of early life. It is usually associated with more or less inflammation of the mucous membrane of the nostrils, larynx, and trachea. We designate the disease coryza, laryngitis, or bronchitis according as one or the other inflammation predominates. Sometimes bronchitis occurs with but slight inflammation elsewhere, and often the coryza and laryngitis abate while the bronchitis is still active. Bronchitis occurs both as a primary and secondary disease. The sec- ondary form is common in connection with measles, whooping cough, pneu- monia, and pulmonary phthisis, and it is not uncommon in remittent and continued fevers. Bronchitis is acute, subacute, or chronic, and according to its extent it is mild or severe. If the smallest bronchial tubes are involved, the inflammation is designated capillary bronchitis — a term not well chosen, but which is conveniently employed in a description of the malady. Bron- chitis is commonly bilateral, affecting the tubes on the two sides with about equal intensity. When due to tubercles or to pneumonia it is often unilateral, being confined to those tubes or nearly to those which lie in the tubercular or inflamed pulmonary tissue. Causes. — The causes of secondary bronchitis are obviously the diseases in connection with which it occurs. The cause of primary bronchitis is the same as that of simple acute laryngitis or coryza — namely, sudden change of temperature from warm to cold, exposure to currents of air, the practice of sending children without sufficient clothing from heated rooms into the open air. the throwing off" of bedclothes at night, etc. Anatomical Characters. — In the most common form of bronchitis the larger bronchial tubes only are affected. They are the seat of the inflamma- tion in most of those cases which are designated " colds " by families, and which are often treated without the aid of the physician. The lining mem- brane of the bronchial tubes presents the ordinary anatomical characters of mucous inflammations. It is reddened uniformly or in patches, intensely or in that milder degree known as arborescence, according to the severity of the inflammation. The secretion of the muciparous follicles is at first arrested and the sur- face of the membrane is dry. In the course of a day or two the secretory function is re-established, and the surface is covered with thin and transpa- rent mucus. A day or two later the secretion becomes thicker, consisting of mucus and pus. Mixed with these substances are epithelial cells, which are exfoliated in abundance from the inflamed surface. At the same time the mucous membrane becomes thickened and more or less softened. If the inflammation be severe, the vessels of the submucous connective tissue are also injected. Usually in about a week in the young child, in from one to two weeks in older children, the inflammation begins to abate. Gradually the inflamed membrane returns to its normal consistence, thickness, and vascularity, and with this return to the healthy state the muco-purulent secretion abates. In this, which is the simplest and most common form of bronchitis, there is no ulceration, and rarely any pseudo-membranous formation if the disease be idiopathic. Pseudo-membranous bronchitis is not unusual as an accom- paniment of pseudo-membranous laryngo-tracheitis. 852 LOCAL DISEASES. Were bronchitis limited to the larger bronchial tubes, it would indeed be a simple affection, but, unfortunately, it has a tendency to extend downward. Commencing in the larger, it gradually invades the smaller tubes in a similar manner to the extension of erysipelas upon the skin. More rarely the inflam- mation commences simultaneously in the larger and smaller tubes. The grav- ity of bronchitis is proportionate to the degree of its extension downward. It may stop at any point in its progress, but if it reach the smaller tubes it is one of the most serious affections of early life. The mucous membrane of the minute tubes, those next to the air-cells, is delicate, with but little submucous connective tissue, and it frequently, at post-mortem examinations, does not present to the eye those distinct inflam- matory changes which are observed in tubes of larger diameter. It is some- times not notably thickened nor its vascularity much increased, even when there is reason to believe from the symptoms that it was the seat of active phlegmasia. As we pass from these minute tubes to those of larger calibre the inflammatory lesions become more distinct. The inflammation produces minute and abundant points of redness and the membrane is evidently thick- ened ; often it is rough or granular. The minute bronchial tubes are very small, especially under the age of three years, and, since in capillary bronchitis a large proportion of them are inflamed, the source of the danger is apparent. It is with difficulty that the patient with capillary bronchitis can by the effort of coughing free the tubes from the secretions which are constantly collecting in them. In weakly children under the age of two years expectoration is most difficult, and hence the great and increasing dyspnoea from which such patients suffer. In severe and unfavorable cases of bronchitis, which are chiefly those in which the small as well as large tubes are inflamed, the following anatomical changes commonly occur : The muco-purulent secretion, which is tenacious, collects more rapidly in the smaller tubes than it is expectorated by the child, whose strength begins to be exhausted. The accumulation of the secretion is chiefly in the tubes which lie in the posterior and inferior portions of the lung. As the obstruction from the muco-pus increases in these tubes, less and less air passes through them into the alveoli with which they communi- cate, while the quantity of air which passes through the unobstructed tubes into the anterior and superior portions of the lung is proportionately increased. The effect, as regards the state of the lung, is obvious. In cases having a fatal issue, and in which we are therefore able to inspect the lesions, we find that the lower and inferior portions of the organ, from which air was to a greater or less extent excluded, have a diminished crepitation ; that they lie a little below the general level, or that certain lobules do ; and that they pre- sent a congested appearance, for. while they contain too little air, they have an excess of blood. We shall also find that the upper and anterior parts of the organ, perhaps the entire upper lobe, contain more than the normal quan- tity of air, so as to rise above the general level. There is distention of the alveoli in these parts, so that they are probably visible to the naked eye, and may appear to be emphysematous ; but this is a state distinct from emphysema. It is merely an inflation of the alveoli to nearly their full capacity. Here and there in the portion of lung in which the inflation has been incomplete lobules may be observed which are entirely collapsed, having a dusky-red color and no crepitation ; while in other parts, if the bronchitis have continued some days, there are nodules of pneumonia. Often when the bronchitis is severe the inflammation, commencing in the bronchial tubes, extends to the lungs, usually to lobules in the lower lobes, constitut- ing broncho-pneumonia. The occurrence of pneumonia is announced by BBOSCHITIS. 853 an aggravation of symptoms, and frequently by the expiratory moan. The incised surface of these portions of the lung to which the access of air has been prevented, whether they are collapsed fully or partially or not, has a reddish color from congestion and is moist from serum and blood. On com- pressing the lung the muco-purulent secretion appears upon the surface in points, having escaped from the divided ends of the tubes. (For other facts relating to Atelectasis the reader is referred to the chapter in which this mal- ady is described.) Exceptionally, even when not accompanied by laryngeal croup, fibrinous exudation occurs in the bronchial tubes, forming a delicate film here and there, and readily detached from the surface underneath, while in rare instances it occurs as a firm and continuous membrane, forming a mould of the tubes, increasing greatly the dyspnoea, constituting a true bronchial croup. If the patient with severe bronchitis survive, the inflammation of the mucous membrane soon begins to abate. The tubes which have been the seat of the disease and the alveoli which have been secondarily involved may return to their normal state almost immediately ; but in other instances such anatomical changes occur in them, even when there is no pneumonia nor atelectasis, that full restoration to their normal state is necessarily some- what slow. AVhen the function of a lobule ceases, as it does when the tube leading to it is obstructed, not only hypersemia occurs, with or without col- lapse, as already stated, but its cells and nuclei, and perhaps other parts, begin to undergo fatty degeneration. These elements become granular, somewhat enlarged and opaque, and here and there mixed with them are other large cells filled with oil-globules. These are the compound granular cells of pathologists, and, occurring in this situation, are produced by meta- morphoses of the epithelial cells. They are epithelial cells which have pro- gressed more rapidly than others in fatty degeneration, having reached that stage of it which immediately precedes liquefaction. We often with the microscope observe not only these corpuscles, but their fragments as they are dissolving. Minute abscesses, usually directly under the pleura, have occasionally been observed at the autopsies of those who have recently had general bron- chitis, and pathologists are not agreed as to the mode in which they are pro- duced. Some of them, if not all, are evidently connected with the minute bronchial tubes, and the quantity of pus contained in each is not usually more than one or two drops. The most reasonable view of their causation is that they are produced in the terminal tubes where the mucus and pus col- lect. The pus acts as an irritant and causes inflammation, and the inflamma- tion increases the quantity of pus. The walls of the tube which is now the seat of an abscess are destroyed by ulceration, and probably also some of the contiguous air-cells. The little cavity is soon surrounded by a delicate mem- brane, the same in character, though less thick and firm, as that which con- stitutes the walls of larger abscesses. The pus presents the usual appear- ance of this liquid, or it may be tinged by the presence of blood-cells, or, again, it may be thick from partial absorption of the liquor puris, so as to resemble softened tubercle. The abscess is ordinarily located in the centre of a collapsed lobule. In certain cases it approaches the surface of the lungs, so as to produce circum- scribed pleurisy, with adhesion of the costal and visceral pleura. At the autopsy of such a case, on separating the adhesions and attempting insuffla- tion, the air passes through the aperture, so that the lung on that side can- not be inflated unless the aperture be closed. Occasionally pneumothorax results from opening of the abscess into the pleural cavity. In severe protracted bronchitis dilation of certain of the bronchial tubes 854 LOCAL DISEASES. sometimes results. The alveoli in the upper lobes may also be distended beyond their physiological capacity, so as to produce emphysema, but, as we have stated above, their maximum distention within physiological limits must not be mistaken for emphysema. Emphysema in the upper lobes is common in feeble young children with relaxed and weakened tissues, occur- ring even without any severe disease of the respiratory organs. It may be vesicular or interstitial. If it be interstitial, the sacs of air often attain considerable size, lying as wedges between the alveoli or like little bladders upon the surface of the lung, where the entrance of air is least obstructed and greatest. Symptoms. — It is evident, from the description which has been given of the anatomical characters of bronchitis, that its symptoms vary greatly in severity in different patients. It usually commences with more or less coryza. The symptoms are headache, flushed face, elevation of temperature, acceleration and fulness of pulse. In the mildest cases these symptoms are scarcely appreciable. The child is observed to sneeze and have some deflux- ion from the nostrils, and this is followed by an occasional mild, almost pain- less cough, which declines in the course of a few days. The respiration and pulse are scarcely accelerated and the appetite is but slightly impaired. There may be a little fretfulness, but the child is not confined to his bed or room, and usually amuses himself with his playthings. Auscultation in these mild cases reveals coarse mucous rales in the larger bronchial tubes, while the smaller tubes are free from mucus. Sibilant and sonorous rales are also observed, especially in the commencement of the bronchitis, at which time the secretion of mucus is suppressed or scanty. The cough in the commencement is for the same reason dry. It becomes looser by the second or third day, the sputum consisting of frothy mucus, with the admixture of pus and epithelial cells. The pus becomes more abundant as the disease continues. Expectoration from the mouth does not usually occur till after the age of four or five years ; under this age the sputum is ordinarily swallowed. The mild form of bronchitis described above, that in which only the larger tubes are affected, is common in infancy and childhood, but bronchitis of a more severe type is also common, due to extension of the inflammation. It has already been stated that there is a tendency in bronchial inflam- mation to extend downward, and symptoms are proportionate in gravity to the degree of this extension. In severe bronchitis the pulse rises to 120 or 130 per minute, and the respiration is in a corresponding degree accelerated. The cough is frequent and painful, the pain being referred to the sternum, and often there is a steady dull pain in this region. The face is flushed and indicative of suffering, the temperature is considerably ele- vated, and the appetite is greatly impaired or lost. There is frequently an exacerbation of symptoms in the latter part of the day. Depression of the inframammary region during inspiration and dilation of the alse nasi accom- pany grave attacks of the inflammation. Auscultation in severe bronchitis reveals the presence of rales in all parts of the chest, sibilant and sonorous sparingly, coarse mucous and subcrepitant more abundantly. General bronchitis or suffocative catarrh, the most dangerous form of this inflammation, is less frequent than bronchitis, which is limited to the larger tubes or to the larger tubes and those of medium size. It may commence quite abruptly, but ordinarily it results from the milder form of the disease. The symptoms at first are such as occur in the common form of bronchial inflammation, but, instead of abating or remaining stationary, they grad- ually increase in severity till suddenly marked dyspnoea supervenes. The BROXCHITIS. 855 inflammation has now reached the minute tubes, and what promised to he an ordinary attack of bronchitis becomes one of great severity and danger. The respiration in severe bronchitis is short and hurried. Sixty to eighty inspirations per minute are not infrequent, while the pulse also is greatly accelerated, attaining as high a number as 140 to 160 or 180 beats per minute. The cough is frequent, and the sputum, which collects in abundance, is expectorated with difficulty. If expectorated so as to be examined, it is found to consist largely of frothy mucus with epithelial cells. After a few clays, if the patient live, it becomes more purulent. Sometimes, as in bron- chitis of the adult, streaks of blood appear upon the mucus. In the first days of severe acute bronchitis the temperature is considerably elevated, the face flushed, and the breathing oppressed. The patient is restless, moving from one part of the bed to another, seeking in vain for relief. The diges- tive function is impaired, as in all severe inflammations ; the tongue is moist and covered with a light fur ; the appetite is nearly or quite lost. The infant takes the breast with difficulty, frequently relinquishing it on account of the dyspnoea ; older children take no solid food in consequence of the ano- rexia and the dyspnoea, and even drinks are swallowed hastily and apparently without relish, since deglutition interferes with respiration. On auscultation in bronchitis of the minute tubes sibilant, and after a day or two subcrepi- tant. rales are observed in every part of the chest. Percussion elicits a good resonance unless the substance of the lung have become involved. As the disease approaches a fatal termination the pulse becomes greatly acceler- ated ; the respiration is also in a corresponding degree frequent and panting, the inspiration being accompanied by increased inframammary depression and dilation of the alae nasi. The face becomes pallid, the prolabia livid, and the tips of the fingers livid and cool. The mucus and pus, accumulating in the air-passages, increase more and more the obstruction to the entrance of air, and finally death occurs from apncea. The nursing infant usually ceases to nurse several hours before death, and a state of stupor commonly pre- cedes the fatal event, due to the accumulation of carbonic acid in the blood. In young infants, especially those under the age of six months, not only in bronchitis of the minute tubes, but in severe ordinary bronchitis, I have often observed toward the close of life intermission in the respiration. It occurs after every six or eight or ten respirations, and equals in duration the time occupied in perhaps half a dozen respiratory movements. It is there- fore an unfavorable prognostic sign, but some in whom it occurs recover by active stimulation. The duration of acute bronchitis varies according to the extent of the inflammation. In the mildest form the patient is convalescent after three or four days, and in severe cases that terminate favorably the disease begins ordinarily to decline by the close of the first week or in the second. The progress of bronchitis is somewhat more rapid in young children than in those of a more advanced age. When convalescence is fully established it is not unusual for the cough to continue three or four weeks, though grad- ually declining. It is loose and painless, and is scarcely regarded by the patient. Death sometimes occurs as early as the second or third day in severe gen- eral bronchitis. The younger the infant, with the same extent and intensity of inflammation, of course the sooner the fatal result. The ordinary dura- tion of fatal bronchitis is from six to eight days. If the patient pass beyond the tenth day, decline of the inflammation may be confidently expected, with recovery, unless there be a complication. Occasionally bronchitis becomes chronic, lasting several months before it 856 LOCAL DISEASES. entirely ceases. The chronic form may result from mild as well as severe bronchitis. The acute fever and accelerated respiration which characterize the acute affection abate, and the general health is nearly or quite restored ; but an occasional cough continues, and the respiration is often audible, from the mucus which collects in the tubes or from thickening of the mucous membrane. Sometimes there is moderate fever, especially in the latter part of the day. On auscultation coarse mucous, with perhaps sibilant and sono- rous, rales are observed in the chest. There is great liability in chronic bronchitis to exacerbations. The dis- ease often seems to be abating and there is prospect of its speedy cure, when all the symptoms are intensified. The exacerbations are due to the fact that the bronchial surface, when it has been a considerable time inflamed, is very sensitive to the impression of cold. Even when the disease is entirely relieved, it is very liable to return by exposure to currents of air or changes of temperature. Chronic bronchitis occurs most frequently in the winter, spring, and autumn, when the weather is changeable, and is most intractable in these periods of the year. Many cases of chronic bronchitis are associated with dilation of the bronchial tubes or with emphysema. The general health in this form of bronchitis, when not depending on a tubercular deposit, ordi- narily remains good. Tubercular bronchitis, which is the result of a grave disease, is treated of in our remarks on Tuberculosis. It is attended with emaciation, and is obstinate on account of the nature of the primary affec- tion. It is due to the irritating effect of tubercular matter lying against the bronchial tubes. Diagnosis. — Bronchitis can ordinarily be diagnosticated by the character of the respiration and cough. The absence of hoarseness, stridulous inspira- tion, and croupy cough excludes laryngitis, and the absence of the expiratory moan and of the stitch-like pain on coughing, which characterize pneumonia and pleurisy, excludes these diseases. Accurate diagnosis, however, can be most readily made by percussion and auscultation. Examination of the chest enables us to state with positiveness not only the nature, but the extent, of the affection. If the inflammation be confined to the larger bronchial tubes, coarse rales are discovered in them, while finer mucous rales are absent. If the bronchitis be in the minute tubes, subcrepitant rales are discovered in them. Percussion gives clear resonance on both sides, except in those instances in which atelectasis or pneumonia has supervened. Prognosis. — Bronchitis limited to the larger bronchial tubes or to these and those of medium size terminates favorably in a large majority of cases. Occasionally, severe inflammation, not extending to the smaller tubes, proves fatal to young infants or those of feeble constitution. Bronchitis extending to the minute tubes is. on the other hand, a disease of great danger. It may be fatal at any period of childhood, but the younger and more feeble the patient the greater the liability to a fatal result. Under the age of one year it is one of the fatal diseases of early life. The prognosis in the commencement of all cases of bronchitis of average severity in the young child should be guarded, on account of the tendency of the inflammation to extend, as has been already stated in the preceding pages. After five or six days extension ceases, and if during that time no increase in the severity of symptoms occurs the prognosis is favorable. Signs which indicate an unfavorable result are increasing frequency of pulse and respiration, difficult and scanty expectoration, restlessness, a countenance expressive of suffering, and a progressively greater accumulation of mucus in the bronchial tubes, as determined by auscultation. Pallor and coldness of the face and extremities, lividity of the tips of the fingers, rapid and feeble pulse, drowsiness, diminution of cough, while the mucus and pus BEOXCHITIS. 857 accumulate in the bronchial tubes, and, in young children, intermissions in the respiration, indicate the near approach of death. Cases may, however, recover by proper treatment, although the symptoms are most unfavorable. It is unnecessary to mention the favorable prognostic signs of bronchitis. This disease, when fully established, continues a certain number of days what- ever remedial measures are employed, and if the symptoms do not increase in severity during the first five or six days, a favorable result is highly prob- able. The prognosis in chronic bronchitis is ordinarily favorable, so far as life is concerned, provided that no emaciation occurs. If there be emaciation, the bronchitis may be due to tubercles in the bronchial glands or lungs, and of course the prognosis is less favorable. Treatment. — Bronchitis may be rendered much milder, and perhaps prevented, by an emetic employed in the first twelve or twenty-four hours in conjunction with a warm bath. The physician is not, however, ordinarily called sufficiently early to render this treatment effectual. Mild Bronchitis. — In mild bronchitis, the inflammation being limited to the larger tubes or to these and those of medium size, simple, soothing, expectorant, and laxative remedies are required. Mild counter-irritation may be produced by camphorated oil or the following : R. Olei caryophvlli, ^ij ; Olei camphorati, ^iv. For external use. And one of the following mixtures may be given : The late Dr. James Jack- son of Boston, in his letters to a young physician, writes of the treatment: " For young children I employ the following : Take of either almond or olive oil. of syrup of squills, of any agreeable syrup, and of mucilage of gum acacia equal parts, and mix them. Of this mixture a teaspoonful may be given to a child two years of age ; a little less if younger and increased if older, so as to double the dose to one in the sixth year. This may be given from three to six times in the twenty-four hours. Sometimes a little opiate must be added at night to appease the urgent cough." Another good medicine is the mistura glycyrrhizae composita, half a teaspoonful of which should be given every two hours to a child of three years and one teaspoonful to one of six years. The syrupus ipecacuanhas compositus of the French Pharma- copoeia, the centre cle la toux, consisting of ipecacuanha, senna, thyme, poppy, sulphate of magnesia, orange-flower water, wine, water, and sugar, being soothing and slightly laxative, is also a useful remedy. These cases also do well with simple mucilaginous drinks and confinement in a warm room. Bronchitis affecting the Medium-sized or Smallest Tubes. — In all cases of this disease in which the cough is dry and painful, or so frequent as to attract attention, the air of the room should be constantly moist. I prefer the use of the croup-kettle or steam-atomizer : R. Sodii bicarbonat, ^ij ; Aq. calcis, Oij. — Misce. Or, R. Terebinthinse, ,^j '■> Aquae purse, Oij. — Misce. In the New York Foundling Asylum the constant inhalation of air con- taining the turpentine vapor has been a favorable mode of treatment. It must be recollected that the muco-pus in the bronchial tubes contains numer- ous microbes, and they descend deeper during inspiration, and. if not expec- torated, by their irritating action tend to produce a downward extension of 858 LOCAL DLSEASES. the inflammation. The inhalation of vapors like those mentioned above not only renders the muco-pus thinner and more easily expectorated, but to a certain extent also produces a disinfectant action. Local treatment applied to the chest in bronchitis is important, since, if properly made, it increases the comfort and obviously diminishes the intensity of the inflammation. Henoch, whose ample experience and sound judgment command attention, if not acceptance of his views, says of local treatment : " I strongly advise hydropathic applications to the chest from the neck to the umbilicus. A napkin or diaper is dipped in water at the temperature of the room, well wrung out, and then placed around the chest, without exercising any compression, so that the arms are free ; this is surrounded by a roll of batting and then covered by a layer of oil-silk or gutta-percha paper. When the fever is high these applications should be renewed at least every half hour ; later they may be kept on for one or even two hours, and this continued for several days and nights. I have occasionally continued it for a week, the cool water being changed to a temperature of 26° to 27° R " (90.5° to 92.8° Fahr.). The benefit derived from the cold-water application is, according to Henoch, threefold : First, the deep inspiration which the application of cold causes, thus expanding portions of the lungs which are liable to atelectasis ; secondly, " derivative irritation of the skin ;" and, thirdly, the production of moisture in the air surrounding the child, which he inhales. Deep inspira- tions are, in my opinion, caused to a greater extent by medicines which excite cough, as ammonia and warm applications certainly produce more derivation to the surface than cold. One benefit from the application of cold Henoch does not allude to, and that is the reduction of temperature. But I prefer for this purpose frequent sponging of the upper extremities and face with cold water, and perhaps its constant application to the head. I have observed marked relief from this use of cold water. For years, in my practice, the following external treatment has been employed with apparent benefit in nearly every case. For infants under the age of three months who have accelerated respiration and painful cough, indicating the need of external treatment, two poultices of ground flaxseed are prepared, covered by thin muslin and made so moist that they wet the hand in holding them. They are made as thin as the pasteboard cover of a book, and of such a size that, applied in front and behind, they cover the entire chest. Camphorated oil is smeared over their under surface three or four times daily, and over their exterior oil-silk is applied. For infants over the age of six months I prefer poultices of the following : R. Pulv. sinapis, %] ; Pulv. seminis lini, ^ xv j- The poultice, to give most relief, should be so wet as to cause constant moist- ure of the surface, and so irritating as to cause constant redness without necessitating its removal. Vesication should never be produced. Flannel wrung out of warm water made slightly irritating by mustard and covered by oil-silk also answers the purpose. External treatment should be employed in most instances so long as the respiration is hurried and cough painful. During the stage of convalescence, instead of the poultice, cotton wadding or batting around the chest increases the comfort and prevents taking cold. Derivation to the surface, early made and continued, tends to check the downward extension of bronchitis. Often improvement in the symptoms is observed, especially less dyspnoea and restlessness, immediately on the em- ployment of the local measures recommended above. JBEOXCHITIS. 859 Internal Treatment. — Medicines are indicated which have a tendency to diminish the inflammation, to prevent its downward extension to the minute bronchial tubes, and to promote expectoration. The bowels should be kept open in all cases of bronchitis. For robust children at or over the age of six months the following prescription is useful in the commencement of the attack : R. Syr. ipecac, Spts. aether, nitr., da. gij ; Ol. ricini, ^iij ; Syr. bal. tolut., 5J. — Misce. Dose : Half a teaspoonful to one teaspoonful, every second hour, for the age of one to two years. But the medicinal agent which experience has shown to be the most use- ful in the bronchitis of children is one of the salts of ammonium. In the treatment of infantile bronchitis depression must be avoided. The cough should be strong and frequent, for the chief danger occurs from the accumu- lation of viscid mucus in the minute tubes, so as to obstruct the entrance of air into the alveoli, leading to atelectasis and causing the dyspnoea which is so painful and prominent a symptom in this disease. Ammonii carbonas or chloridum better than any other agent promotes expectoration by exciting cough and rendering the mucus less viscid, and it does not reduce the strength. When anxious parents ask me to prescribe something to relieve the cough, I reply that the more frequent the cough the better it is for the infant, since it aifords the means of freeing the tubes from the accumulating mucus. Gas- tric catarrh has been found in infants who have perished after repeated doses of the ammonium carbonate administered for pulmonary diseases. I there- fore prescribe it in water, and direct it to be administered in milk. In feeble cases and cases attended by dyspnoea the carbonate is preferable to the chlo- ride, since it is more stimulating and it promotes the cough by slightly irri- tating the fauces. The ammonii chloridum may in most instances be given with benefit from the commencement, both in mild and severe bronchitis, in infants under the age of one year, but in severe cases it is apparently less efficient than the carbonate. The following is a convenient formula for its employment : R. Ammonii chloridi, 3j ; Syr. bal. tolut., §ij. — Misce. Fifteen drops contain one grain, which is the dose at the age of three months. Five drops should be given at the age of one month, and thirty at the age of six months, in a little water. This expectorant should be given frequently, as every half hour or every hour in cases of severity. The urgent symptoms are relieved by free expectoration, which this medicine tends to produce. It should be given night and day, at the short intervals mentioned, until amelioration of symptoms occurs. The benefit from its use is most apparent under the age of eighteen months, or at the age when capillary bronchitis and atelectasis are most liable to occur. Medicines which exert a greater controlling effect on the action of the heart than those which we have mentioned are often required during the progress of severe " bronchitis." If the patient give evidence of declining strength while the pulse is unusually rapid and the temperature elevated, quinine given in moderate doses, as two grains every fourth hour to a child of two years, has seemed to me useful as a heart tonic. It may be employed in the following formula : 860 LOCAL DISEASES. R. Quiniae sulphatis, gss ; Syr. yerbse santse comp., ^ij. — Misce. Give one teaspoonful every fourth hour. The tincture of digitalis in doses of one or two drops every second hour for infants between the ages of six months and two years is also useful as a heart tonic. In a case recently under treatment by Dr. Jacobi and myself the infant, aged twenty -three months, having a temperature varying from 102J° to 105J°, respiration 82 to 105, and pulse 165 and higher, took four drops of tincture of digitalis, besides the quinine and ammonii chloridum, three days, with apparently a good result from the digitalis. This remedy was afterward continued in two-drop doses, and the patient recovered. For robust children, with a strong and rapid pulse, with a temperature above 102°, the use of an antipyretic is indicated. Tincture of aconite, drop j, or phenacetin, gr. j, with citrate of caffein, gr. ss, may be given every third hour to an infant of one year. If the temperature fall to 102°, the antipyretic should in ordinary cases be discontinued, since it is in a measure depressing. Its use is seldom required longer than two or three days. For feeble children, or those who have atelectasis or pneumonia complicating the bronchitis, quinine is preferable to either of the above antipyretics. When and how to employ opiates to procure the needed rest in the bron- chitis of children should be carefully considered. We have stated that a frequent and strong cough is required in the infant in order to prevent clog- ging of the minute tubes with muco-pus and to prevent atelectasis. Still, some respite from the cough, if it be frequent, is required to prevent exhaus- tion. I prefer for young infants to give the opiate separately from the ex- pectorant, and only occasionally as they may need sleep. The following is a useful formula for an infant of six months if it be restless and without the proper amount of sleep : R. Liq. opii composit. (Squibb), gtt. x; Potass, bromidi, gj ; Syr. rubi idsei (raspberry), t ^j ; Aquae, ^iss. — Misce. Dose : One teaspoonful when needed. Eight drops of paregoric may be given in place of the above. Twice the dose of either of these opiates is sufficient at the age of twelve months. For older children Dover's powder — an eligible form of which is Squibb's liquid Dover's powder, the tinctura ipecacuanhas composita, one minim of which corresponds to one grain of the powder — is a useful remedy to procure sleep. During convalescence medicines should be administered less and less fre- quently or in smaller doses. Emetics in ordinary cases of bronchitis are not required, except in the commencement. In severe bronchitis, however, espe- cially when the smaller tubes are inflamed, they sometimes appear to be use- ful. The cases which may need their administration are those in which mucus and pus collect in the tubes more rapidly than they are expectorated, so as to give rise to urgent dyspnoea. An emetic administered under such circum- stances may give prompt and decided relief. The object to be gained is obviously very different from that in the commencement of bronchitis, and such agents should be employed as act promptly with little depression. Ipecacuanha is probably the best emetic for this purpose. Infants oppressed by the accumulation of mucus and pus may sometimes be relieved by tickling the fauces with the finger. This provokes vomiting, and the viscid mucus which collects at the entrance of the glottis is removed by the finger. ATELECTASIS. 861 The diet should, as a rule, be nutritious through the entire disease ; but robust patients or those who have ordinary health, if over the age of two years and affected with primary bronchitis, are sufficiently nourished by light diet, chiefly farinaceous, in the first days of the attack, after which animal broths are proper. Whatever food is given in severe bronchitis must be in the form of drinks, since the appetite is lost and solid food is not taken, while the thirst is such that liquids are less likely to be refused. In primary bronchitis, if mild or of ordinary severity, alcoholic stimu- lants are not required. In secondary bronchitis they are often needed, and also in severe primary bronchitis if there be dyspncea with evidences of prostration. CHAPTER VIII. ATELECTASIS. In certain new-born infants the lungs do not undergo inflation or only a portion of the lobules is inflated — to wit, those in the upper lobes — while the remainder of the organ continues unchanged from the foetal state. This non- inflation of the lung is designated congenital atelectasis. It is apparently not due, unless in rare instances, to defective formation of the respiratory apparatus, for at the autopsies of cases which have ended fatally, as most cases do at an early period, insufflation is easy, there being no occlusion of the air-passages nor unusual adhesion of the walls of the alveoli to prevent the admission of air. Physicians have believed that in some instances they discovered the cause in an enlarged thymus gland, which compressed the lower part of the trachea, but this cause has not seemed to exist or was exceptional in cases which I have observed ; for although the thymus at birth is large, having nearly the size of an unexpanded lung, it has not seemed to me to be unduly enlarged in most atelectatic cases which I have examined after death. The ordinary proximate cause of atelectasis neonatorum is feebleness of inspiration, whether due to general debility, as in infants born prematurely, or weakened by placental hemorrhage in the last months of foetal life, or, as is frequently the case, to injury of the brain and consequent impairment of the function of the pneumogastrics during birth. I have more fully treated of this form of atelectasis in the chapters which relate to the maladies inci- dental to the birth of the child, and to these the reader is referred. Acquired atelectasis, or collapse of lung, is less extensive than con- genital atelectasis, being confined to a portion of a lobe and often to only a few lobules. It occurs chiefly during the period of infancy and in feeble children. It is a common malady in foundling asylums in wasted infants who perish before the close of the first year. I have frequently at the autopsies of such infants observed it along the thin inferior margins of the lower lobes and in the tongue-like prolongation of the left upper lobe. In this class of cases catarrh of the bronchial tubes appears to have little or no agency in causing the collapse. The cause is found in the impaired functional activity of the lungs. In the state of debility the heart beats feebly and the stream of blood from it to the lungs is small and slow, so that the inspira- tion of a small amount of air suffices for its decarbonization. The inspira- tions also are seen to be feeble, causing little expansion of the walls of the 862 LOCAL DISEASES. thorax. Consequently, the entire lung is imperfectly inflated, as is seen in fatal cases, but the distant thin portions of the organ are least expanded. These, receiving little or no air, soon begin to contract from the presence of the elastic tissue, and collapse or atelectasis ensues. This has been the most common form of atelectasis in cases of this malady which I have observed in foundling asylums, and it probably occurred in the manner which I have described. Another case of acquired atelectasis to which all writers allude is bron- chial catarrh, which, commencing in the larger tubes, extends downward into those of smallest size. By the swelling of the mucous membrane and the accumulation of viscid muco-pus, which cannot be expectorated, certain of these tubules become occluded, so that the inspired air is shut off from the alveoli situated beyond them. Occlusions are obviously most likely to occur in the bronchitis of feeble infants whose cough has little expulsive force, so that debility is also a factor in the production of this form of atelectasis. The portion of lung withdrawn from the respiratory function soon collapses, the air which it contained being probably in part expired, but chiefly absorbed. Atelectasis is not, however, so important or frequent a complication of bronchitis as was formerly supposed, for catarrhal pneumonitis due to exten- sion of the inflammation from the bronchioles into the lung has been mistaken for it. Solid non-crepitant nodules or portions of lung are frequently observed at the autopsies of infants who have perished of severe bronchitis, and these may be atelectatic or pneumonic, but they are more frequently the latter than was formerly supposed. The possibility of insufflating these solid portions when removed from the body after death was till within a few years regarded as decisive proof of atelectasis. It is now known that this is not a reliable test, since a lung solidified by recent catarrhal pneumonitis can be almost as readily inflated as one which is collapsed ; but the inflated pneumonic lung is more solid and resisting when pressed between the thumb and fingers than is the collapsed lung. The decisive proof is afforded by the microscope, by which cell-pro- liferation is discovered within the alveoli in catarrhal pneumonitis, while it is lacking in simple collapse. An increase of the dyspncea not infrequently occurs in severe infantile bronchitis, without either pneumonia or collapse from the accumulation in the bronchioles of the secretion which is with difficulty expectorated, but if dulness on percussion and other physical signs indicate solidification of the lung at some point, of course pneumonia or col- lapse has occurred. If a sufficient amount of lung be involved to produce well-marked physical signs, the disease is in most instances pneumonia and not collapse, though it may be the latter. Both these pathological states may, however, occur in the same lung as complications of severe bronchitis. The severe paroxysmal cough of pertussis, especially when accompanied by considerable secretion, frequently produces collapse of portions of the lower lobes, while it causes emphysema in the upper lobes. Symptoms. — Atelectasis resulting from bronchitis gives rise to no new symptoms. So far as it has any appreciable effect, it aggravates certain symptoms of the primary disease, but as it is ordinarily limited to a small area, this effect is not very marked. When a bronchial tube is so occluded by muco-pus that the alveoli with which it communicates collapse, there is ordinarily at the same time more or less accumulation of this secretion in other tubes throughout the lungs. Therefore, the entrance of air into the alveoli with which these tubes communicate is slow and difficult, but usually without complete obstruction and without true atelectasis, but with a semi- collapse such as we observe in fatal croup. This explains the dyspnoea which is present in these cases. If the secretion be expectorated from these tubes. ATELECTASIS. 863 the dyspnoea abates, even if the plug which has completely occluded a tube and the consequent atelectasis remain. Atelectasis occurring in wasted and feeble infants in consequence of the diminished force of the inspirations does not in most instances give rise to any prominent symptom, since it occurs chiefly in distant thin portions of the lungs. I have observed an occasional short, nearly painless, cough in such infants when the autopsy revealed no pulmonary lesion except the atelectasis. Anatomical Characters. — The portion of lung which is affected with recent atelectasis has a dark-brown or dark-bluish color. It is depressed below the general level of the lung, is firm and non-crepitant on pressure, and its incised surface is smooth. Hypersemia supervenes, because a portion of lung in which the circulation continues, but from which air is excluded, becomes congested. In acquired atelectasis the congestion is especially marked, since the vessels which have been adapted by growth for a larger area are com- pressed into one of smaller extent, so that they become tortuous and bulging within the lumina of the alveoli, while the free flow of blood through them is retarded by the constriction of the elastic fibres of the lung. An obvious and certain result of the hyperemia is the transudation of serum into the alveoli, producing oedema. This union of pulmonary hyperaemia with oedema, by which air is excluded from the alveoli, constitutes the state known to pathologists as splenization, and in proportion as it occurs the lung depressed by the atelectasis rises toward the general level. It may even rise above it, and it now has a doughy, elastic feel. The pathology of these cedematous atelectatic spots, heretofore obscure, has been clearly explained by Eindfleisch. If the patient live and the atelectatic lobules do not soon return to a state of health, they undergo further changes. Eindfleisch says : " From the series " (of changes, provided inflammation do not occur) " we especially ren- der prominent two conditions — inveterate oedema and slaty induration. But inflammation does commonly occur after a time in a collapsed lung." Those who are familiar with the post-mortem examination of infants will fully agree with Eindfleisch when he says : " Splenization, quite generally taken, appears to present extraordinarily favorable preliminary conditions for the occurrence of inflammatory changes. It may directly represent the initial hyperaemia of acute inflammation, and be followed by lobular and lobar, but constantly catarrhal, infiltrates." It is well known by pathologists that pro- tracted congestion, active or passive, of whatever organ or tissue, is very liable to pass from a state of simple stasis of blood to One of cell-prolifer- ation, and the atelectatic lung, as I have myself observed at autopsies, affords a common example of this. I have several times made or have procured microscopic examinations of the atelectatic portions of lungs of infants who had died for the most part in a wasted and enfeebled state, and have found in them clear evidence of the presence of a catarrhal pneumonia. The interesting fact therefore must be recognized that atelectasis frequently passes to a state of inflammation, so as to present the characters of ordinary hypostatic pneumonia, and no doubt undergo the same subsequent changes. Atelectasis when recent and simple or uncomplicated may soon disappear by the expectoration of the obstructing secretion, if such be present or if there be no obstruction by increased force of inspiration. If it do not soon disappear, it undergoes one of the ulterior changes alluded to above, and henceforth the symptoms and history are those of the new malady which has supervened. Treatment. — The treatment of acquired atelectasis is simple. If it be recent and there be evidence that it is due to the accumulation of the secre- tion in the bronchial tubes, an emetic which acts promptly and with the 864 LOCAL DISEASES. least possible depression may be very useful. It is especially indicated if there be little or no pneumonia, the strength not greatly reduced, and there be dyspnoea with insufficient decarbonization of blood in consequence of the abundance of the secretion in the smaller tubes. An emetic which acts promptly and with little prostration may aid greatly in establishing the res- piratory function in collapsed lobules by expelling the obstruction and pro- ducing a freer and deeper inspiration. One of the best if not the best emetic for this purpose is sulphate of copper, given in a dose of one or two grains to a child of one year. With or without the use of the emetic, our main reliance must be on sustaining and stimulating measures, by which the cough, the cry, and the inspirations acquire more volume and force. Most cases require alcoholic stimulants and the ammonium carbonate. Rube- facient applications to the chest are also commonly employed, and are probably useful. CHAPTEE IX. PNEUMONIA. Catarrhal pneumonia is the common form of pneumonia under the age of three years. In most cases it results from bronchitis by extension of the inflammation. Hence it is designated by the terms broncho-pneumonia and lobular pneumonia. Etiology. — Catarrhal pneumonia, as we have stated above, commonly results from simple bronchitis. The inflammation, affecting first the larger bronchial tubes, extends to the bronchioles, and from them to the air-cells in certain lobules. Its causes under such circumstances are evidently the same as those of the bronchitis which precedes and accompanies it. It often occurs as a complication of certain infectious maladies, among which we may mention pertussis, measles, diphtheritic croup, influenza, and, more rarely, scarlatina, variola, typhoid fever, and erysipelas. Ill-nourished, rachitic, and anaemic children with little power of resistance are most liable to it. It is in the cities especially common among the children of the tenement-houses, who live in small, overcrowded, overheated, and dirty apartments, and are frequently taken from these apartments to the lower temperature of the streets or are exposed at open windows. Different opinions have been expressed as to the mode in which pneumonia supervenes upon capillary bronchitis. We have already called attention to the theory of Buhl, that the alveoli become inflamed by the entrance into them from the bronchioles, during inspiration, of inflammatory products, which act as an irritant. A form of subacute catarrhal pneumonia sometimes results from hypostasis or passive congestion. It is not uncommon in infant asylums in infants enfeebled by chronic disease, who have weak action of the heart and languid circulation. Lying in their cribs day after day, with little movement of the body, they are very liable to passive congestion of depending portions of their lungs, and this by and by eventuates in a pneumonia presenting some peculiarities of the catarrhal form. It is sometimes designated hypostatic pneumonia. It is so frequent in foundling asylums, where feeble infants are received and treated, that certain physicians, whose observations have been largely in such institu- tions, have almost ignored any other form of pneumonia in infants. Billard, a close and accurate observer, wrote nearly half a century ago : " Pneumonia of infancy presents peculiar characters, in which it differs from the same affection in adults. Instead of being an idiopathic affection arising from irritation developed in the pulmonary tissue under the influence of atmo- PNEUMONIA. 865 spheric causes, which often excite disease, the pneumonia of young infants is evidently the result of a stagnation of blood in their lungs. Under these circumstances this blood may be regarded as a kind of foreign body It would therefore appear that inflammation of the lungs, which produces hepatization, arises in infants, in general, from some mechanical or physical cause.'" Yalleix also states that he found the lesions of pneumonia in a majority of the infants who died in the Hopital des Enfants Trouves. The statements of Yalleix are applicable also to the Infants' Hospital, the Found- ling Asylum, and the Nursery and Child's Hospital of New York City, as regards those cases in which death results from chronic disease. We shall see hereafter that hypostatic pneumonia is also a common complication of chronic infantile entero-colitis, the summer complaint of the cities. Catarrhal pneumonia of infants sometimes results from atelectasis or collapse. It is not unusual to find, at the autopsies of infants who have died in a state of emaciation and feebleness, portions of the lungs remote from the bronchi collapsed, as, for example, the thin edges of the inferior lobes and the tongue-like process of the upper lobe, the process which lies over the heart. The immediate cause of the collapse has been a bronchitis, or it has resulted directly from the general weakness of the infant and its feeble respirations. Now, a collapsed lung soon becomes the seat of passive congestion. The functional activity of an organ favors circulation through it, and if the function be abolished the flow of blood in the part is retarded and stasis more or less complete results. The hypergemic state of collapsed pulmonary lobules presents the same anatomical condition for the superven- tion of pneumonia as occurs in cases of hypostatic congestion. Consequently, cell-proliferation soon begins in the collapsed alveoli, the volume of the affected lung increases, and it becomes firmer and more resisting to the touch, and the microscope reveals the characters of a subacute but genuine catarrhal pneu- monitis. I have made or have procured microscopic examinations of a con- siderable number of such specimens, and have found the alveoli more or less filled with cells of the epithelial character. (See chapter on Atelectasis.) Pneumonia resulting from hypostatic congestion and that occurring from atelectasis are not only subacute, but usually protracted. Anatomical Characters. — If we have an opportunity to make a post- mortem inspection of the inflamed lung when broncho-pneumonia has con- tinued a few days, we will find the pleura covering it either normal or covered in spots with a thin film of fibrin. The bronchial tubes contain muco-pus, and their walls are thickened and congested. The inflamed lobules are few or many, and they are more numerous in the lower lobes and in its posterior portion than elsewhere. Their incised surface is not granular, as in croupous pneumonia, but smooth, and its color in recent cases is a pale red or deep red. In protracted cases the color may be grayish, but the change from red to gray hepatization does not occur as early as in lobar or croupous pneumonia, so that weeks after the commencement of inflammation in the lobule its color may be red. White points or lines in the lobule indicate the location of the bronchioles. The inflamed lobule is in some cases very distinct from the surrounding healthy parenchyma, but in other instances it gradually blends with it. In some cases the air-vesicles contain chiefly pus, in others chiefly epithe- lial cells or epithelial cells and pus, and in others still epithelium, pus, and fibrin. Mixed with these inflammatory products we detect also red blood- corpuscles. The capillaries in the walls of the vesicles are large and sinuous. The amount of inflammatory products in the alveoli varies greatly in different cases. The alveoli may be only partially filled, or they may be so packed that it is difficult to detect the alveolar walls. The adjacent non-hepatized 55 S66 LOCAL DISEASES. lobules do not exhibit any marked change, except that their epithelial cells may be somewhat swollen and more distinct than in health. The bronchial tubes not only contain more or less muco-pus and epithelial cells, but their walls are frequently thickened and infiltrated with pus-cells and connective- tissue cells. This infiltration causes the bronchioles to appear as white lines or dots in the inflamed area. In protracted cases the red color changes to gray, this change commencing in the interior of the lobules and extending outward. In gray hepatization the epithelial and pus-cells have undergone granulo-fatty degeneration. If resolution do not occur and the disease reach a still more advanced stage, the granulo-fatty degeneration becomes more complete, and the lobules enter the stage of cheesy degeneration, becoming yellowish -white and hard and homo- geneous, the elements which make up the lobules being no longer discernible. The ulterior change in the gravest cases is softening and the formation of cavities, or interstitial pneumonia may supervene, with an increase of the Fig. 240. 'v Fig. 240 represents an inflamed air- vesicle from the lung of a child who died of catarrahal pneumonia supervening on pertussis. From Delafleld's Pathological Anatomy. connective tissue. Cheesy degeneration and interstitial pneumonia are much more frequent in lobular pneumonia, the disease which we are describing, than in lobar or croupous pneumonia, and when the stage of cheesy degen- eration is reached the conditions are present in which tuberculosis is likely to supervene. In a large proportion of instances, when broncho-pneumonia has not con- tinued longer than two or three weeks, the inflamed lobules can be inflated after death. We would infer that this would be possible in cases in which the alveoli are only partially filled with the cellular elements. It was for- merly supposed that if an infant died, having had the dyspnoea and other symptoms characteristic of severe bronchitis or broncho-pneumonia, and por- tions of the lungs were found firm and without air, if they could be inflated, the pathological state was atelectasis ; if they could not be inflated, it was pneumonia. But I have many times been able to inflate lobules that were undoubtedly inflamed, though when inflated they were still semi-solid on palpation, so that other tests besides the fact of insufflation or non-insufflation enable us to determine whether atelectasis or pneumonia be present. Still, as we have elsewhere stated, a lung primarily collapsed is very liable to take on a low grade of pneumonia. PNEUMONIA. 867 Croupous pneumonia, also designated fibrinous and lobar, is the common form of pneumonia in the adult, and it is not infrequent in children over the Ficx. 241. Fig. 2-11 represents lobular pneumonia of a more severe grade, some fibrin being present in the centre of the air-vesicle. From Delafield's Pathological Anatomy. age of five years. It rarely occurs under the age of three years, but cases have been reported. It involves an entire lobe or a large part of a lobe. Besides the parenchyma, the smaller bronchial tubes also participate in the inflammation. Croupous pneumonia is usually a primary disease, but it is occasionally secondary, as, for example, when it occurs in certain debilitating diseases, as nephritis, or in infectious diseases, as in measles and pertussis. Etiology. — Formerly croupous pneumonia was commonly attributed to catching cold, but the microscopic examinations and experiments of Klebs, Friedl'ander, and Frankel have shown that this disease is microbic, and the two latter gentlemen, it is believed, have detected the microbe which causes the inflammation in ordinary cases, and they have given it the name pneumo- coccus. It has a breadth of about one-third its length, and it occurs in groups of two or more surrounded by a gelatinous envelope. According to the observations of Salvioli, Eberth, and Nauwerk, it appears that the pneumococci may also enter the general circulation, and, being conveyed to distant organs, may excite inflammation in them ; as, for example, nephritis, meningitis, and pericarditis. In ordinary cases of croupous pneumonia it is probable that the pneumococcus has entered the lungs by inspiration of infected air, and certain observers believe that it sometimes enters the blood and produces disease elsewhere, while the lungs escape. Croupous pneumonia is more common in certain years and certain seasons than in others. Its frequency in the spring months has been mentioned by physi- cians in different countries. It was common among children in April, 1890, in New York City after a mild and very rainy winter, the disease commencing suddenly with considerable elevation of temperature, and the physical signs of pneumonia being sufficient for diagnosis on the second, third, or fourth 868 LOCAL DISEASES. day. Epidemics of croupous pneumonia sometimes occur in certain localities, lasting weeks or months, and there are also certain infected houses in which new cases of this inflammation occur during many months. In the Amberg prison in 1880, 161 cases of pneumonia were treated, and in the ceiling of the dormitory in which most of the cases occurred Keller detected pneunio- cocci, cultivated them, and successfully inoculated animals with them. Bad ventilation, overcrowding, and uncleanliness favor the occurrence of pneumo- nia, and epidemics have ceased when troops were removed from crowded and infected barracks to those that were more spacious and cleaner. It is the opinion of some good observers that other microbes besides the pneumococcus may cause croupous pneumonia — that when this form of pneu- monia occurs in the common infectious diseases, as scarlet fever, pertussis, and measles, the specific microbes of these diseases enter the alveoli and excite the inflammation. Prof. Prudden, who has given much attention to the pathology of pneumonia, expresses the opinion that while the pneumo- coccus ordinarily causes croupous pneumonia, it may result from other microbes, especially when it occurs as a complication of the common microbic or infectious diseases. It is a question also whether it does not sometimes occur without the agency of microbes — especially from taking cold, in accord- ance with the popular belief — and in those rare cases in which it results from severe injuries it seems probable that the microbe is not the causal agent. Anatomical Characters. — Croupous or lobar pneumonia affects an entire lobe or even an entire lung. Its first stage is that of congestion, which is characterized by distention of the arterioles and an increased afflux of blood to the part. In the second stage, or that of red hepatization, the lung becomes more solid and resisting on palpation, and at the same time it breaks down easily on pressure. Its color is a deep red, and its section presents the appearance of granules closely aggregated. Each granule is the contents of an air-cell. The bronchial tubes connecting with the inflamed lobule contain muco-pus, fibrin, and epithelium, and the pleura covering the inflamed lobe is coated with fibrin. The substance which fills the air-vesicles and gives the torn or incised surface of the inflamed lobe its granular appearance consists of epithelial cells, pus-cells, red blood-globules, and fibrin. The blood-vessels are dis- tended with non-coagulated blood. The fibrin usually occurs in a network. The epithelial cells are abundant, and they are frequently enlarged and granular. The pus-cells are abundant ; the red corpuscles are few, or they may be so abundant that they fill some of the air-vesicles. When the second stage, or that of red hepatization, is completed, the air-vesicles are entirely filled with the inflammatory products, so that in the cadaver they cannot be inflated. The third stage, or that of gray hepatization, gradually supervenes after a few days upon the stage of red hepatization, a gray mottling first occurring ; subsequently the gray color becomes complete. In this stage the same elements remain, but the congestion diminishes, the red corpuscles lose their color, and the inflammatory products gradually undergo granular degeneration. When they are filled with granules the red color is entirely replaced by the gray. Dr. Delafield states that the inflamed lung was found in this state in one-fourth of the cases examined by him. Death occurred in these cases between the fourth and twenty-fifth days. The stage of resolu- tion succeeds in favorable cases, in which the inflammatory products soften, liquefy, and are absorbed or expectorated. The hepatized lung, instead of resolving, may undergo a change identical with or closely resembling cheesy degeneration. It becomes dry and firm and of a white cheesy color. Epi- thelium, pus, and fibrin can be detected in some of the alveoli, while in others they are replaced by a granular mass. Again, in severe cases portions of the PNEUMONIA. 869 lung may undergo necrosis in consequence of arrest of circulation. Delafield has observed in these cases the presence of a large amount of fibrin, and but little pus and epithelium. At a later stage the cavities formed contained pus. Fig. 242. fV Fig. 242 represents an air-vesiele from the lung of a patient who died forty-eight hours after the commencement of croupous pneumonia. The vesicle is only partially filled with in- flammatory products, on account of the brief duration of the inflammation. From Dela- field's Pathological Anatomy. This is a serious state, which is likely to eventuate in cheesy degeneration of the bronchial glands and tuberculosis. Septic or embolismal pneumonia sometimes occurs in infancy and child- hood, as it more frequently does in the adult, from an embolus detached from a clot which had formed in some remote vein, in consequence of arrest of cir- culation in it, by inflammation of the contiguous tissues. This is described by writers as a distinct form of pneumonia, designated embolic or embolismal. A specimen showing this mode of causation was exhibited by me at the New York Pathological Society in February, 1868. An infant, born January 22, 1868, of strumous parents had been fretful, but without appreciable ailment till February 3d, when inflammation of the connective tissue occurred on the anterior aspect of the left leg, a little below the knee. This extended downward, sup- Fig. 243. purated, and the pus was evacuated February 5th. In the mean time three other similar inflammations occurred — two on the right foot and leg, and the other over the parietes of the chest in the right inframammary re- |L "||^ &t\r gion. Suppuration occurred in all of these. |tk $M§^i t On February 8th this infant was suddenly ^, ^M\^3k '* *J seized with extreme dyspnoea, and died in a Tfe^^lHPjt^li^lB^T few hours. Numerous minute puriform col- iSf^*^*/*v Pulv. amyli, J Resorcin, gr. x. These pastes should be spread thickly on the part and covered by a many- tailed bandage of porous cloth. The pastes which become firm contain gelatin, glycerin, and zinc. Unna's is one of the best of them. It has the following formula : R. Gelatini, \ -- . Zinci oxidi, ) aa ' 3^f ' Glycerini, ^iij ; Aquse, 3 iv. — Misce. Unna usually adds 2 per cent, of ichthyol, but if this kind of medicine is required, thiol, which is the chemical equivalent of ichthyol, may be substi- tuted for it, and other antiseptics may be added if needed. These pastes are properly used upon surfaces that are dry or with little discharge. The paste is heated in a spoon or convenient vessel until it is liquid, when it has the consistence of cream. It may be applied with a stiff brush or with the side of the finger, and cotton wool daubed upon it to prevent adhesion to the clothing. If the discharge of an eczematous eruption be considerable, desiccating powders are required, as the following : DISEASES OF THE SKIN. 965 R . Zinci oxidi, 1 part ; Pulv. amyli (rice or maize), 3 parts. — Misce. R. Zinci oxidi, \ , Lycopodii, | e q uai P arts - R. Bismutlii subnitrat., 5J ; Ziiici stearat, gij. — Misce. In eczema that is extensive, and not profuse, the surgeon's lint soaked with calamine liniment (prepared calamine, 9ij ; zinci oxidi, £ss ; lime-water and olive oil, da. 5ss) makes a soothing and effectual application. When the discharge is profuse the glycerole of the subacetate of lead 1 : 10, applied warm, is one of the best applications. The ammoniated or yellow oxide of mercury, gr. 10 to 60, rubbed up with glycerin 1 ounce, is useful for scaly patches and for the scalp when the acute stage has abated. Some derma- tologists, when the inflammation has considerably abated, add a small amount of a mercurial to the soothing ointment employed, as 1 or 2 per cent, of the oleate of mercury upon localized patches. In pustular eczema iodoform or aristol is the most efficient agent for local use. From 5 to 10 grains of this added to any astringent ointment, such as zinc or lead, quickly destroy the cocci of pus, so that the eruption soon becomes serous or dry. I have obtained benefit by applying sweet oil over the pustular patches and dusting aristol over the oil. Tar is a useful remedy if applied at the right stage or in the right form of eczema. Its use is not indicated, and it may do harm, in acute eczema. It is most useful in the squamous and papular forms, effectually relieving the irritation, as in the following formula : R. Olei picis liquidse, 3 SS- 5J '■> Olei cadini, rr^v ; Ung. aquae rosse, ^ij. — Misce. Apply three or four times daily. Eczema is so common that it will aid the physician to call to mind the mode of treating different forms of it by prominent dermatologists. White of Boston and Duhring of Philadelphia employ for acute eczema the lotio nigra, either of the full strength or diluted with an equal quantity of water. It is applied with a sponge or a wad of absorbent cotton for a quarter of an hour. The black powder is allowed to remain on, and then a little zinc oint- ment is smeared over it, and this is repeated every three or four hours. Unna of Hamburg strongly recommends ichthyol, applied externally, in eczema. As an ointment or lotion of the strength of 5 to 50 per cent, it is applied on the moist obstinate patches which often occur on the hands and arms. Used in the percentage mentioned, a good vehicle for it is Unna's zinc paste mentioned above. Thiol, which has the same chemical characters as ichthyol, may be used in place of the latter, as it is less offensive. A very important part of Crocker's recent treatise on skin diseases, which two prominent New York dermatologists inform me is the best book yet published in this branch of medicine, relates to the regional treatment of eczema. His remarks on this subject I will condense, as follows: Eczema of the Head. — Cut the hair short. Soften the crusts with strips of flannel dipped in oil, and fasten them on with a calico cap for four to six hours. The crusts may then be removed. If the disease be eczema pustu- losum, gr. v of iodoform to ^j of vaseline on strips of lint should be kept on with the cap, and renewed morning and evening. The old ointment should be wiped off. In a week the eruption will be serous or dry instead 966 LOCAL DISEASES. of pustular. Oleate of zinc or lead or boracic acid, gss to ^j, should then be substituted in place of the iodoform, with perhaps later the addition of a few grains of amnioniated mercury. In eczema vesiculosum these ointments should be used at once. Where there is much irritation a few minims of the oil of cade to the ounce is a good addition, and the hairs should be extracted if there is pustular inflam- mation around them. Eczema of the Ears. — Calamine liniment (prepared calamine, 9ij ; zinci oxidi, £ss ; lime-water and olive oil, da. gss), freely applied and painted inside the meatus several times daily, gives most relief. The lactate-of-lead lotion (subacetate of lead, 33, and fresh milk, §ij), shaken well in the bottle, or the glycerole of the subacetate of lead (subacetate of lead 1 part, and glycerin 10 parts) is also a good application. Eczema of the Face. — In infants this is common. The following remedies are useful for external treatment : Lassar's paste, described above, or the lead, zinc, or boracic-acid ointment. (The lead ointment is made by boiling together equal parts of diachylon and sweet oil.) The boric-acid ointment consists of finely-powdered boric acid, gss, and benzoated lard, gj ; and Wil- son's " ung. zinci oxidi benzoat.," much employed for eczema, consists of prepared lard, ^iij ; powdered benzoin, gss. Melt together at a gentle heat for twenty-four hours in a closed vessel, strain, and add oxide of zinc, ^j. The chief difficulty is to prevent scratching, and to accomplish this almond oil should be applied under the dressing, and, if necessary, the hands secured to the sides of the patient. Eczema of the eyelids (blepharitis), common in the scrofulous, has long been successfully treated by the application of weak mercurial ointments. The crusts should be softened with oil and removed, after which 1 part of the ung. hydrarg. nitratis and 8 parts of vaseline should be smeared along the edges. In the strumous the syrup of the iodide of iron should be em- ployed. Eczema of the lips sometimes leads to fissures resulting from the frequent motion. The liq. plumbi subacetatis, tt^xv, mixed with white vaseline or lard, should be prescribed for application over the lips, or, if this be inade- quate, the following formula, recommended by Hebra, may be cautiously painted on : R. Acidi carbolici, ,^ij ; Glycerini, ") _ -. Athens, } aa ' 3J J Spts. vini recti, ^vj. — Misce. Though having the utmost confidence in Hebra's opinion, I think, on account of the highly irritating nature of carbolic acid, that it would be judicious to employ only ^ss of this agent in the above prescription for children, or not use it, but wait for the slower action of milder measures. Eczema of the Palms. — In all instances it is necessary to remove the thick epidermis. The hard and thickened skin may be rubbed by pumice- stone or fine sand-paper. Unna's plan of employing salicylic-acid plaster, applied fresh every two or three days, is good. The thickened epidermis may be peeled off in this manner. The disintegration and removal may also be produced by the constant application of a pancreatic emulsion. When the epidermis is removed salicylic acid, gr. x to lx, added to ^j of the gelatin-zinc paste, which is useful as a base, should be applied, and re- newed once in twenty -four hours. Thiol and ichthyol are also said to have a good effect in diminishing the thickness of the epidermis, but if either be DISEASES OF THE SKIN. 967 used it should be with the salicylic acid, the efficacy of which in diminishing the thickness of the epidermis is well known. Eczema of the Xails. — This disease is somewhat protracted on account of the difficulty in applying remedies around the matrix. A useful remedy is — R. Aristol, 5j; Olei oliva?, ^iij ; Lanolin, ,§j- — Misce. A good remedy also is salicylic acid, 5J, mixed with sweet oil, ]§ss, and lanolin, §j. Eczema genitalia of the scrotum, genitalia, and other contiguous parts sometimes occurs. All causes which might excite this inflammation should be removed, and calamine liniment be applied, not by rubbing, but upon sur- geon's lint soaked with it or a thin layer of absorbent cotton, which for pur- poses of cleanliness may be covered with oil-silk. Bulkley recommends applying, before the liniment is used, a handkerchief dipped in water as hot as can be borne for two or three minutes. The Pathogenic Effects of Microbes. Recent microscopic examinations have almost conclusively demonstrated the fact that various diseases presenting different clinical histories are pro- duced by the entrance of microbes into the cutaneous tissue. Impetigo Contagiosa. — This consists of discrete vesicles or pustules due to contagious pus, and occurs most frequently in children of the poor and in those who are cachectic and who live in disregard of sanitary requirements. Occurring frequently in an epidemic form, crops of vesicles appear for several days, with mild fever, the disease abating in about two weeks. In some instances this disease has no fever and no definite course, but the eruption occurs chiefly around the mouth, chin, nostrils, and occipital regions. Two or more vesicles or pustules may unite, forming one of larger size, but the discrete eruption is also present in adjacent parts. The initial stage in this disease is vesicular. The vesicles are as large as a pea or larger, but they soon become pustular, flat, and irregular. Impetigo contagiosa varies greatly in extent and severity. There may be a few distinct eruptions, or they may unite in extended patches, spreading over the body. Under such circumstances the vesicular form predominates. When the disease occurs upon the limbs, the vesicles or pustules are liable to be broken and become scabbed, and the surrounding surface forms an areola. This has been designated ecthyma, but the more typical eruption on the face shows that the eruption on the limbs is an impetigo contagiosa changed by friction. Etiology. — The theory that impetigo contagiosa is produced by conta- gious pus is now accepted by dermatologists. Scratching readily produces the transference of the contagious principle from one place to another. It appears to be most frequently and abundantly produced in the cachectic and poorly nourished. Of four hundred children with this disease observed by the late Mr. Startin, three-fourths were children under the age of seven years. Pathology. — The fact that impetigo contagiosa is undoubtedly conta- gious, as its name implies, leads to the belief that its cause is microbic. Crocker found in the liquid cautiously withdrawn from unbroken vesicles and pustules, chains of micrococci in twos and multiples of twos. They were most abundant in pustules and in the margins of epithelial cells, but not in 968 LOCAL DISEASES. the pus-cells. The liquid was withdrawn in a capillary tube and blown upon the cover-glass. E. A. Barton obtained pure cultures of staphylococcus pyogenes aureus from the fluid of unbroken vesicles, and Dubreuilh of Bor- deaux and others in independent examinations have discovered the same organism, so that the theory may be considered established that this disease is caused by the streptococcus. Diagnosis. — The absence of redness around the eruption unless it be rubbed, and the inoculability of the liquid in the vesicles or pustules, are diagnostic. Prognosis. — The disease with correct treatment will not continue more than two or three weeks, but if neglected the contagiousness of the eruption and its inoculability may cause its continuance for an indefinite time. Treatment. — The crusts should be soaked in sweet oil until they can be detached. After they are removed the following ointment should be con- stantly applied, and the cure soon results : R. Hydrarg. ammoniati, gr. x ; Cerat. simplic, ^j. — Misce. Seborrhcea. — This term, as the name indicates, is applied to an increased flow of the secretion from the sebaceous glands. The sebaceous substance undergoes some alteration in consistence in different instances, so as to form oily, waxy, or scaly concretions upon the surface. The purpose of the seba- ceous matter or sebum is to lubricate the skin, and the glands which furnish it occur upon nearly every part of the surface, except the palms of the hands and soles of the feet. Although the sebaceous glands are so numerous, it is difficult to collect sufficient sebum for microscopic examination. Lutz pub- lishes the following mean of eight analyses of this substance taken from a case of general hypertrophy of the sebaceous system : l Water 357 Oleine 270 Margarine 135 Butvric acid and butvrate of soda 3 Casein ^ * 129 Albumin . 2 Gelatin 87 Phosphate of soda and traces of phosphate of lime 7 Chloride of sodium 5 Sulphate of soda 5 Seborrhea sicca is a term applied to the waxy and scaly forms. These forms may be associated or pass into each other, and they are regarded as the chief cause of premature baldness. The oleaginous ingredients of the sebum render the skin supple and glossy. The waxy form varies according to the location and the age. The vernix caseosa of the new-born is regarded as sebum of the waxy form. In the nor- mal state the sebaceous material is abundantly secreted in infancy, and it often accumulates upon the scalp, chiefly at the vertex, where it forms a yel- lowish mass which collects dust and dirt. It is sometimes quite thick and of a caseous consistence. The skin underneath has a healthy appearance, unless it be irritated by decomposition of the oleaginous matter, when it becomes inflamed and an eczema results. The secretion which collects under a narrow and long prepuce in the male child, and around the clitoris and between the labia in the female, when proper ablution cannot be or is not performed, consists of epithelial cells and seba- 1 Flint's Physiology. DISEASES OF THE SKIN. 969 ceous matter, and its irritating property is very likely to cause inflammation, a balanitis, or a vulvitis, according to the sex. All physicians who have per- formed the simple operation of stretching the prepuce, so as to expose the glans in order to remove the irritating smegma, or have performed the more severe operation of circumcision, know how frequently a catarrhal inflamma- tion has been excited by the smegma, so as to cause a vascular adhesion of the prepuce to the glans. This inflammation is produced by the decomposing epithelial cells and smegma. The relation of the sebaceous glands and the hair-follicles is intimate. The sebaceous glands are racemose — that is, existing in distinct lobules, which discharge their contents into a common duct, and this duct opens into the hair-follicle at about the junction of its upper third with the lower two- thirds. From two to five of these racemose glands are arranged around each large follicle. The effect of the waxy form of seborrhoea when the secretion is sufficient to form a crust of a yellow, dirty appearance is to distend and plug the hair- follicles. This leads to atrophy of the hair and premature baldness. Seborrhoea furfur acea, or the scaly form, has been designated by the terms pityriasis simplex, dandruff, etc. Many, more frequently adults than children, have their scalp constantly covered with white, fine, shining crusts which are readily detached by the hair-brush, so as to alight like small flakes upon their clothes. When this form of seborrhoea occurs upon the scalp it occupies the same position as the waxy secretion, and, like the latter, may lead to baldness. The scalp underneath may be of normal appearance, but it may be red and itch or burn from more or less inflammation which has been estab- lished. In children seborrhoea furfuracea, exhibiting small shining scales, may occur over nearly the entire body and limbs. Such children exhibit often .symptoms of the strumous cachexia. Seborrhoea universalis is more rare than the local disease. One form of it is the vernix caseosa which covers the body of the new-born, and continues to be secreted until the infant is a few days old. It sometimes gives rise to tension of the skin and fissures. If the whole integument is affected, it may shine as if varnished. Fissures, painful when moved or touched, arise from the angles of the mouth, upon the joints, and in the gluteal folds. The rigidity of the mouth and nose and the pain of the fissures may render trac- tion of the nipple insufficient for the infant's nutrition. Kaposi says : " The children die in a few days from inanition and loss of heat unless relief is afforded by inunction and softening of the incrustations and by artificial maintenance of the heat of the body. This condition is correctly termed 1 ichthyosis sebacea ' or ' seborrhoea squamosa neonatorum.' " Although the skin, when the sebaceous material is removed, appears normal or slightly reddened, we find openings of the glands on close inspection, which corre- spond with the hair-follicles, into which thread-like prolongations extend. Seborrhoea of the scalp may be mistaken for any of those diseases in which scales and crusts form upon this part. Especially, it may be mistaken for eczema squamosum or impetiginosum, but in eczema the skin of the affected part is red and moist, while in seborrhoea it is white and dry. More- over, the eruption which is characteristic of the form of disease present occurs also often upon other parts. In psoriasis, for which seborrhoea may also be mistaken, the eruption always presents a well-defined patch, and the scales are abundant, larger, and more firmly attached than in seborrhoea, while the surface is very red. Psoriasis occurs not only upon the scalp, but likewise usually upon the exposed surfaces, where this eruption can be more easily differentiated. Favus and herpes tonsurans are caused by fungi which the microscope reveals, and which are never present in seborrhoea. 970 LOCAL DISEASES. Prognosis. — This is favorable in seborrhea, both in its local and general forms. Most cases with correct treatment soon improve, and can be perma- nently cured. The disease has no ill effect upon the constitution, but is sometimes painful from the rhagades and tension, and, besides the unsightly appearance which it produces, it may be complicated by eczema, comedoes, and acne upon conspicuous parts like the features. Treatment. — We have to deal with epidermis, crusts of fat, scales, and secondary deposits of morbid products. First of all, they must be softened, detached, and removed. They are softened and detached most rapidly and effectually by the fluid fats, and are then removed by the action of soap and water. For this purpose as domestic remedies butter and lard have been used, and physicians have obtained the desired result by rubbing in warm vaseline, cod-liver oil, or sweet oil. Upon the scalp, which is the most com- mon seat of seborrhoea in infants, the oil is best rubbed in by a pledget of lint, a small sponge, or a firm brush, sufficient pressure and friction being used to cause permeation of the crust, and the head is then covered by a cap of flannel or other suitable substance. In this manner the oil is applied four or five times daily, and allowed to remain on over night. Within a day or two the crusts become soft, friable, and broken, so as to be readily detached. When this occurs they are gently removed by washing. In infants attempts to remove the sebaceous matter should be performed gently, and not until the scabs are completely softened and broken ; in adults the process may be expedited by cutting the hair. When the crusts are softened and disintegrating, glycerin soap is prefer- able for cleansing the tender surface of infants, as it is less irritating than the ordinary toilet soap. In older children, as well as in adults, the following formula from Hebra is useful in cleaning the surface after it has undergone the treatment mentioned above : R. Saponis viridis, 100 grammes ; Solve leni calore in spir. vini, 200 ' ' Filtre et adde — Olei lavenduke, "I -- o a Olei bergamoti, J aa " 6 Misce. Filtra. A coarse flannel cloth or a sponge is used for making the application, with an abundance of lukewarm water. By the thorough ablution performed in this way affected parts are entirely cleaned, when they should be dried. By this mode of treating seborrhoea hairs that are held together by the crusts are often detached, and patients sometimes attribute the baldness which results to the treatment. The seborrheal process, however, caused the detachment of the hair and more or less baldness. The skin when cleaned by the method described appears red, but the redness fades under proper treatment, and the unpleasant sensation, fissures of the thin corium, and reproduction of the sebaceous deposits are prevented by applying oily substances. Kaposi recommends the following after the skin has lost its tenderness and the corium has regained its thickness. The application must be made for several weeks to the scalp of spiritus vini gallici r either used pure or in the following formula : R. Acidi carbolici, 0.15; Acidi borici, 3.00 ; or Acidi salicylici, 3.00 ; Spts. vini gallici, qs. ad 100.00. — Misce. Inasmuch as the treatment of the corium by soap and alcohol tends to DISEASES OF THE SKIN. 971 render it brittle, it is befst in the subsequent treatment to apply some bland oil or fat for weeks or perhaps months. General seborrhoea must be treated in the same manner as local forms of it, allowance being made for the age. The cutis testacea (ichthyosis sebacea neonatorum) requires vigorous rubbing of the surface with sweet oil, or the application of cloths soaked with a bland ointment and applied over the face, limbs, body, fingers, and toes, and retained by a flannel binder. The infant is kept in an incubator or in a poor conductor of heat, as down or flannel. It should be washed daily in a warm bath with glycerin soap, after which the oil is applied. Parasites of the Skin. A complete treatise on diseases of the cutaneous system requires the description of a considerable number of vegetable and animal parasites which grow upon or burrow in the skin. It is our purpose to describe only such as occur most frequently in America. The parasitic diseases are observed chiefly among the filthy who seldom bathe or change their clothes. The most common of these diseases is — Scabies, or the Itch. — This is contagious by contact or transference. It is caused by a minute animal parasite, and its chief lesions are the burrows produced by the female in order to deposit her eggs, and such injuries as result from the scratching due to the intense itching incident to the burrow- ing. The itch-mite, or acarus scabiei, consists of the male and female, and the symptoms and lesions are mainly due to the latter, which when removed from its burrow is barely visible to the naked eye as a minute yellowish- white hemispherical body. Viewed under the microscope, it is seen to be crab-like, with legs and a proboscis ; the rounded body has wavy transverse furrows, so that the parts move over each other with facility. From obser- vations made by Eichstedt, Guddens, and others, the female has been found within half an hour after being placed upon the skin to have concealed her- self in the epidermis, and the burrow which she constructs is arched, tortuous, and four or five lines in length. The young acarus has six, the mature eight, articulated legs, with suckers upon the two anterior pairs and hairs on the posterior. The head, which can be elongated or retracted, is provided with two jaws. The upper surface is covered with spines directed backward so as to prevent retrogression in the burrow. She leaves behind her in the cunic- ulus, as she advances, her moulted skin, excreta, and eggs, which hatch on the eleventh day. The mother-acarus is always found at the remote end of the burrow, where it can be seen by the unassisted eye as a minute whitish or sometimes brownish speck, and from which it can be lifted by the point of a needle, to which it clings. The cuniculi can also be seen by the naked eye, looking, says Niemeyer, like the " scars of needle-scratches." and con- taining the young acari in various stages of growth. The acarus by its burrowing produces an irritation and troublesome itch- ing, which is the chief cause of the suffering of the patient. At the point where the acarus penetrates the cuticle the inflammation gives rise to a single, small, and acuminate vesicular or papular eruption, the cuniculus extending away from it. We often find ecthymatous pustules and abrasions intermin- gled with the vesicles, the result of frequent scratching. The itching is most intense and the acarus most active at night, when the patient is warm in bed. Scabies most frequently appears, especially in adults, first upon the hands, between the fingers, where the skin is thin, and it extends thence along the forearm and over the thighs and abdomen. In children it not infrequently occurs upon the buttocks, thighs, feet, etc., while the hands and forearms escape. 972 LOCAL DISEASES. Fig. 269. Fig. 270. Fig. 269. The itch animalcule, Acarus scabiei, viewed upon the back, showing its figure and the arrangement of its spines and filaments. The female, which is somewhat larger than the male, has a length of one-eightieth to one-sixtieth of an inch. Fig. 270. The foot and last joints of the leg of the itch animalcule. Fig. 271. Ova of the itch animalcule. Fig. 272. The male itch animalcule, viewed upon the under surface, showing its legs and lobuiated feet. Fig. 273. Burrow of the female acarus (after Kaposi). Diagnosis. — Correct diagnosis is important, because the treatment required is different from that in any other exanthem, and because the DISEASES OF THE SKIN. 973 suspicion of having this disease always renders one solicitous to know the exact nature of the eruption. Scabies can be diagnosticated from those dis- eases for which it may be mistaken by the following characters : its occur- rence where the cuticle is thin and delicate, as between the fingers, along the anterior aspect of the forearm, upon the abdomen, thighs, and inside of the feet : small size, acuminate shape, and isolated position of vesicles ; the inter- mingling with the vesicles of other forms of eruption, as papules and pustules, and the presence of linear scars and abrasions produced by the scratching ; itching most intense at night ; absence of fever ; absence of the disease from posterior aspect of body and arms and from head and face. Scabies may be distinguished by the vesicular character of the eruption from all other exan- thematic affections except eczema, sudamina, and herpes. Eczema is most common on the scalp and face, where scabies does not occur, and unlike scabies its vesicles are round and thickly aggregated in clusters ; in eczema there is a smarting or prickling sensation very different from the intense itch- ing of scabies. In herpes the vesicles are large, rounded, and in clusters, and attended by a burning or prickling sensation, with but little itching. The eruption in sudamina is vesicular and discrete, as in scabies, but it is globular and accompanied by no itching or other local symptoms. Treatment. — As scabies is due to a species of acarus which burrows in the epidermis, it can only be treated successfully by measures which destroy this animalcule. If it be destroyed, the disease gets well of itself. Sulphur has been employed for a long period for this purpose, since sulphurous acid, which is evolved from the sulphur, is destructive to the animalcule. The unguentum sulphuris, if thoroughly applied, will rarely fail to eradicate sca- bies. The internal use of sulphur aids the external treatment, since a portion of the gas which is generated escapes through the pores of the skin. The chief objection to the employment of sulphur is its exceedingly unpleasant odor, which is noticeable, however disguised by perfume. Sulphur or any other substance employed externally has more effect if it be preceded by a bath, which softens the epidermis, and therefore favors the entrance of the remedy into the pores of the skin and the cuniculi. Helmerich's ointment is very effectual in the treatment of scabies. It consists of two parts of sulphur, one of carbonate of potassium, and eight of lard. " M. Hardy afterward perfected the method, so as radically to cure the disease in two hours. He proceeded in the following manner : The patient first undergoes a friction of his whole body for half an hour with soft soap, in order to cleanse the skin and break up the burrows ; a warm bath of an hour's duration follows, during which the skin is thoroughly rubbed, in order to complete the destruction of the burrows ; after which frictions for half an hour and upon the whole surface are practised with Helmerich's ointment. This completes the cure. Out of 400 patients subjected to this treatment only 4 returned to the hospital." l M. Albin Gras experimented with different substances in order to ascer- tain their relative destructiveness to the acarus. The following table gives some of the results of his experiments : Immersed in pure water, the acarus was alive after three hours. saline water, the acarus moved freely after three hours. Goulard' s solution, the acarus lived after one hour, olive, almond, or castor oil, the acarus lived more than two hours, lime-water, the acarus died in three-fourths of an hour, vinegar, " twenty minutes, alcohol, " turpentine, " " nine " iodide of potassium, the acarus died in four to six minutes. 1 Stille's Therapeutics, etc., vol. ii. p. 561. 974 LOCAL DISEASES. It is seen that vinegar, lime-water, alcohol, turpentine, and iodide of potassium destroy the acarus in a short time. They may be employed in the same manner as the sulphur ointment. Camphor is also destructive to this animalcule, and the linimentum camphorse, thoroughly applied, is a good remedy for uncomplicated scabies. In order to avoid the odor of sulphur, which is so offensive, one of the following ointments may be employed if the patient be fastidious: R. Unguent, hydrarg. ammoniat. , ^j ; Moschi, gr. ij ; 01. lavendul., gtt. ij ; 01. amygdal., 3j. — Misce. 1 If scabies be extensive, this should not be used, as its application over a considerable area might endanger salivation, but the following, which is rec- ommended by Bazin, and is said to cure the disease with three applications, may be used instead : R. Anthemis pulv., Adipis, 01. olivse, da. ^j. — Misce. In cases which have been protracted, and in which ecthymatous and other secondary eruption have occurred, the scabies can ordinarily be readily cured, while the other eruptions remain and disappear more slowly. A knowledge of this is important, since the sulphur or other ointment employed for the cure of scabies should be discontinued when the itching ceases and vesicles no longer appear, and tonic or other treatment appropriate to cure these secondary eruptions should be employed instead. The sulphur ointment continued after the scabies is cured does harm, since it irritates the cuticle. It is essential in the treatment of scabies that the linen be frequently changed. Pediculosis. — The pediculi, or, in common parlance, lice, " are wingless insects without metamorphosis, with two simple small eyes. They first bite into the skin with their mandibles, and then insert the head into the wound in order to suck " (Kaposi). Three varieties of these insects inhabit the sur- face of man. The one abides upon the scalp, the second in the vestments, and the third upon the pubes. Hence the classification — 1. The pediculus capitis ; 2. The pediculus vestimenti ; 3. The pediculus pubis. The piercing of the skin with the mandibles, the suction of the blood and serum, and the formation of crusts or wheals cause intense itching with scratching. Hence result excoriations, vesicles, papules, furuncles, abscesses, crusts, which produce a resemblance to certain other eruptive diseases, but which are chiefly due to the intense itching and unavoidable scratching. The lesions of course vary according to the number and variety of the pediculi and the duration of the disease. The three varieties of pediculi seldom wander from the regions which they primarily occupy. The first variety rarely pass beyond the scalp ; the second variety occupy the folds of the vestments, to which they suddenly retreat when the garments are disturbed ; and the third variety seldom leave the pubic region. The pediculus capitis has the length of two millimetres, and is of a gray color ; its head and limbs are thicker and chest broader than are those of the pediculus vestimenti. 1 From Wilson. DISEASES OF THE SKIN. 975 Treatment. — In the treatment of pediculosis capitis the use of petro- leum according to the following formula will be found safe and effectual : R. Petrolei, 100 parts ; 01. oliva?, 50 " BaJs. Peru, 20 " Rub freely into the hair. If there be moderate eczema, naphthol oil, 5 per cent., may then be applied, and the head wrapped in flannel. In twenty -four hours the lice are dead, and the nits, which are attached to the hairs at different distances, are incapable of growth. The scalp is then washed with the spiritus saponatus kalinus. prepared according to the following formula of Hebra : R. Saponis viridis, 100 grammes ; Solve leni calore in spir. vini, 200 " Filtra et adde — Olei lavendulae, 01 ei bergamoti, da. 3 " The eczematous crusts which occur from the irritation and scratching in pediculosis are softened and broken up by this treatment. Daily oiling and washing the surface complete the cure. The treatment of pediculosis corporis by a complete change of clothing and a bath of the entire surface with soap and water speedily cures the dis- ease, since the insect which causes this form of pediculosis lives in the vest- ments. Of course the worn clothes should be burnt. Pediculosis pubis is cured by applications which destroy the insect, among which we may mention 1 part of corrosive sublimate to 250 of water, and by naphthol, as well as by petroleum. The nits are destroyed by carbolic acid, 1 part to 50 of water. FORMULARY. Within the last few years the investigations of dermatologists have revealed the important causal relation of bacteria to the cutaneous diseases. Unna believes that eczema, which is probably the most common cutaneous malady of early life, is parasitic, " due to some micrococcus not yet deter- mined," and he adduces the success of antiseptic local treatment as a proof of this theory. Crocker says : ' c My own view is this : that while a limited number of local skin diseases are parasitic, in most the dermatitis, however caused, only opens the door to parasites, whose presence keeps up local irri- tation, and that their destruction is an important step in the restoration of the skin ad integrum." Again Crocker writes : " . . . . Micrococci are so ubiquitous that their invariable presence may be demonstrated in any par- ticular disease ' : of the skin. Hence germicides are regarded as important agents in the initial treatment, as well as during the progress of those mal- adies in which the cuticle is so injured by disease that it no longer prevents the invasion of microbes. The lotio nigra is one of the best, if not the best, germicide wash employed for this purpose. 1 drachm of calomel is mixed with 1 pint of lime-water, and by double decomposition the very active and safe germicide calcium chloride and the oxide of mercury are produced. The former is the anti- septic required. By the judicious use of this remedy, followed by an oint- ment like Lassar's, many of the acute eczemas rapidly yield. The following formulae, most of which have been obtained from Crocker's and Kaposi's recent treatises, will be found useful to the practitioner : 976 LOCAL DISEASES. Baths. 1. Cold, 40°- 65° Fahr. 2. Cool, 65°- 75° " 3. Tepid, 85°- 95° " 4. Warm, 95°-100° " Lotions. 5. R. Hyd. chlor. corros., g r - ij ; Tine, benzoin., 3 ss ; Misturae amygdalae, %— M. For freckles (Duhring). 6. R. Hyd. chlor. corros., gr. vj ; Acidi aceti dilut., 3ij ; Sodii borat., 9ij ; Aquae rosae, 5iv.— M. For freckles (Bulkley ) . Apply twice daily 7. R. Corrosive sublimate, gr. iv ; Dilute nitric acid, 3J; 3J ; Dilute hydrocyanic acid. Glycerin, |;viij. — M. For syphilitic eruptions, pityriasis versic- olor, chloasma, freckles (Startin )• Soft Soap. 8. R . Oil of cade, ] Soft soap, V da gss; Alcohol, J Olive oil, Ijss; Oil of lavender, 3Jss. — M. For chronic eczema, psoriasis of the scalp or knee. 9. R. Soft soap or green soap, alcohol, equal parts. — M. To remove scales of psoriasis and sebor- rhoea. Sulphur. 10. E. Sulphur precipitat, Alcohol, For acne. 11. R. Sulphur, "1 Alcohol, Ether, Glycerin, Carb. potash, Rose-water, For acne, or, without the water, rubbed in, for comedones. 12. R. Potassium sulphuret, £ss ; Lime-water, 3 x vj. — M. For pustular and parasitic diseases and pityriasis versicolor. 13. R. Sulphuris loti, 3J ; iEtheris, f £>iv ; Alcoholis, f^iijss.— M. Shake bottle, and apply with a swab of cotton every three or four hours. For acne I have used this with a good result. 14. R. Lime-water, Olive or linseed oil, ad. — M. For burns and superficial inflammations of skin. da. £j.— M. da. ^ij ; ^viij.— M. 15. R. Prepared calamine, ^ij ; Zinci oxidi, ^ss ; Lime-water, olive oil, da. ^ss. — M. For eczema and acute dermatitis. The parts are wrapped with this lotion. 16. R. Menthol, chloral, camphor, equal parts. Triturated to liquefaction. Apply for pruritus and superficial pains. 17. Tar. The liquor carbonis detergens has recently come into use as an eligible preparation for certain skin diseases. It is designated in one of the books as an alcoholic solution of coal- tar. The following formulae are used for chronic eczema and pruritus : 18. R. Liq. carb. detergentis, f ^ss ; Acidi nitrici dilut., gj ; Aquae camphorae, ad ^viij. — M. 19. R . Liq. carb. detergentis, ^j-ij ; Liq. plumbi subacetatis, <5J-ij ; Aquae rosae, ,§ viij. — M. 20. Liq. carbonis detergentis, diluted, 1 part to 40 or 80 of spirit or water. — M. 21. R . Ung. picis (B. P.). 22. R. (a) Creosote, "] gj or more of (b) Olei cadini, I either to ^j (c) 01. rusci, J of lard.— M. Useful in psoriasis and chronic inflam- mations. Astringent Lotions. 23. Collodion (non-flexible). It acts by mechanical compression, and is useful when such is required, as in acne rosacea, lupus erythematosus, and in small naevi. 24. Tincture of hamamelis, 1 part to 4 of water. For dilated capillaries. 25. R. Tannic acid, gr. xl ; French vinegar, ,^ss ; Water, ,^vij. — M. For seborrhcea and hyperidrosis. 26. R. Boric acid, a saturated solution. For eczema and erythema. Stimulants for the Scalp, or Hair Lotions. The following formulae are given for children of half the strength which is recommended by distinguished dermatol- ogists for adults : 27. R. Tine, of cantharides, 5ss; 28. For seborrhoea capitis and alopecia. Distilled vinegar, .^iijss ; Rose-water, ad §viij— M . Hyd. chlor. corros., gr. ij ; Ammon. chloridi, gr. x; Resorcin, gr. xx ; Eau de Cologne, Eiy, Glycerin, &y, Aquae rosae, to Oj.— M. FORMULARY. 977 Sedative Astringent Lotions. Zinc or Calamine Lotion, Prepared as follows : 29. R. Powdered calamine (the na- tive carbonate of zinc), ^ij ; Oxide of zinc, £ss ; Glycerin, w\,xv ; Eose- water, 5 j . — M. For erythema and eczema when little or no discharge, and for active hyperaemic states. Bismuth Lotion. 30. R • Bismuth, subnitrat. , gr. viij I Oxide of zinc, gss ; Glycerin, ^^vj ; Hydrarg. chlor. corros., gr. J ; Eose- water, ^ j . — M. For acne rosacea and other hyperaemic states. Lead Lotion. 31. R. Solution of subacetate of lead, ir b v-xx ; Glvcerin, Ti\,xv ; Water, gj — M. For erythema, eczema, and excoriations. Sedative Astringent Ointments. Boric Acid. 32. R. Boric acid, ^ss ; Benzoated lard, Jj. — M. The boric acid should be ground into an impalpable powder before the admixture. Used in eczema and as an antiseptic in wounds and excoriations. Lead. 33. R. Carbonate of lead, gr. iv ; Glycerin, 3j ; Simple ointment, Jj. — M. For erythema. Zinc. Wilson' s benzoated zinc ointment, a well- known remedy for eczema, is prepared as follows : 34. R. Lard, ^vj ; Powdered benzoin, gj. — M. Melt together for twenty-four hours at a gentle heat in a closed vessel, and then strain and add oxide of zinc ^j. Stir till cool and strain. Antiseptic Ointments. 35. R. Iodoform, gr. iij-v ; Vaselin or lard, ^j. — M. To cover the unpleasant odor of iodo- form, creolin n^v to 5J may be added. 36. R. Aristol, gr. iij-v ; Vaselin or lard, §j.— M. Aristol, used in powder, is also very effectual in curing sores and the surround- ing inflamed tissue. 62 Mercury. 37. R. Ammoniated mercury, gr. x ; Lard, fj.— M. A specific for impetigo contagiosa after the crusts are broken. Sulphur. 38. R. Iodide of sulphur, gr. x to 3ss, added to lard, 5J. — M. For acne. Antipruritic Lotions. 39. R. Borax, Glycerin, Water, Use in urticaria seborrhoea. £ss; Oij.- and as a -M. head-wash in 40. R. Borax, Carbonate of ammo- nia, da. 3iss ; Glycerin, Jj ; Hydrocyanic acid, dilute, sjiij ; Water, S vn j- — M. Use diluted one to four times. For vesicular diseases and seborrhoea. 41. R. Acidi carbolici, £j ; Tinct. camphorae, Jij ; Aquae, Oj.— M. An excellent application to the surface in pruritus of any kind, provided that the skin be not broken. 42. R. Terebene, |j ; Water, ,^viij. — M. For pruritus and urticaria. 43. R. Salicylic acid, ^ij ; Borax, gj • Glycerin, q. s. for 3J. — M. Mix the acid and borax with ^iv of gly- cerin. Heat gently until dissolved : then add glycerin to make ^j. This can be di- luted with glycerin, alcohol, or water to any extent. ^j of the first mixture, .^j alcohol, and water to ^viij make a good proportion for pruritus and urticaria. 44. R. Menthol, gr. ij ; Water, §j.— - M. For same. 45. R. Subacetate of lead, Water, For same. 46. R. Benzoic acid, Water, For same. Ml ; 5viij.— M. p; Sviij.— M. Pastes. Unna's Gelatin Paste. 47. R. Oxide of zinc, Glycerin, ^iij ; Gelatin, da. £i^s : Distilled water, 5jiv. — M. 978 LOCAL DISEASES. To this, as a base, 5 to 10 gr. of an anti- septic, as salicylic acid, resorcin, aristol, or ichthyol, or the chemical equivalent of the latter — namely, thiol — may be added. At the ordinary temperature it is elastic like rubber, and must be melted by sufficient heat before its application. When applied it should be dabbed with a light layer of wool to prevent adhesion to the clothes. This is known as Unna's paste, and is much used in subacute and chronic eczema and whenever the discharge is slight or absent. It is not adapted for parts covered with hair or for use in hot weather unless it be covered by the light wool mentioned above. 48. Lassar 1 s is another paste largely used. It has the following composition : R. Zinc oxide and pow- dered starch, ad. ,^ij ; Vaselin, Jss ; Salicylic acid, gr. x. — M. Used for eczemas and other inflamma- tions, whether moist or dry, if the dis- charge be moderate. It should be spread thickly on, and be covered with cheese- cloth. If the inflammation be acute, it is better to leave out the salicylic acid for a time. For Animal Parasites. 49. R. Ung. sulphuris, B. P. For the vegetable parasitic eruptions and scabies. 50. Wilson's Formula : R. Sulphur, gss; Carbonate of potash, gj ; Benzoated lard, ^ijss ; Oil of chamomile, Tt\,xv. — M. 51. Wilkinson's Formula: R. Sulphur, ^ Tar, V da. %j; Lard, J Precipitated chalk, ^ss ; Sulphide of ammo- nium, Ttlxv. — M. For tinea tonsurans and scabies. Kaposi recommends the following oint- ment: 52. R. Naphthol, 15 parts ; Prepared chalk, 10 " Lard, 100 " Soft soap, 50 " — M. 53. R. Iodide of sulphur, Iodide of potas- sium, da. gjss ; Water, Ixxx. — M. INDEX TO FORMULARY. Acne, Nos. 10, 11, 13, 38. Acne rosacea, 23, 30. Alopecia, 27, 28. Antiseptics, 32, 35, 36. Burns, 14, 48. Capillaries, dilatation of, 24. Chloasma, 7. Comedones, 11. Dermatitis, 15. Eczema, 8, 15, 16, 17, 18, 19, 20, 21, 22, 26, 29, 31, 32, 34, 47, 48. Erythema, 26, 29, 33. Excoriations, 31, 32. Freckles, 5, 6, 7. Hyperemia, 1, 2, 3, 4, 29, 30. Hyperidrosis, Nos. 25. Impetigo contagiosa, 37. Lupus erythematosus, 23. Nsevus, 23. Parasiticides, 12, 49, 50, 51, 52, 53. Pityriasis versicolor, 7, 12. Pruritus, 16, 17, 18, 19, 20, 39, 40, 41, 42, 43, 44, 45, 46. Psoriasis, 8, 9, 22. Scabies, 49, 50, 51, 52, 53. Seborrhea, 9, 25, 27, 28, 39, 40. Syphilis, 7. Tinea tonsurans, 51. Urticaria, 16, 39, 42, 43, 44, 45, 46. Wounds, 32. INDEX. Abnormalities in circulatory system, con- genital, 89 Acrania, 81 Adenoid vegetations, 700 Alveola, 697 Anaemia, simple or secondary, 507 etiology, symptoms, diagnosis, 509 treatment, 510 Primary, 511 etiology, morbid anatomy, 511 symptoms, diagnosis, treatment, 512 Lymphatic, 512 etiology, morbid anatomy, 512 symptoms, diagnosis, prognosis, treat- ment, 513 Splenic, 513 etiologv, morbid anatomy, svmptoms, 513 diagnosis, prognosis, treatment, 514 Pernicious, 514 Idiopathic, 514 morbid anatomy, symptoms, etiology, treatment, 514 Aneurysm of arteries, 923 Angeioma, 482 Animal heat in infancy, 75 Ankle-joint, diseases of, 569 Anus, absence of, imperforate, 488 Appendicitis, 799 etiology, anatomical character, 799, 800 symptoms, 800-802 diagnosis, 802 prognosis, 803 treatment, 804 Arthritis, acute suppurative, 551 treatment, 552 Artificial feeding, 53-57 Atelectasis, 861 Acquired, 861 symptoms, 862 anatomical characters, 862 treatment, 863, 864 Atresia oris, 476 Attitude of infant, 72 B. Bathing of infant, 65 Bladder, extroversion of, 489 Bones, injuries of, 530 long bones, 530, 531 diagnosis, treatment, 531-533 clavicle, 533 humerus, 534 Bones, injuries of, ulna, radius, epiphysis, femur, 535 condyles, 537 tibia* fibula, 538 Inflammations of, 538 etiology, 538 periostitis, 539 symptoms, 539, 540 treatment, 540, 541 chronic, 542 syphilitic, 542 epiphysitis, acute, 542 causes, symptoms, treatment, 542,543 osteomyelitis, acute (diaphysitis), 543 treatment, 548 chronic diffuse, 548 symptoms, progress, 548 treatment, 549 Tuberculosis of, 549 diagnosis, prognosis, treatment, 550 Arthritis, acute, suppurative, 551 Bowleg, 496 Brain, congestion of, 578 causes, 578 symptoms, 579 anatomical characters, 580, 581 Brain, incomplete, 83 Burns, scalds, 829 Bronchitis, 851 causes, anatomical characters, 851-853 symptoms, 854 duration, 855 diagnosis, prognosis, 856 treatment, 857 of mild bronchitis, 857 of bronchitis affecting the tubes, 857, 858 internal, 859, 860 C. Calculus in genito-urinary organs, 935 urinary, 941 Caput succedaneum, 99 Caries, vertebral, 519 prognosis 520 treatment, 521 . Spinal abscesses, 524 Catarrh, intestinal, of infancy, 730 etiology, 731 age, dentition, 736 symptoms, 736-739 anatomical, 739 diagnosis, prognosis, 743 979 980 INDEX. Catarrhal laryngitis, 820 Cephalhematoma, 100 Cerebral hemorrhage, 584 Cerebro-spinal fever, 421 history, 421 etiology, 423 contagiousness, 424 secondary, sex, age, 427, 428 mode of commencement, 430 nervous system, 431 digestive system, 435 •pulse, temperature, 437 respiratory system, 438 cutaneous surface, 438, 439 urinary organs, 439 special senses, 440 symptoms of endemic, 441 prognosis, diagnosis, 446, 447 treatment, 448 curative, 449 internal, 452-455 Cerebro-spinal system, disease of, 576 Chicken-pox, 326 Childhood, 17 anatomy, physiology, 17, 18 Cholera infantum, 743 anatomical characters, 744 diagnosis, prognosis, treatment, 747 treatment medicinal, 749 antiseptic, 749 irrigation of stomach, 749, 750 alkalies, astringents, 750 stimulants, 750 Chorea, ansemia, 653 rheumatism, 653 fright, irritation, 656 intestinal irritation, 657 lesions of brain, 657 anatomical characters, 658 symptoms, 659 prognosis, course, 660 diagnosis, 661 treatment, medicinal, 661, 662 Circulatory system, abnormalities of, 89 Circumcision, 944 Clavicle, injuries of, 533 Clothing of infants, 66 Club-foot, hollow (pes cavus), 502 Colitis, 752 Colostrum, 32 Condyles, fracture of, 537 Congestion of the stomach, 719 Conjunctivitis of newly-born, 102 mild or catarrhal, 103 Constipation, 754 symptomatic, causes, 754 idiopathic, causes, 756 treatment, 760 hygienic measures, 761 therapeutic measures, 762 of newly-born, 130 symptoms, treatment, 131, 132 Coryza, anatomical characters, 818 symptoms, prognosis, treatment, 819 Cow's milk, diseases communicated by, 57 Craniotabes, 170 Cretinism, 469 diagnosis, 471 treatment, 473 Croup, pseudo-membranous, or true croup, 831 etiology, 831, 832 anatomical characters, 833, 834 symptoms, diagnosis, 834, 835 prognosis, 836 treatment, preventive, 837, 838 surgical, 838, 839 Cryptorchia, 935 Curvatures, lateral, of spine, 525 Cyanosis, 89-99 D. Dactylitis, strumous, 190 syphilitica, 237 Deformities, 476 Dentigerous cysts, 697 Dentition, 691 pathological results of, 691 diagnosis, 693 treatment, 694 Second, 695 Eanula, 696 Tonsils, abscesses of, 698 Chronic inflammation of tonsils, 698 symptoms, 698 Tonsillitis, recurrent, 699 treatment, 700 Adenoid vegetations, 700 treatment, 701 Diaphysitis, 543 Diarrhoea of the newly-born, 128 simple, 726 causes, 726 symptoms, anatomical characters, 727 prognosis, treatment, 728 choleriform, 743 Digestive apparatus, diseases of, 680 Stomatitis, simple or catarrhal 680 ulcerous, 681 aphthous, 683 Gangrene of the mouth, 684 Dentition, 691 alveola, 697 Dilatation of stomach, 723 Diarrhoea, 726 system in infancy, 78 Digits, supernumerarv, 490 Union of, 491 Flexion of phalangeal joints, 492 Dilatation of the stomach, 723 Diphtheria, 328 etiologv, 331 Klebs-Loeffier bacillus, 832 pseudo-diphtheria, 333 mixed infection, 334 age, 334-345 incubative period, 336 modes of propagation, 337 contracted from animals, 338 INDEX. 981 Diphtheria, diagnosis, 340 anatomical characters, 342 blood, brain and spinal cord, 344 tonsils, lungs, 345 lymphatic glands, heart, 346 mouth, stomach, intestines, 347 spleen, liver, kidneys, 347 symptoms, 348 temperature, 349 nares and eye, 350 ear, 351 albuminuria, 351 paralysis, 354 clinical history, 355 time of commencement, 356 loss of tendon-refiexes, 357 palatal paralysis, 357, 358 multiple paralysis, 359 cardiac paralysis, 359-363 its cause, 363 prognosis, 365 treatment, preventive, 366 hygienic, 368 stimulants, quinia, 370 tinctura ferri chloridi, 371 potassium chlorate, 372 hvdrargvri chloridum corrosivum, "373 hvdrargyri perchloridum (Br. "Phar.), 373 calomel, 374 trypsin, papoid, 374 peroxyde of hydrogen, 375 Diseases, local, of newly-born, 101 Hsematoma of the sterno-cleido- mastoid muscle, 101 Mastitis, 102 Conjunctivitis, 102 mild or catarrhal, 103 Ophthalmia neonatorum, puru- lent, 103 Gonorrheal, 103-108 Umbilical vegetations, 108 hemorrhage, 109 Icterus, 112 Septicemia of new-born, 115 first group, 115-119 second group, 119-122 third group, 122, 123 Thrush, 123 Dysuria, 935 E. Eclampsia, 614 causes, 615 premonitory stage, symptoms, 616 partial, 617 anatomical characters, 618 diagnosis, prognosis, symptoms, 619 treatment, 620 Eczema, 956-967 Elbow, disease of, 555 Encephalocele, 83-85 Endocarditis, 917 Enteritis, 752 Entero-colitis, 730 Epilepsy, 622 etiology, predisposing causes, 622 age, exciting causes, 622 mental emotion, traumatism, 623 symptoms, 623 attacks, minor and major, 624 anatomical characters, 627 pathology, 628 diagnosis, 629 prognosis, 630 treatment, 630-634 Epiphysis, injury of, 535 Epiphysitis, acute, 542 Erysipelas, 463 age, point of commencement, 464 causes, 465 premonitory symptoms, 466 symptoms, 466 prognosis, duration, modes of death, 467 pathological anatomy, prophylaxis, modes of treatment, 467-469 Erythema, or rose-rash, 952 Exercise of infant, 68, 69 F. Feeding, infantile, 47 over-feeding, 47 insufficient, 48 artificial, 53-57 Feet, distortions of, 497 Femur, injury of, 535 treatment, 535-537 Fever, scarlet, 250 Intermittent, 399 Remittent, 405 Typhoid, 407 Cerebro-spinal, 421 Growing, 543 Foot, amputation of, 575 G. Gangrene of the mouth, 684 anatomical characters, 684 age, causes, 685 symptoms, diagnosis, 686 prognosis, treatment, 687, 688 efflorescence, furring, and erup- tion upon tongue, 690 Gastritis, 719 cause, age, 720 symptoms, anatomical characters, 721 Follicular, 722 Diphtheritic, 723 Gastro-intestinal bacteria, 723 Genito-urinary organs, diseases of, 927 nerves in, 928 etiology, 929 prognosis, treatment, 931-935 Calculi, dysuria, cryptorchia, 935 Vulvitis, 936 Preputial dilatation, 937 Kidnev, abscess of (pvonephrosis), 938" Perinephric abscess, 938 982 INDEX. Genitourinary organs, diseases of, ^Nephrectomy, 940 Urinary bladder, 940, 941 calculi, 941, 942 Urethra, wounds of, 942 Penis, 944 Scrotum, 947 Testicles, tubercles of, 947 sarcoma of, 947, 948 German measles, 298 Glottis, spasm of, 634 Growing fever, 543 Growth of infant, 26 Hsematoma of sterno-cleido-mastoid mus- cle, 101 Haemophilia, etiology, anatomical appear- ance, diagnosis, prognosis, treat- ment, 515 Hare-lip, 476 Heart, diseases of, 912 position in childhood, 912 functional disorders, diagnosis, prog- nosis, 912 treatment, 912, 913 Pericarditis, 913 Myocarditis, 916 Endocarditis, 917 ulcerative, 919 chronic, 920 Hemorrhage, intracranial, 581 cerebral, 584 meningeal, 587 Hernia of the abdomen, 809 inguinal, 809, 810 symptoms, 811 femoral, 811 umbilical, 811 treatment, 812-814 strangulated, 814 umbilical, 817 Hip-joint, diseases of, 558 Hodgkin's disease, 512 Human milk, 33 Humerus, injuries of, 534 Hydrencephalocele, 83-85 Hydrocephalus, congenital, 589 anatomical characters, 589 etiology, symptoms, 592 diagnosis, prognosis, 593 treatment, 594 acquired, 595 causes, anatomical characters, 595 symptoms, treatment, 596 spurious, 611 anatomical characters, symptoms, 612 diagnosis, prognosis, 613 treatment, 614 Icterus neonatorum, 112 treatment, 115 Impetigo contagiosa, 967 Incubator, the, 76, 77 Indigestion, 714 symptoms, 715 prognosis, diagnosis, 716 treatment, 717 Infancy, attitude, movements, voice, 72 Respiratory system in health, 73 in disease, 73, 74 Circulatory system, 74 Pulse in health, 74 in disease, 75 Animal heat, 75 Digestive system in, 78 Nervous system in, 79 Therapeutics in, 80, 81 Infant, care of, bathing, 65 clothing, sleep, 6Q, 67 exercise, 68, 69 Infantile feeding, 47 diseases, diagnosis, 70 general observations, features, 70, 71 appearance of head, trunk, limbs, 71 Intestinal catarrh of infancy, 730 Intermittent fever, 399 etiology, 400 symptoms, 402 treatment, 404 Intracranial hemorrhage, causes, 581 anatomical characters, 582 Intubation, 839 indications for, method of operating, 842 difficulties of operator, 844 accidents and dangers of, 845 asphyxia, 846 extraction, 846 time of removal of tube, 846 management after intubation, 847, 848 Intussusception, 779 without symptoms, 779, 780 with symptoms, 780 previous health, causes, 780 seat, pathological anatomy, 781 in small intestines, 784 in large intestines, 782 symptoms, 787 diagnosis, 788 duration, prognosis, 789 J. Joints, diseases of, 552 Synovitis, acute, serous, 552 treatment, 552 suppurative, 553 Tubercular affections of, 553 cause, diagnosis, 553 prognosis, treatment, 554 Shoulder-joint, inflammation, 554 simple, acute, treatment, 554 tubercular, treatment, 554, 555 Elbow-joint, 555 Wrist-joint, 556 tubercular form, 556 treatment, 557 Hip-joint, synovitis, simple and acute, treatment, 558 IXDEX. 983 Joints, diseases of, Hip-joint, tubercular, 558, 559 symptoms, diagnosis, treatment, 559-567 Knee-joint, 567 synovitis, acute, 567 chronic, treatment, 567 tubercular disease of, 568 progress, symptoms, prognosis, 568 treatment, 568, 569 Ankle-joint, synovitis of, 569 treatment, 569, 570 tubercular disease of, 570 treatment, 570-573 Tarsus, synovitis of tarsal joints, treatment, 573 tubercular disease of tarsal joints, 573 symptoms, treatment, 573-575 K. Keratitis, Herpetic or phlyctenular, 198 duration, prognosis, 199 treatment, 200 Parenchymatous or diffuse, 201 treatment, 201, 202 Kidney, abscess of, 938 tuberculosis of, 939 tumors of, 939 Knee-joint, diseases of, 567 Knock-knee, 492 L. Lactation of infant, 27 rules in regard to, 38-42 Laryngismus stridulus, 179, 634 causes, 635 anatomical characters, 636 symptoms, 636 diagnosis, prognosis, modes of death, 637 treatment, 638 Laryngitis, catarrhal, 820 Acute, 820 symptoms, 821 Chronic, 822 anatomical characters, 822 treatment, 822 Spasmodic, 822 causes, symptoms, 823 anatomical characters, pathology, 824 diagnosis, 824 prognosis, treatment, 825 Laryngotomy, 828 thyrotomy, burns and scalds, 829 Larynx, diseases of, 828 Leukaemia (leucocythsemia), 511 Lockjaw, 132 M. Malformations, 82 Acrania, 82, 83 Malformations, Incomplete brain, 83 Meningocele, encephalocele, hydren- cephalocele, 83-85 Spina bifida, 86-88 Congenital abnormalities in circulatory system, 89 Cyanosis, 89-99 Caput succedaneum, 99 Atresia oris, microstoma, 476 Macrostoma, 476 Hare-lip, 476, 477 fissure partial, 477 single, 478 double, 479 Hypertrophy of mucous glands and of lips, 480 Tongue-tie, hypertrophy of tongue, 481 Angeioma, papillomata, 482 Palate, congenital defects of, 482 . Staphylorraphy, 483 Urinoplasty, 485 Contracted soft palate, 486 Rectum, imperforate, absence of, 487 Anus, contraction of, 487 imperforate, absence of, 488 Bladder, extroversion of, 489 Digits, supernumerary, 490 union of, flexion of phalangeal joints, 491, 492 Knock -knee (genu valgum), 492 treatment, 493 Out-knee (genu extrorsum), 495 treatment, 495 Bowleg, 496 Feet, distortions of, 497 talipes calcaneus, 499 varus, 500 valgus, 501 hollow, club (pes cavus), 502 hypertrophy of toes and foot, 503 Mastitis, 102 Measles, etiology of, 242 symptoms, 242-244 complications, 245, 246 anatomical characters, nature, 247 diagnosis, prognosis, 247, 248 treatment, 248, 249 Measles, German, 298 Mela?na neonatorum, 504 age, etiology, 504-506 diagnosis, prognosis, treatment, 507 Meningitis, tubercular and non-tubercular, 596 age, pathological anatomy, 598 causes, 601 premonitory stage, 602 symptoms, 603 diagnosis, prognosis, 607, 608 treatment, 609 Meningocele, 83-85 Milk, human, 33 modified by diet, 34 by retention in breast, 34 by age and mental impressions, 35 by the catamenial function, 36 984 INDEX. Milk, human, modified by pregnancy, and other causes, 36 effect of medicine on, 37 differences in quantity and quality, 38 rules in regard to lactation, 38-42 Milk, cow's, diseases communicated by, 57 Mortality of early life, 22 causes, 24, 25 prevention, 26 Mother, in pregnancy, care of, 19 Movements of infant, 72 Mumps, 395 etiology, incubation, 395 symptoms, anatomical characters, 396 complications, sequelae, 396, 397 diagnosis, prognosis, treatment, 397, 398 Myocarditis, 916 cause, symptoms, 916 diagnosis, treatment, 917 Myxcedema, 469 N. Nsevus, 924 diagnosis, treatment, 924-926 Necrosis, 545 Nephrectomy, 940 lumbar, 940 abdominal, 940 Nephritis in scarlet fever, 275, 276 Nervous system in infancy, 79 Nose, imperforate, 827 hemorrhage of, 827 foreign bodies in, 827, 828 o. (Edema neonatorum, 150 (Esophagus, 711 Stricture of, 711 Oesophagitis, 712 anatomical characters, symptoms, treatment, 713 Oi'dium albicans, 123 Ophthalmia neonatorum, 103-108 prognosis, 105 prevention, 106 treatment, 107, 108 preventive treatment, 107 Purulent neonatorum, gonorrhoea^ 103 Strumous, 198 Herpetic or phlyctenular keratitis, 198 duration, prognosis, 199 treatment, 200 Parenchymatous or diffuse keratitis, 201 treatment, 201, 202 Osteomyelitis, acute, 543 Necrosis, 545 of entire diaphysis, 546 Chronic circumscribed, 547 treatment, 548 Chronic diffuse, 548 symptoms, progress, treatment, 548, 549 Osteoparesis imperfecta, 153 Palate, congenital defects of, 482 Papillomata, 482 Paralysis in young children, 664 facial, 671 causes, symptoms, prognosis, 671 treatment, 672 pseudo-hypertrophic, 672 anatomical characters, 674 causes, prognosis, treatment, 675 Rachitic, 180 in diphtheria, 363 Paraphimosis, 945 Parasites of the skin, 971 Parotitis, parotiditis, 395 Pemphigus neonatorum, 151 simplex, 151 cachecticus, 152 anatomy, 152 treatment, 153 Penis, 944 Pericarditis, 913 pathology, 913 symptoms, diagnosis, 914 prognosis, treatment, 915 Perinephric abscess, 938 Periostitis, 539 Peripharyngeal abscess, 704 anatomical characters, symptoms, 705 diagnosis, prognosis, 707 swallowing foreign substances, 708 Peritonitis, 805 etiology, 805, 806 symptoms, 807 diagnosis, prognosis, 808 treatment, 808, 809 Pertussis, 381 incubative period, 381 age, cause, 382 pathological anatomy, 383 symptoms, 383 first and second periods, 384 third period, 385 complications, 385-388 diagnosis, prognosis, 389 treatment, 390 carbolic acid, cocaine, 390, 391 antipvrine, quinine, 391, 392 sulphur, 393 of complications, 394 prophylaxis, 395 Pharyngitis catarrhal, anatomical cha- racters, 701 causes, symptoms, prognosis, 702 diagnosis, treatment, 703 Phimosis, 944 Pleurisy, 876 frequency, 876, 877 ; causes, 878-882 anatomical characters, 882 Plastic, 883 Sero-fibrinous, 884 Purulent, 884, 885 Hemorrhagic, 885-888 symptoms, 889 physical signs, 891 INDEX. 985 Pleurisy, hemorrhagic, palpitation, percussion, 891, 892 auscultation. 892-894 diagnosis, 894 prognosis, S9o. 896 treatment, 897 internal remedies, 898 Second stage, 899 Thoracentesis, 901 indications for, 901, 902 mode of operating, 903 for empyema, 904 admission of air into pleural cavity, 905 injury by instruments, 906 washing out cavity, 906-908 use of tent and tube in empyema, 908 Paracentesis thoracis, 908-911 Excision of the rib, 911 Pneumonia, 864 Catarrhal, 864 etiology, 864 anatomical Croupous, 867 etiology, 867 anatomical characters, 868 Septic or embolismal, 869 cheesy degeneration, 870 symptoms, 870, 871 physical signs, 872 diagnosis, 873 prognosis, 874 treatment, 874 of catarrhal pneumonia, 874 of croupous pneumonia, 874, 875 local, 875, 876 Poliomyelitis acuta anterior, 664 symptoms, 664 progress, etiology, 666 diagnosis, prognosis, 669 treatment, 670 Pott's disease, 519 Preputial dilatation, 937, 938 Prurigo, 954, 955 Pulse of infant, 26 in health, 74 in disease, 75 Purpura, 515 etiology, anatomical appearances, 515 symptoms, diagnosis, prognosis, treat- ment, 516 Pyonephrosis, 938 R. Kachitis, 156 frequency, 156 diagnosis, 158 age of occurrence, 159 etiology, 159 inheritance, 159 an ti hygienic conditions, food, 160 pathology, 161 changes in soft tissues (mucous mem- branes, ligaments, spleen, liver), abdominal protuberance, kidneys, urine, brain, spinal cord, 162, 163 Rachitis, changes in osseous system in health, 163-165 anatomical characters : 1, in the stage of proliferation and altered nutrition, 165 2, of the rachitic child, 169 changes in cranial bones, 169 craniotabes, 170 changes in the vertebrae, 171 in maxilla? and ribs, 172 in bones of upper extremities and pelvis, 174 in bones of lower extremities, 175 effect on dentition, 176 3, of stage of reconstruction, 176 symptoms, 177 laryngismus stridulus in, 179 rachitic paralysis, 180 acute rickets, 180 treatment, hygiene, 181 medicinal, 183-185 Radius, fracture of, 535 Ranula, 696 Rectum, absence of, imperforate, 487 Remittent fever, 405 symptoms, diagnosis, treatment, 406 Respiration of infant, 26 Respiratory system in infants, 72 Rheumatism, acute, 455 causes, 456 symptoms, 457 pathology, 459 duration, prognosis, 460 diagnosis, treatment, 461-463 Rotheln, 298 premonitory stage, 300 symptoms, tegumentary system, 300, 301 mucous membrane, 301 respiratory and digestive system, 302 pulse, temperature, 302 complications, prognosis, 303 nature, incubative period, 303 contagiousness, 303-305 complications, diagnosis, prognosis ; treat- ment, 306 Rubeola (see Measles). S. Scalds and burns, 829 Scarlet fever, 250 etiology, 250-252 incubative period, 252, 253 contagiousness, 254 variations in type, 254-257 age, 258 clinical facts, 259 symptoms, ordinary form, 260-263 grave form, 264, 265 irregular form, 265, 266 complications and sequela?, 266-270 coryza, 270 inflammation of middle ear, 270 scarlatinous rheumatism, 272 pleuritis, 273 dilatation of the heart, 273 986 INDEX. Scarlet fever, complications, etc. : nephritis, parenchymatous, 275 interstitial, 276 anatomical characters, 278 diagnosis, 279 prognosis, 281 treatment, 283 prophylaxis (care of patient, in- fected articles), 283-285 hygienic, 285 therapeutic, in mild cases, 286 in severe cases, 287-289 of complications and sequelae, 289- 298 Sclerema neonatorum, 149 Scorbutus, etiology, 516 morbid anatomy, symptoms, diagnosis, prognosis, treatment, 517, 518 Scrofula, 186 causes, 187 anatomical characters, 188 symptoms, 191 prognosis, 193 treatment, prophylactic, 193 curative, 194 strumous, dactylitic, 190 Scrotum, 947 Hydrocele, variocele, 947 Scurvy (see Scorbutus). Septicaemia of the new-born, 115 first group, 115-119 second group, 119-122 third group, 122, 123 Shoulder, diseases of, 554 Skin, diseases of, 949 Erythema, or rose-rash, 950 diagnosis, treatment, 951 duration, pathology, 952 Urticaria, varieties, 952 papulosa, 953 etiology, pathology, 953 diagnosis, prognosis, treatment, 954 Prurigo, 954 symptoms, etiology, 954, 955 pathology, diagnosis, prognosis, treatment, 955 Eczema, 956 vesiculosum, squamosum, rubrum, 956 pustulosum, impetiginodes, papillo- sum, erythematosus, 957 age, 957 etiology, pathology, anatomy, 958- 962 " diagnosis, prognosis, treatment, 962, 963 treatment, local, 963-965 of the head, 965, 966 of the ears, face, evelids, lips, palms, 966 of the nails, genitalia, 967 Microbes, pathogenic effects of, 967 Impetigo contagiosa, 967 etiology, pathology, 967 diagnosis, prognosis, treatment, Skin, diseases of, Seborrhoea, seborrhoea sicca, 968 furfuracea universalis of the scalp, 969 prognosis, treatment, 970 Parasites of the skin, 971 scabies or the itch, diagnosis, 972 treatment, 973 pediculosis, 974 Skull, injuries of, 530 depression of, diagnosis, treatment, fractures, 530 Sleep of infant, 67 Spina bifida, 86 Spinal cord and coverings, diseases of, 676 membranes, congestion of, 677 anatomical characters, 677 symptoms, treatment, 678 Spine, lateral curvature of, 525 diagnosis, 526 treatment, 527 Staphylorraphy, 483 St. Guy's dance, 650 Stomach, 719 congestion of, 719 Stomatitis, 680 simple or catarrhal, 680 symptoms, appearance, treatment, 681 ulcerous, 681 causes, symptoms, prognosis, treatment, 682 aphthous, 683 causes, symptoms, diagnosis, 683 prognosis, treatment, 684 Strumous ophthalmia, 198 St. Yitus's dance, 650 Synovitis, acute, serous, 552 suppurative, 553 Syphilis, etiology, 230 "clinical history, 232-235 visceral lesions, 235 osseous lesions, 236 prognosis, 238 treatment, 238-241 T. Tarsus, synovitis of, treatment, 573 Temperature of infant, 26 Testicles, tubercles of, 947 sarcoma of, 947, 948 Tetanus neonatorum, 132 time of commencement, fatal cases, 135 favorable cases, 136 period of commencement, 136 symptoms, 141 mode of death, 142 prognosis, 142 duration in fatal cases, 143 in favorable cases, 143 diagnosis, preventive treatment, 143, 144 treatment, 145-149 Tetany, 640 causes, 640 symptoms, 644 INDEX. 987 Tetany, pathology, 64S diagnosis, prognosis, 649 treatment, 650 Therapeutics of infancy, 80, SI Thoracentesis, 901 Thrush, 123 causes, anatomical characters, 124, 125 symptoms, 126 diagnosis, prognosis, treatment, 127, 128 Thvrotomy, 829 Tibia, fracture of, 538 Tongue, tongue-tie, hypertrophy of, 481 Tonsil, abscess of, 698 chronic inflammation of, 698 Tonsillitis, recurrent, 699 Tracheotomy, 848-850 Tubercular affections of joints, 553 Tuberculosis, 202 etiology, 202-205 anatomical characters of the tubercle, 205 in infancy and childhood, 207 lungs, 208-211 abdominal viscera, 211-214 encephalon, 214-216 bronchial glands, 216 physical signs, 217-219 diagnosis, 219-222 prophylaxis, 222, 223 treatment, 224 high altitude, 224 benefit of evergreen forest and use of turpentine, 225, 226 creosote, 226-228 guaiacol, 228 tuberculin, 229 of bone, 549 diagnosis, prognosis, treatment, 550 Typhoid fever, 407 causation, 407—410 anatomical characters, 410 pathology, 411 incubative period, symptoms, 412 duration, 413 relapses, second attacks, 414 complications, 414, 415 diagnosis, 415, 416 prognosis, 416 treatment, 416-420 U. Ulna, injury of, 535 Umbilical hemorrhage, 109 etiology, prognosis, treatment, 111 Vegetations, 108 progress, treatment, 109 Uranoplasty, 485 Urethra, 942 wounds of, 943 foreign bodies in, 943 calculus of, 943, 944 imperforate, 944 Urticaria, varieties, 952 V. Vaccinia, 316 appearances, symptoms, 319 anomalies, complications, sequela?, 320 vaccination, subsequent, 322 protection from, 323 virus, selection of, 324-326 Varicella, 326 symptoms, 326, 327 complications, sequelae, 327 diagnosis, prognosis, treatment, 327, 328 Variola, 306 etiology, incubative period, stage of in- vasion, 307 stage of eruption, 308 of desiccation and desquamation, 309 Varioloid, 310 mode of death, 310, 311 anatomical characters, 311, 312 prognosis, diagnosis, 312 treatment, 314-316 Vascular growths, 694 Vertebral caries, 519 Vessels, diseases of, 923 Voice in infant, 72 Vulvitis, 936 etiology, 936, 937 treatment, 937 w. Weaning, 46, 47 Weight of infant, 26 Wet-nurse, selection of, 42-45 Wet-nursing, 28 its advantages and hindrances, 28 physical conditions, if improper, 29-31 course, 45, 46 Whooping cough, 381 Worms, intestinal, 765 Ascaris lumbricoides, 765 symptoms, 772 diagnosis, prognosis, 774 treatment, 775 Oxyurus vermicularis, 767 Tape-worm, Taenia solium, 768 Taenia saginata, 769 elliptica, or cucumerina, 770 Bothriocephalus latus, 770 Trichocephalus dispar, 770 Wrist-joint, diseases of, 556 LEA BROTHERS & COS CLASSIFIED CATALOGUE OP Medical m Surgical Publications. T3 o N ASKING the attention of the profession to the works advertised in the follow- Q< *■* ing pages, the publishers would state that no pains are spared to secure a O* O continuance of the confidence earned for the publications of the house ^ ~f* by their careful selection and accuracy and finish of execution. mm q^ The printed prices are those at which books can generally be supplied by booksellers ^ +* ^ throughout the United States, who can readily procure for their customers any works not ** ^ Q) kept in stock. Where access to bookstores is not convenient books will be sent by mail by 4) "^ C/5 the publishers postpaid on receipt of the printed price, and as the limit of mailable weight &£) has been removed, no difficulty will be experienced in obtaining through the post-office S g mZ any work in this catalogue. I$o risks however are assumed either on the money or © O on the books, and no publications but our own are supplied, so that gentlemen will in ^j '■£ ^3 most cases find it more convenient to deal with the nearest bookseller. ■ ^ '^ J3 LEA BROTHERS & CO. UJ QJ Nos. 706, 708 & 710 Sansom St., Philadelphia, October, 1895. & ^ J3 6 ■ S +* T5 N "* Practical Medical Periodicals. THE AMERICAN JOURNAL OF THE MEDICAL a To one address, jg g © SCIENCES, Monthly, $4.00 per annum. I d* ' t>»,2 SjJ i *P / • « 7 ^ " ~tj S THE MEDICAL NEWS, Weekly, $4.00 per annum. J per annum. 3 ST 5 THE nEDICAL NEWS VISITING LIST (4 styles, see page 3), $1.25. O ^ -2 With either or both above periodicals, in advance, 75c. *« S THE YEAR=BOOK OF TREATMENT (see page 16), $1.50. With either « 3 § JOURNAL or NEWS, or both, 75c. Or JOURNAL, NEWS, VIS- ^ g -2 ITINQ LIST AND YEAR=BOOK, in all $10.75, for $8 50 in advance, g 5 ^ Subscription Price Reduced to $4.00 Per Annum. THE MEDICAL NEWS. | J3 Y KEEPING closely in touch with the needs of the active practitioner, The News has achieved a reputation for utility so extensive as to render practicable its reduction in price from five to Four Dollars per annum. It is now by far the cheapest as well as the best large weekly medical journal published r** in America. Employing all the recognized resources of modern journalism, such as the cable, telegraph, resident correspondents, special reporters, etc., The News supplies in the 28 quarto pages of each issue the latest and best information on subjects of importance and value to practitioners in all branches of medicine. The foremost writers, teachers and practitioners of the day furnish original articles, clinical lectures and notes {Continued on next page.) 2 Medical Periodicals, Visiting List, Ledger. THE flEDICAL NEWS===Continued. on practical advances; the latest methods in leading hospitals are constantly reported ; a condensed summary of progress is gleaned each week from a large exchange list, com- prising the best journals at home and abroad ; a special department is assigned to abstracts requiring fall treatment for proper presentation ; editorial articles are secured from writers able to deal instructively with questions of the day ; books are carefully reviewed; society proceedings are represented by the pith alone ; regular correspondence is furnished from important medical centres, and minor matters of interest are grouped each week under news items. In a word The Medical News is a crisp, fresh, weekly professional newspaper and as such occupies a well-marked sphere of usefulness, distinct from and complementary to the ideal monthly magazine, The American Journal of the Medical Sciences. The American Journal J PuWished MonthIy of the | at $4.00 Medical Sciences I Per Annum - The American Journal entered Avith 1895 upon its seventy-sixth year, still main- taining the foremost place among the medical magazines of the world. A vigorous existence during two and a half generations of men amply proves that it has always adapted itself to meet fully the requirements of the time. Being the medium chosen by the best minds of the profession during this period for the presentation of their ablest papers, The American Journal has well earned the praise accorded it by an unquestioned authority — "From this file alone, were all other publications of the press for the last fifty years destroyed, it would be possible to reproduce the great majority of the real contributions of the world to medical science during that period." Original Articles, Eeviews and Progress of the Medical Sciences constitute tne three main departments of this ideal medical monthly. COMMUTATION RATE. Taken together, The Journal and The News afford to medical readers the ad- vantages of the monthly magazine and the weekly newspaper. Thus all the benefits of medical periodical literature can be secured at the low figure of $7.50 per annum. Subscribers can obtain, at the close of each volume, cloth covers for The Journal (one annually), and for The News (one annually), free by mail, by remitting Ten Cents for The Journal cover, and Fifteen Cents for The News cover. The Medical News Visiting List for 1896 Is published in four styles, Weekly (dated for 30 patients) ; Monthly (undated, for 120 patients per month) ; Perpetual (undated, for 30 patients weekly per year) ; and Per- petual (undated, for 60 patients weekly per year). The 60-patient Perpetual consists of 256 pages of assorted blanks. The first three styles contain 32 pages of important data and 176 pages of assorted blanks. Each style is in one wallet-shaped book, leather- bound, with pocket, pencil, rubber, and catheter scale. Price, each, $1.25. With thumb- letter index, 25 cents extra. This list is all that could be desired. It con- j The new issue maintains its previous reputation, tains a vast amount of useful information, especi- I It adapts itself to every style of book-keeping; ally for emergencies, and gives good tables of doses ! there is space for all kinds of professional records; and therapeutics.— Canadian Practitioner. it is furnished with a ready reference thumb-letter Its compactness and simplicity are such as to index, and has a most valuable text. — Medical indicate that the highest point of perfection has ; Record. been reached in works of this class.— University I For convenience and elegance it is not surpass- Medical Magazine. \ able. — Obstetric Gazette. SPECIAL COMBINATIONS WITH THE VISITING LIST, see p. 1. J^^The safest mode of remittance is by bank check or postal money order, drawn to the order of the undersigned ; where these are not accessible, remittances for subscriptions may be sent at the risk of the publishers by forwarding in registered letters addressed to the Publishers (see below;. The Medical News Physicians' Ledger. Containing 300 pages of fine linen " ledger " paper ruled so that all the accounts of a large practice may be conveniently kept in it, either by single or double entry, for a long period. Strongly bound in leather, with cloth sides, and with a patent flexible back which permits it to lie perfectly flat when opened at any place. Price, $4.00. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. Medical Dictionary, Quiz Manuals. 3 THE STUDENTS' DICTIONARY OF MEDIGINE AND THE ALLIED SCIENCES, COMPRISING THE PRONUNCIATION, DERIVATION AND FUEL EXPEANATION OF MEDICAL TERMS; TOGETHER WITH MUCH COLLATERAL DESCRIPTIVE MATTER, NUMEROUS TABLES, ETC. By ALEXANDER DUANE, M. D., Assistant Surgeon to the New York Ophthalmic and Aural Institute; Reviser of Medical Terms for Webster's International Dictionary. In one square octavo volume of 658 p sheep, $5.00. Thumb-letter Index for quick Dr. Duane has spared no time, pains or expense in his endeavor to bring before the proiession, and especially the students of medicine, a book em- bodying completeness and explicitness. The vocabulary is abundant and its fulness is paral- leled by the explanation accorded each word. It also contains extensive tables. Each word is fol- lowed by its correct pronunciation, a new feature in works of this kind, given by means of a simple and obvious phonetic spelling. Derivation, the greatest aid to memory, is faliy treated of, and for the convenience of those who do not understand Greek, the English letters are substituted for those of the Greek in giving the roots of the words derived from that language. The author's expe- rience as a lexicographer is fully attested by his position as Reviser of Medical Terms for Web- ster's International Dictionary. We predict that this will become a standard and favorite work of its class. — Medicr.l Fortnightly. jges. Cloth, $4.25; half leather, $4.50; full use, 50 cents extra. From A. L. Loomis, M, D , Professor Fatholoqy arid Practice of Medicine, Medical Department, Univer- sity Gty of New York, New York. It seems to me entirely satisfactory for the pur- pose for which it is intended. From J. C. Wilson, M. D , Professor of Medicine, Jefferson Medical College, Phila-delphia. It appears to be well suited to the purposes of the medical student, being simple as regards deri- vations and pronunciation, explicit yet sufficiently comprehensive in definitions, and thoroughly up to the times. From James T. Whittakee, M. D., Professor Theory and Practice of Mtdicine, Medical College of Ohio, Cincinnati, O. I find it admirably adapted to the wants of stu- dents, and thoroughly modern in every particular in which I have taken occasion to consult it. I shall certainly recommend it to my class. THE STUDENTS' QUIZ SERIES. ANEAY Series of Manuals, comprising all departments of medical science and practice, and prepared to meet the needs of students and practitioners. Written by promi- nent medical teachers and specialists in New York, these volumes may be trusted as authoritative and abreast of the day. Cast in the form of suggestive questions, and concise and clear answers, the text will impress vividly upon the reader's memory the salient points of his subject. To the student these volumes will be of the utmost service in pre- paring for examinations, and they will also be of great me to the practitioner in recalling forgotten details, and in gaining the latest knowledge, whether in theory or in the actual treatment of disease. Illustrations Lave been inserted wherever advisable. Bound in limp cloth, and in size suitable for the hand and pocket, these volumes are assured of enormous popularity, and are accordingly placed at an exceedingly low price in com- parison with their value. For details of subjects and prices see below. ANATOMY {Double Number) — By Fred J. Brockwat, M. D., Assistant Demonstrator of Anatomy, College of Physicians and Surgeons, New York, and A. O'Mallet, M.D., Instructor in Surgery, New York Polyclinic. $1.75. PHYSIOLOC Y— By F. A. Manning, M. D., Attending Surgeon, Manhattan Hosp.,N. Y. $1. CHEMISTRY AND PHYSiCS — By Joseph Strtjthers, Ph. B., Columbia College School of Mines, N.Y., and D. W. Ward, Ph. 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D., Assistant Dermatologist, Van- derbilt Clinic, New York. $1. DISEASES OF THE EYE, EAR, THROAT AND NOSE— By Frank E. Miller, M.D., Throat Surgeon, Vanderbilt Clinic, New York, James P. McEvoy, M.D., Throat Surgeon, Belle- vue Hosp., Out-Patient Dep., New York, and J. E. Weeks, M. D., Lect. on Ophthal. and Otol., Bellevue Hosp., Med. Col., N. Y. $1. OBSTETRICS — By Charles W. Hatt, M.D., House Physician, Nursery and Child's Hospi- tal, New York. $1. GYNECOLOGY— By G. W. Bratenahl, M. D., Assistant in Gynecology, Vanderbilt Clinic, New York, and Sinclair Tousey, M. D., Assist- ant Surgeon, Out-Patient Department, Roose- velt Hospital, New York. $1. DISEASES OF CHI LDREN-ByC. A. Rhodes, M. D.. Instructor in Diseases of Children, New York Pest-Graduate Medical College. SI. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. Dictionaries, TWENTY-FIRST EDITION. WITH APPENDIX. Dunglison's Dictionary OF MEDICAL SCIENCE. With the Pronunciation,. Accentuation and Derivation of the Terms. Containing a full Explanation of the various Subjects and Terms of Anatomy, Physiology, Medical Chemistry, Pharmacology, Pharmacy, Therapeutics, Medicine, Hygiene, Dietet- ics, Surgery, Ophthalmology, Otology, Laryngology, Dermatology. Gynecology, Obstetrics, Pediatrics, Medical Jurisprudence and Dentistry, etc., etc. By Kobley Dunglison, M. D., late Professor of Institutes of Medicine in the Jefferson Medical College of Phila- delphia. New (21st) edition, thoroughly revised and greatly enlarged. With the Pro- nunciation, Accentuation and Derivation of the Terms, by RrcHAUD J. Dunglison, A. M., M, D. With Appendix. Ju st ready. In one very large and handsome royal octavo volume of 1225 pages. Cloth, $7.00 ; leather, raised' bands, $8.00. Thumb-letter Index for quick use, 75 cents extra. THIS great medical dictionary, which has been for more than two geoerations the standard of the English speaking race, is now issued in a thoroughly revised and greatly enlarged and improved edition. The new words and phrases aggregate by actual count over 44,000. Though the new edition contains far more matter than its predecessor, the whole is accommodated within a volume convenient for the hand. The revision has not only covered every word, but it has resulted in a number of important new features designed to confer on the work the utmost usefulness, and to make it answer the most advanced demands of the times. Pronunciation has been introduced throughout by means of a simple and obvious system of phonetic spelling. At a glance the proper sound of a word is clearly indicated, and thus a most important desideratum is supplied. Derivation affords the utmost aid in recollecting the meanings of words, and gives the power of analyzing and understanding those which are unfamiliar. It is indicated in the simplest manner. Greek words are spelled with English letters, and thus placed at the command of those unfamiliar with the Greek alphabet. Definitions, the essence of a dictionary, are clear and full, a characteristic in which this work has always been preeminent. In this edition much explanatory and encyclopedic matter has been added, especially upon subjects of practical importance. Thus under the various diseases will be found their symptoms, treatment, etc. ; under drugs their doses and effects, etc., etc. A vast amount of information has been clearly and conveniently condensed into tables in the alphabet. In a word, Dunglisoris Medical Dictionary, in its remodelled and enlarged shape, is equal to all that the student and practitioner can expect from such a work. The new " Dunglison" is new indeed. The vast amount of new matter and the thoroughness with which the work has been brought down to date cannot fail to strike even the least observant reader. The immense advances made in all branches of medical science here find represen- tation. A prominent and very useful feature of the old book is retained and amplified in this— we mean the tables, which recur with great fre- quency and represent a vast amount of condensed information. In respect to accuracy the book quite equals and usually surpasses any of its contempo- raries that we are acquainted with. The American Journal of the. Medical Sciences. Covering the entire field of medicine, surgery and the collateral sciences, its range of usefulness can scarcely be measured. Perhaps the most valu- able feature in the present work is the addition of a vast amount of practical matter. The type is commendably clear.— Medical Reco'i d. The new subjects and terms treated are no ies the existing condition of medical science. Thus, under the healing Hernia, besides the definition of the condition, a condensed table is given of the various forms, and a brief re-ume is given of the therapeutical indications. Under the heading Murmurs, besides a description of the various forms, a table is given of the significance of the murmurs of valvular origin. Under Bacteria the leading classifications are recorded, and a para- graph is devoted to the question of the determina- tion of the pathogenic properties, and another to modes of culture of the bacteria— The Montreal Medical Journal. So fully have derivations and definitions been considered, and so great is the amount of prac- tical matter, such as symptoms, treatment and prognosis of many of the diseases described, that the volume is entitled to be called aa encyclo- pedia rather than a dictionary.— The Brooklyn Medical Journal. A thorough system of phonetic spelling gives than forty-four thousand, sufficient in themselves ; the pronunciation of all woids that arenot sosira- to form a" large volume. There has been a praise- i pie as to require no key. — New Orleans Medical and worthy attempt to render the work an epitome of \ Surgical Journal. The National Medical Dictionary, Including English, French, German, Italian and Latin Technical Terms used in Medicine and the Collateral Sciences, and a Series of Tables of Useful Data. By John S. Billings, M. D., LL. D., Edin. and Har?., D. C. L., Oxon., member of the National Academy of Sciences, Surgeon U. S. A., etc. In two very handsome royal octavo volumes containing 1574 pages, Avith two colored plates. Per volume — cloth, $6.00 ; leather, $7.00; half morocco, marbled edges, $8.50. Subscription only. Address the publishers. A.part from the boundless stores of information chief modern languages. There cannot be two which may be gained by the study of a good diction- opinions as to the great value of this dictionary as ary.oneis enabled by the work under notice to read a book of ready reference for all sorts and condi- intelligently any technical treatise in any of the four | tions of medical men, — London Lancet. Lea Brothers & Co., Publishers, 706, 70S & 710 Sanson Street, Philadelphia. Anatomy, Dictionary. THIRTEENTH EDITION. GRAY'S ANATOMY N COLORS OR IN BLACK Anatomy, Descriptive and Surgical, BY HENRY GRAY, P. R, S., LECTURER ON ANATOMY AT ST. GEORGE'S HOSPITAL, LONDON. Edited by T. PICKERING PICK, F. R. C. S., Surgeon to and Lecturer on Anatomy at St. George's Hospital, London, Examiner in Anatomy, Royal College of Surgeons of England. A new American from the thirteenth enlarged and improved London edition. In one imperial octavo volume of 1118 pages, with 636 large and elaborate engravings on wood. Price, with illustrations in colors, cloth, $7 ; leather, $8. Price, with illustrations in black, cloth, $6 ; leather, $7. SINCE 1S57 Gray's Anatomy has been the standard work used by students of medicine and practitioners in all English-speaking races. So preeminent has it been amocg the many works on the subject that thirteen editions have been required to meet the demand. This opportunity for frequent revisions has been fully utilized and the work has thus been subjected to the careful scrutiny of many of the most distinguished anatomists of a generation, whereby a degree of completeness and ac- curacy has been secured which is not attainable in any other way. In no former revision has so much care been exercised as in the present to provide for the student a)l the assistance that a. text-book can furnish. The engravings have always formed a distin- guishing feature of this work, and in the present edition the series has been enriched and rendered complete by the addition of many new ones. The large scale on which the illustrations are drawn and the clearness of the execution render them of unequalled value in affording a grasp of the complex details of the subject. As heretofore the name of each part is printed upon it, thus conveying to the eye at once the position, extent and relations of each organ, vessel, muscle, bone or nerve with a clearness impossible when figures or lines of reference are employed. Distinctive colors have been utilized to give additional prominence to the attachments of muscles, the veins, arteries and nerves. For the sake of those who prefer not to pay the slight increase in cost necessitated by the use of colors, the volume is published also in black alone. The illustrations thus constitute a complete and splendid series, which will greatly assist the student in forming a clear idea of Anatomy, arid will also serve to refresh the memory of those who may find in the exigencies of practice the necessity of recalling the details of the dissecting room. Combining as it does a complete Atlas of Anatomy with a thorough treatise on systematic, descriptive and applied Anatomy, the work covers a more extended range of subjerts than is customary in the ordinary text-books. It not only answers every need of the student in laying the groundwork of a thorough medical education, but owing to its application of anatomical details to the practice of medicine and surgery, it also furnishes an admirable work of reference for the active practitioner. We always had a kindly regard for the illustra- tions in Gray, where each organ, tissue, artery, and nerve bear their respective names, and in this edi- tion color has been worked to advantage in bring- ingout the relationship of vessel and nerve. Of late years, many works on anatomy have been intro- duced to the profession, bat as a reference book for the practical everyday physician, and as a text-book for the student, we think it will be difficult to sup- plant Gray. — Buffalo Med. and Surg. Journal. It has thoroughly and completely established itself as the anatomy, par excellence.— Brooklyn Medical Journal. It embraces the whole of human anatomy, and it particularly dwells on the practical or applied part of the subject, so that it forms a most useful, intelligible and practical treatise for the student and general practitioner.— Dublin Journal of Medi- cal Science \ In modern times no book on any medical sub- ject has held the position of a standard so long as Gray's Anatomy. For logical arrangement, clear, terse, pointed, and yet full description, it is the peer of any work on any scientific subject. A pioneer in "helpful drawings, it is still in the van and leads in every improvement. The physician or student who requires but one work on anatomy will not need to ask which, nor will those who will have more than one need to ask which one to add. The work is admitted to be easily first on anatomy in any language. — TheAmer. Practitioner and News. Teachers of anatomy are almost unanimous in recommending "Gray" as the standard work for the student. The illustrations are conceded to be the best that have jet been given to the profes- sion. In short, Gray\f Ana'owy is the ideal text- book on this subject — Cleveland Med. Gazette. Gray's has been the unvarying standard for anatomical study by the vast majority of English- speaking medical "students for so long that it would seem an anomaly to see a student acquire such knowledge from some other source. — Medi- cal Fortnightly. The matchless book of the doctor's or surgeon's library is and has been Gray's Anatomy. Since 1857 it has held the leadirg place in all colleges as a text-book and has bren the one central figure in the many text-books in anatomy that have claimed attention. It is still the standard text-bock.— The Kansas City Medical Index. The careful scrutiny to which it has been sub- jected in forty years, and the successive issues of thirteen editions have made it what it is to-day, the most perfect work of its kind extant.— Uni- versity Medical Magazine. HOBLYN'S DICTIONARY OF MEDICINE. A Dictionary of the Terms Used in Medicine and the Collateral Sciences. By Richard D. Hoblyn, M. D. In one large royal 12m o. volume of 520 double- columned pages. Cloth, $1.50; leather, §2.00. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. Anatomy, Physiology. HUMAN MONSTROSITIES BY BARTON C. HIRST, M.D., and GEORGE A. PIERSOL, M. D. Professor of Obstetrics in the University Professor of Anatomy and Embryology of Pennsylvania. in the University of Pennsylvania. Magnificent folio, containing 220 pages of text, illustrated with engravings, and 39 fall page, photographic plates from nature. In four parts, price, each, $5, Limited edition, for sale by subscription only. Address the Publishers. We have before us the fourth and last part of the latest aud best work on human monstrosi- ties. This completes one of the masterpieces of American medical literature. Typographically and from an artistic standpoint, the work is uu- must slways retain the honor of being the first of its kind written in the English language. — The British Medical Journal. This work promises to be one for which a place must be found in th6 library of every anatomist, exceptionable. In this last and final volume pathologist, obstetrician and teratologic. Itisthe is presented the most complete bibliography of j joint production of an obstetrician, and an embry- teratologicalliterature extant. No library will be j oiogist, and his-tolcgist, and this fact makes it complete without this magnificent work.— Jour- certain that both the obstetric and anatomical nal of the American Medical Association. j sides of the subject will be fully represented and Altogether, Human Monstrosities is a satisfactory described. The book promises to be one of the production. It will take its place as a standard greatest value to the English-speaking medical work on teratology in medical libraries, and it | world.— Edinburgh Medical Journal. Allen's System of Human Anatomy. A System of Human Anatomy, Including Its Medical and Surgical Relations. For the use of Practitioners and Students of Medicine. By Harrison Allen, M. D,, Professor of Physiology in the University of Pennsylvania. With an Introductory Section on Histology by E, O. Shakespeare, M. D. ; Ophthalmologist to the Philadelphia Hospital. Comprising 813 double-columned quarto pages, with 380 illustrations on 109 full page lithographic plates, many of which are in colors, and 241 engravings in the text. In six Sections, each in a portfolio. Price per Section, $3.50 ; also bound in one volume, cloth, $23.00 ; very handsome half Eussia, raised bands and open back, $25.00. For sale by subscription only. Address the Publishers. Holden's Landmarks, Medical and Surgical. Landmarks, Medical and Surgical. By Luther Holden, F. E. C. S., Surgeon to St. Bartholomew's Hospital, London. Second American from the third and revised English ed., with additions by W. W. Keen, M. D., Professor of Artistic Anatomy in the Penna. Academy of Fine Arts. In one 12mo. volume of 148 pages. Cloth, $1.00. Clarke & Lockwood's Dissector's Manual The Dissector's Manual. By W. B. Clarke, F. E. C. S., and C. B. Lock- wood, F. E. C. S., Demonstrators of Anatomy at St. Bartholomew's Hospital Medical School, London. In one pocket-size 12mo. volume of 396 pages, with 49 illustrations. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 30. Messrs. Clarke and Loekwood have written a book | intimate association with students could have that can hardly be rivalled as a practical aid to the given. With such a guide as this, accompanied dissector. Their purpose, which is "how to de- ' by so attractive a commentary as Treves' Surgical scribe the best way to display the anatomical ! Applied Anatomy (same series), no student could structure," has been fully attained. They excel in i fail to be deeply and absorbingly interested in the a lucidity of demonstration and graphic terseness i study of anatomy.— New Orleans Medical and Sur^ of expression, which only a long" training and ■ gical Journal. Treves' Surgical Applied Anatomy. Surgical Applied Anatomy. By Frederick Treves, F. E. C. S., Senior Demonstrator of Anatomy and Assistant Surgeon at the London Hospital. In one pocket- size 12mo. volume of 540 pages, with 61 illustrations. Limp cloth, red edges, $2.00. See Students' Series of Manuals, p. 30. Bellamy's Surgical Anatomy. The Student's Guide to Surgical Anatomy : Being a Description of the most Important Surgical Begions of the Human Body, and intended as an Introduction to Operative Surgery. By Edward Bellamy, F. R. C. S., Senior Assistant- Surgeon to the Charing- Cross Hospital. In one 12mo. vol. of 300 pages, with 50 illus. Cloth, $2.25. Wilson's Human Anatomy. A System of Human Anatomy, General and Special. By Erasmus Wilson, F. E. S. Edited by W. H. Gobrecht, M. D., Professor of General and Surgical Anatomy in the Medical College of Ohio. In one large and handsome octavo volume of 616 pages, with 397 illustrations. Cloth, $4.00 ; leather, $5.00. HARTSHORNE'S handbook of anatomy AND PHYSIOLOGY. Second edition, revised. 12mo., 310 pages, 220 woodcuts. Cloth, $1.75. HORNER'S SPECIAL ANATOMY AND HISTOL- OGY. Eighth edition. In two octavo volumes of 1007 raepi. with 320 woodcuts. Oloth. $fi.OO. CLELAND'S DIRECTORY FOR THE DISSEC- TION OF THE HUMAN BODY. 12mo., 178 pp. CI th, $1.25. Lea Brothers & Co., Publishers, 706, 708 & 710 Sanson) Street, Philadelphia. Physics, Physiology, Anatomy, Chemistry. 7 Draper's Medical Physics. Medical Physics. A Text-book for Students and Practitioners of Medicine. Bv John C. Draper, M.D., LL. D., Prof, of Chemistry in the Univ. of the City of New York. In one octavo vol. of 734 pages, with 376 woodcuts, mostly original. Cloth, $4. No man in America was better fitted than Dr. I culties to be encountered in bringing his subject Draper for the task he undertook and he has pro- within the grasp of the average student, and that vided the student and practitioner of medicine i he has succeeded so well proves once more that with a volume at once readable and thorough. I the man to write for and examine students is the Even to the student who has some knowledge of ! one who has taught and is teaching them. The physics this book is useful, as it shows him its j book is well printed and fully illustrated, and in applications to the profession that he has chosen, every way deserves grateful recognition.— The Dr. Draper, as an old teacher, knew well the diffi- I Montreal Medical Journal. Reichert's Physiology.— Preparing. A Text-Book on Physiology. By Edward T. Reichert, M. D., Professor of Physiology in the University of Pennsylvania, Philadelphia. In one very handsome octavo volume of 800 pages, fully illustrated. Power's Human Physiology.— Second Edition. Human Physiology. By Henry Power, M. B., F. R. C. S., Examiner in Physiology, Royal College of Surgeons of England. Second edition. In one 12mo. vol. of 509 pp., with 68 illustrations. Cloth, $1.50. See Students 1 Series of Manuals, p. 30. Robertson's Physiological Physics. Physiological Physics. By J. McGregor Robertson, M. A., M. B., Muirhead Demonstrator of Physiology, University of Glasgow. In one 12mo. volume of 537 pages, with 219 illus. Limp cloth, $2. See Students' Series of Manuals, page 30. The title of this work sufficiently explains the I ments. It will be found of great value to the nature of its contents. It is designed as a man- ! practitioner. It is a carefully prepared book of ua! for the student of medicine, an auxiliary to ! reference, concise and accurate, and as such we his text-book in physiology, and it would be particu- | heartily recommend it. — Journal of the American iarly useful as a guide to his laboratory experi- | Medical Association. Dalton on the Circulation of the Blood. Doctrines of the Circulation of the Blood. A History of Physio- logical Opinion and Discovery in regard to the Circulation of the Blood. By John C. D Alton : M. D., Professor Emeritus of Physiology in the College of Physicians and Sur- geons, New York. In one handsome l2mo. volume of 293 pages. Cloth, $2. Dr. Dalton's work is the fruit of the deep research I ation for those plodding workers of olden times, of a cultured mind, and to the busy practitioner it I who laid the foundation of the magnificent temple cannot fail to be a source of instruction. It will of medical science as it now stands. — New Orleans inspire him with a feeling of gratitude and admir- | Medical and Surgical Journal. Bell's Comparative Anatomy and Physiology. Comparative Anatomy and Physiology. ByF. Jeffrey Bell, M. A., Professor of Comparative Anatomy at King's College, London. In one 12mo. vol. of 561 pages, with 229 illustrations. Limp cloth, $2. See Students' Series of Manuals, page 30, The manual is preeminently a student's book — I it the best work in existence in the English clear and simple in language and arrangement, language to place in the hands of the medical It is well and abundantly illustrated, and is read- student. — Bristol Medico- Chirurgical Journal. able and interesting. On the whole we consider | Ellis' Demonstrations of Anatomy.— Eiglith Edition. Demonstrations of Anatomy. Being a Guide to the Knowledge of the Human Body by Dissection. By George Viner Ellis, Emeritus Professor of Anatomy in University College, London. From the eighth and revised London edition. In one verj handsome octavo volume of 716 pages, with 249 illus. Cloth, $4.25 ; leather, $5.25. Roberts' Compend o! Anatomy. The Compend of Anatomy. For use in the dissecting-room and in pre- paring for examinations. By John B. Eoberts, A. M., M. D., Lecturer in Anatomy in the University of Pennsylvania. In one 16mo. vol. of 196 pages. Limp cloth, 75 cents. WOHLER'S OUTLINES OF ORGANIC CHEM- ISTRY. Edited by Fittig. Translated by Ika Remsen, M. D , Ph. D. In one 12mo. volume of 550 pages. Cloth, $3. LEHM ANN'S MANUAL OF CHEMICAL PHYS- IOLOGY. In one octavo volume of 327 pages, with 41 illustrations. Cloth, $2.25. CARPENTER'S HUMAN PHYSIOLOGY. Edited by Henry Power. In one octavo volume.' CARPENTER'S PRIZE ESSAY ON THE USE AND Abuse of Alcoholic Liquors in Health and Dis- ease. With explanations of scientific words. Small 12mo. 17S pages. Cloth, 60 cents. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street Philadelphia. 8 Physiology— (Continued), Chemistry. Foster's Physiology.— Sixth American Edition. Just Ready. Text-Book of Physiology. By Michael Foster, M. D., F. K. S., Prelec- tor in Physiology and Fellow of Trinity College, Cambridge, England. Sixth American edition, with notes and additions. In one handsome octavo volume of 922 pages, with 257 illustrations. Cloth, $4.50; leather, $5.50. Notices of previous edition are appended. It is unquestionably the standard text book on I stowed upon it. Apparently nothing that is known physiology for students and practitioners. The moderate price of this well-issued book at once shows how popular the work has become. The style is plain enough even for the beginner; the details are sufficient for the teacher; and the manner of dealing with the topics is well-ar- ranged for the advantage of the practitioner. — Virginia Mediial Monthly. Foster's Physiology is an accepted text-book in almost every medical college in this country, and already commended to ail medical students. For the physician who aims to keep abreast of all that is new that is true in medicine, a work like this is a necessity. The illustrations are excellent and are well printed — The Cincinnati Lancet-CU- ic. One cannot read a single chapter without being impressed with the care that the author has be- up to the present year concerning vital processes has escaped his painstaking attention. The details receive the fullest consideration. The additions which have been made to this last edition are caused by an effort to explain more fully and at greater length what seemed to be the most funda- mental and important topics. The publishers have subjected it to the searching revision of one of the foremost American professors of physio- logy. We have nothing but words of the highest praise for the classical and thorough manner in which the work is written, as well as for the liber- ality of the publishers for selling such a large work, and one which must necessarily be very costly to produce, for an extremely moderate price. — The Canada Medical Record. Dalton's Physiology.— Seventh Edition. A Treatise on Human Physiology. Designed for the use of Students and Practitioners of Medicine. By John C. Dai/ton, M. D., Professor of Physiology in the College of Physicians and Surgeons, New York, etc. Seventh edition, thoroughly revised and rewritten. In one very handsome octavo volume of 722 pages, with 252 beau- tiful engravings on wood. Cloth, $5.00 ; leather, $6.00. From the first appearance of the book it has been a favorite, owing as well to the author's renown as an oral teacher as to the charm of simplicity with which, as a writer, he always succeeds in investing even intricate subjects have never been in any doubt as to its sterling worth. — iV T . Y. Medical Journal. Professor Dalton's well-known and deservedly- appreciated work has long passed the stage at which it could be reviewed in the ordinary sense. It must be gratifying to him to observe the fre- | The work is eminently one for the medical prac quency with which his work, written for students titioner, since it treats most fully of those branches and practitioners, is quoted by other writers on physiology. This fact attests its value, and, in great measure, its originality. It now needs no such seal of approbation, however, for the thou- sands who have studied it in its various editions of physiology which have a direct bearing on the diagnosis and treatment of disease. The work is one which we can highly recommend to all our readers. — Dublin Journal of Medical Science. Chapman's Human Physiology. A Treatise on Human Physiology. By Henry C. Chapman, M. I)., Professor of Institutes of Medicine in the Jefferson Medical College of Philadelphia. In one octavo volume of 925 pages, with 605 engravings. Cloth, $5.50 ; leather, $6.50. It represents very fully the existing state of physiology. The present work has a special value to the student and practitioner as devoted more to the practical application of well-known truths which the advance of science has given to the profession in this department, which may be con- sidered the foundation of rational medicine. — Buf- falo Medical and Surgical Journal. Matters which have a practical bearing on the practice of medicine are lucidly expressed; tech- nical matters are given in minute detail; elabo- rate directions are stated for the guidance of stu- dents in the laboratory. In every respect the work fulfils its promise, whether as a complete treatise for the student or for the physician ; for the former it is so complete that he need look no farther, and the latter will find entertainment and instruction in an admirable book of reference.— North Carolina Medical Journal. Schofield's Elementary Physiology. Elementary Physiology for Students. By Alfred T. Schofield, M. D., Late House Physician London Hospital. In one 12mo. volume of 380 pages, with 227 engravings and 2 colored plates containing 30 figures. Cloth, $2.00. Frankland & Japp's Inorganic Chemistry. Inorganic Chemistry. By E. Frankeand, D. C. L., F. E. S., Professor of Chemistry in the Normal School of Science, London., and F. E. Japp, F. I. C, Assistant Professor of Chemistry in the Normal School of Science, London. In one handsome octavo volume of 677 pages with 51 woodcuts and 2 plates. Cloth, $3.75 ; leather, $4.75. Clowes' Qualitative Analysis.— Third Edition. An Elementary Treatise on Practical Chemistry and Qualitative Inorganic Analysis. Specially adapted for use in the Laboratories of Schools and Colleges and by Beginners. By Frank Clowes, D. Sc, London, Senior Science-Master at the High School, Newcastle-under Lyme, etc. Third American from the fourth and revised English edition. In one 12mo. vol. of 387 pages, with 55 illus. Cloth, $2.50. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. Chemistry — (Continued). Simon's Chemistry.— New (5th) Edition. Just Ready. Manual Of Chemistry. A Guide to Lectures and Laboratory work for Begin- ners in Chemistrv. A Text-book specially adapted for Students of Pharmacy and Medi- cine By W. Simon", Ph. D., M. D., Professor of Chemistry and Toxicology in the College of Physicians and Surgeons, Baltimore, and Professor of Chemistry in the Maryland Col- lege of Pharmacy. New (5th) edition. In one 8vo. vol. of 501 pp., with 44 woodcuts and 8 colored plates illustrating 64 of the most important chemical tests. Cloth, $3.25. The exhaustion of the very large fourth edition in less than two years indicates the leading posi- tion achieved by'Professor Simon's Chemistry as a text-book in medical and pharmaceutical colleges. It furnishes an admirable selection of material bearing upon the laws and phenomena of chem- referred to this series of colorsand color changes. The new edition has been most carefully revised in accordance with the advance of science and in order to bring it into complete harmony with the new Pharmacopoeia. All chemicals mentioned in the last issue of that wcrk are included. Special istry. 'As an aid to laboratory work a number of i care has been taken to detail the most modern experiments have been added. Physicians as well methods for chemical examination in clinical as students will appreciate the value of the colored diagnosis. The author's experience as a physician plates of reactions, which give a permanent and and as a teacher of medical and pharmaceutical accurate series of standards for comparison of students is reflected in the special adaptation of tests, a matter not susceptible of satisfactory his book to the needs of all concerned with the explanation in words. In medical practice im- applications of chemistry to the' art of healing. — portant pathological and toxicological questions Southern Practitioner. depending on the test-tube may with certainty be Attfield's Chemistry.— New (14th) Edition. Just Ready. Chemistry, General, Medical and Pharmaceutical; Including the Chemistry of the U. S. Pharmacopoeia. A Manual of the General Principles of the Science, and their Application to Medicine and Pharmacy. By John Attfield, M. A., Ph.D., F. I.C., F. R. S., etc., Professor of Practical Chemistry to the Pharmaceutical Society of Great Britain, etc. Fourteenth edition, specially revised by the Author for America, to accord with the new U. S. Pharmacopoeia. In one 12mo. volume of 794 pages, with 88 illustrations. Cloth, $2.75; leather, $3.25. This substantial and handsome treatise on those parts of chemical science, which are of special in- terest to the physician and the pharmacist, is adapted not only "to be a manual of instruction, but also a work of reference. It is replete with the latest information, and considers with more or less completeness the chemistry of every substance recognized officially or in general practice. The analytical tables are most excellent. Organic Chemistry receives attention in a most compre- hensive manner, as do practical toxicology and j copceia, of which it is a worthy companion. — The physiological chemistry". The concluding parts i Pittsburg Med ; cal Review. consist of a laboratory guide to physical and quantitative chemical analysis and of a large number of useful tables. The etymological notes, scattered through the book, are a very valuable feature, as are also the questions following each section. The eighty-eight illustrations leavenoth- ing to be desired. The metric system, and the modern scientific chemical nomenclature, have been entirely adopted, bringing the work into close touch with the latest United States Pharma- Fownes' Chemistry.— Twelfth Edition. A Manual of Elementary Chemistry; Theoretical and Practical. By George Fownes, Ph. D. Embodying Watts' Physical and Inorganic Chemistry. New American, from the twelfth English edition. In one large royal 12mo. volume of 1061 pages, with 168 engravings and a colored plate. Cloth, $2.75 ; leather, $3.25. Fownes' Chemistry has been a standard text- book upon chemistry for many years. Its merits are very fully known by chemists and physicians everywhere in this country and in England. As the science has advanced by the making of new discoveries, the work has been revised so as to keep it abreast of the times. It has steadily maintained its position as a text-book with medi- cal students. In this work are treated fully: Heat, Light and Electricity, including Magnetism. The influence exerted by these forces in chemical action upon health and disease, etc., is of the most important kind, and should be familiar to every medical practitioner. We can commend the work as one of the very best text-books upon chemistry extant. — Cincinnati Med. News. Bloxam's Chemistry.— Fifth Edition. Chemistry, Inorganic and Organic. By Charles L. Bloxam, Professoi of Chemistry in King's College, London. .New American from the fifth London edition, thoroughly revised and much improved. In one very handsome octavo volume of 727 pages, with 292 illustrations. Comment from us on this standard work is al- most superfluous. It differs widely in scope and aim from that of Attfield, and in its way is equally beyond criticism. It adopts the most direct meth- ods in stating the principles, hypotheses and facts of the science. Its language is so terse and lucid, and its arrangement of matter so logical in se- quence that the student never has occasion to Cloth, $2.00 ; leather, $3.00. complain that chemistry is a hard study. Much attention is paid to experimental illustrations of chemical principles and phenomena, and the mode of conducting these experiments. The book maintains the position it has always held as one of the best manuals of general chemistry In the Eng- lish language. — Detroit Lancet. Luff's Manual of Chemistry. A Manual of Chemistry. For the use of students of medicine. By Arthur P. Luff, M. D., B. 8c, Lecturer on Medical Jurisprudence and Toxicological Chemistry, St. Mary's Hospital Medical School, London. In one 12mo. vol. of 522 pages, with 36 engravings. Cloth, $2.00. See Students 1 Series of Manuals, page 30. Greene's Manual of Medical Chemistry. For the use of Students. By William H. Greene, M. D., Demonstrator of Chemistry in the University of Pennsyl- vania. In one 12mo. volume of 310 pages, with 74 illus. Cloth, $1.75. Lea Brothers & Co., Publishers, 706, 708 &710 Sansom Street, Philadelphia. 10 Chemistry — (Continued), Pharmacy. Caspari's Pharmacy.— Just Ready. A Treatise on Pharmacy, for Students and Pharmacists. By Charles Caspari, Jr, Ph. G., Professor of the Theory and Practice of Piannacy in the Maryland College of Pharmacy, Joint Editor of The National Dispensatory, fifth edition. In one very handsome octavo volume of 678 pages, with 288 engravings. Cloth, §4.50. The author is widely known as joint editor of The National Dispensatory (see next page) and as Professor of Pharmacy in one of the foremost pharmaceutical colleges in America. He is therefore exceptionally qualified to prepare a work of the highest merit, both as a text-book for students, and as a practical reference for pharmacists m all the multifarious details of their operations. Modern in every particular, convenient in size through avoid- ance of obsolete and unnecessary matter, and richly illustrated, Caspari's Pharmacy is equally assured of immediate popularity with pharmacists and of adoption as the standard text-book for pharmaceutical students. Vaughan & No?y on Ptomains and Leucomains— New Ed. Ptomains, Leucomains, Toxines and Antitoxines. By Victor C. Vaughan. Ph. D., M. D., Professor of Physiological and Pathological Chemistry, and Associate Professor of Therapeutics and Materia Medica in the University of Michigan, and Frederick G. Novy, M. D., Instructor in Hygiene and Physiological Chemistry in the University of Michigan. New (third) edition. In one 12mo. volume of about 500 pages. In press. A notice of the previous issue is appended. This book is one that is of the greatest import- ance, and the modern physician who accepts bacterial pathology cannot have a complete knowledge of this subject unless he has carefully perused it. To the toxicologist the subject is alike of great import, as well as to the hygienist and sanitarian. It contains information which is not easily obtained elsewhere, and which is of a kind that no medical thinker should be without. — The American Journal of the Medical Sciences. Remsen's Theoretical Chemistry.— Fourth Edition. Principles of Theoretical Chemistry, with special reference to the Con- stitution of Chemical Compounds. By Ira Bemsen, M. D., Ph. D., Professor of Chem- istry in the Johns Hopkins University, Baltimore. Fourth and thoroughly revised edi- tion. In one handsome royal 12mo. volume of 325 pages. Cloth, $2 00. The fourth edition of Professor Remsen's well- I lation into German and Italian speaks for its ex- known book comes again, enlarged and revised, alted position and the esteem in which it is held Each edition has enhanced its value. We may say j by the most prominent chemists. We claim for without hesitation that it is a standard work on this little work a leading place in the chemical the theory of chemistry, not excelled and scarcely literature of this country. — The American Journal equalled by any other in any language. Its trans- | of the Medical Sciences. Charles' Physiological and Pathological Chemistry. The Elements of Physiological and Pathological Chemistry. A Handbook for Medical Students and Practitioners. Containing a general account of Nutrition, Foods and Digestion, and the Chemistry of the Tissues, Organs, Secretions and Excretions of the Body in Health and in Disease. Together with the methods for pre- paring or separating their chief constituents, as also for their examination in detail, and an outline syllabus of a practical course of instruction for students. By T. Cranstoitn Charles, M. D., F. E. S.~ M. S., formerly Assistant Professor and Demonstrator of Chem- istry and Chemical Physics, Queen's College, Belfast. In one handsome octavo volume of 463 pages, with 38 woodcuts and 1 colored plate. Cloth, $3.50. Dr. Charles is fully impressed with the impor- | nowadays. Dr. Charles has devoted much space tance and practical reach of his subject, and he to the elucidation ot urinary mysteries. He does has treated it in a competent and instructive man- this with much detail, and yet in a practical and ner. We cannot recommend a better book than intelligible manner. In fact, the author has filled the present. In fact, it fills a gap in medical text- \ his book with many practical hints.— Medical Rec- books, and that is a thing which can rarely be said j ord. Hoffmann and Powers' Analysis. A Manual of Chemical Analysis, as applied to the Examination of Medi- cinal Chemicals and their Preparations. Being a Guide for the Determination of their Identity and Quality, and for the Detection of Impurities and Adulterations. For the use of Pharmacists, Physicians, Druggists and Manufacturing Chemists, and Pharmaceu- tical and Medical Students. By Frederick Hoffmann, A. M., Ph. D., Public Analyst to the State of New York, and Frederick B. Power, Ph. D., Professor of Analytical Chem- istry in the Philadelphia College of Pharmacy. Third edition, entirely rewritten and much enlarged. In one octavo volume of 621 pages, with 179 illustrations. Cloth, $4.25. Ralfe's Clinical Chemistry. Clinical Chemistry. By Charles H. Eaefe, M. D., F. E. C. P., Assistant Physician at the London Hospital. In one pocket-size 12mo. volume of 314 pages, with 16 illus. Limp cloth, red edges, $1.50. See Students' Series of Manuals, page 30. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. Pharmacy, flateria fledica, Therapeutics. 11 NEW AND THOROUGHLY REVISED EDITION. The National Dispensatory. Containing the Natural History, Chemistry, Pharmacy, Actions and Uses of Medi- cines, including those recognized in the Pharmacopoeias of the United States, Great Britain and Germany, with numerous references to the French Codex. By Alfred Stille, M. D., LL. D , Profess rr Emeritus of the Theory and Practice of Medicine and of Clinical Medicine in the University of Pennsylvania, John M. Maisch, Phar. D., late Professor of Materia Medica and Botany in Philadelphia College of Pharmacy, Secretary to the American Pharmaceutical Association, Charles Caspari, Jr., Ph. G., Professor of Pharmacy in the Maryland College of Pharmacy, Baltimore, and Henry C. C. Maisch, Ph. G., Ph.' D. New (fifth) edition, thoroughly revised in accordance with the new U. S. Pharmacopoeia (Seventh Decennial Eevision). In one magnificent imperial octavo volume of 1910 pages, with 320 engravings. Cloth, $7.25 , leather, $8.00. With Ready Eeference Thumb letter Index, cloth, $7.75; leather, $8.50. ON the first appearance of The National Dispensatory fifteen years ago it was at once recognized by the pharmaceutical and medical professions as satisfying the need for a work affording all necessary information upon its subject, with authoritative accuracy, and with a completeness and convenience attainable only by the exclusion of obsolete matter. Its success in filling this want is fully attested by the rapid demand for five editions, and the opportunity thus afforded has been well used in successive revisions, each placing it abreast of the day and maintaining the characteristics which had won for it a leading position. Of all its issues the present embodies the results of the most exhaustive revision. The sweeping changes in the new United States Pharmacopoeia are thoroughly incorpor- ated, with official authorization of the Committee of Eevision, and full use has been made of all valuable material in the latest issues of foreign Pharmacopoeias. The volume is accordingly rich in pharmaceutical and chemical information, with data, formulas, tables, etc., gathered from all official sources, but this constitutes only a single department of its usefulness. As an encyclopaedia of the latest and best therapeutical knowledge it deals not only with all official drugs, but also with all the new synthetic remedies of value and with the unofficial prep irations now so largely in use. Pharmacists will appreciate its systematic descriptions of the materia medica, its clear explanations of chemical and pharmaceutical processes and tests, and its illustrations of important drugs and of the most improved apparatus. Physicians will readily perceive the indispensable assistance offered by its authoritative statements as to the efficacy of drugs in the light of the most recent medical advances. Arranged alphabetically in the text, this information is placed most suggestively at command by the recommendations grouped under the various Diseases in the Therapeutical Index. Together with the General Index this covers more than one hundred treble-columned pages containing 25,000 references. The immensity of detail comprised in this single volume of 1900 pages is thus most forcibly indicated. Though the present edition contains far more matter than its predecessor it is maintained at the same price in view of the ever- increasing demand. 'Weights and Measures are given in both Ordinary and Metric Systems. In brief the new edition of The National Dispensatory is presented to the medical and pharmaceutical professions as the equivalent of a whole library of pharmaceutical and therapeutic information ; it is the standard of accuracy, the embodiment of completeness without inconvenient bulk, and a marvel of cheapness owing to the widespread demand for it as the authority. The careful examination of this large volume will strike the reader with surprise at the great number of new articles added, and the amount of useful and accurate information regarding their properties, methods of preparation and therapeu- tical effects. The large number of new articles containing all the latest synthetic remedies and unofficial remedies, compass the entire range of available information in the line of the work. A number of very complete tables together with all the official re-agents and solutions for qualitative and quantitative tests, appear in the appendix. Altogether this work maintains its previous high reputation for accuracy, practical useiulness and encyclopaedic scope, and is indispensable alike to the pharmacist and physician. Every druggist knows of it and uses it, and almost every physi- cian properly consults it when desirous of settling all doubtful questions regarding the properties, preparation and uses of drugs. — Medical Record. The descriptions of materia medica are clear, thorough and systematic, as are also the explana- tions of chemical and pharmaceutical processes and tests. The therapeutical portion has been re- vised with equal care and the statements of the action and uses have been arranged not only alphabetically under the various drugs, but for practical medical usefulness have also been placed at the instant command of those seeking infor- mation in the treatment of special diseases by being arranged under the various diseases in a therapeutical index. The readiness with which any of the vast amount of information contained in this work is made available is indicated by the twenty-five thousand references in the two in- dexes at the end of the volume. — Boston Medical and Surgical Journal. It is the official guide for the medical and phar- maceutical professions. — Buffalo Medical and Sur- gical Journal. The book is recommended most highly as a book of reference for the physician and is invalu- able to the druggist in his every-day work. — The Therapeutic Gazette. This edition of the Dispensatory should^be recog- nized as a national standard. — The North American Practitioner. Lea Brothers & Co., Publishers, 706, 708 & 770 Sanson) Street, Philadelphia. 12 Therapeutics, flateria Fledica — (Continued). Hare's Text-Book of Practical Therapeutics.— New (5th) Edition. A Text-Book of Practical Therapeutics ; With Especial Reference to the Application of Remedial Measures to Disease and their Employment upon a Rational Basis. By Hobart Amory Hare, M. D., Professor of Therapeutics and Materia Medica in the Jefferson Medical College of Philadelphia ; Sec. of Convention for Revision of U. S. Pharmacopoeia. With special chapters by Drs. G. E. de Schweinitz, Edward Martin and Barton C. Hirst. New (5th) and revised edition. In one octavo volume of 740 pages. Cloth, $3.75 ; leather, $4.75. Just ready. A few notices of the previous edition are appended. We deem the portion of the work descriptive of remedies admirable by reason of the clearness and conciseness with which it is written. The descriptions of diseases, though exceedingly- brief, are nevertheless sufficiently explicit and so expressed as to render the work a very practical text-book, and also one which will serve prac- titioners for ready reference. The methods of practical needs of every-day medicine com- mended it from the first to the progressive and working therapeutist. It is not only knowing what to give, but when and where to give, and how the drug will act in given conditions, that makes one a scientific practitioner rather than an ignorant empiric. The book in such respects supplies every need. The author is well known treatment are at once sensible and practical. The as a progressive therapeutist, and it goes without more experienced the practitioner who turns to this book for reference, the more sure will be the approval of the methods of treatment here pro posed. — The North American Practitioner. The fact that the fourth edition of this work has appeared within four years attests its value to the general practitioner, and its appreciation by the medical student. Its wide application to the saying that all the new or valuable drugs receive their lull share of attention, and it is a great deal to say in this, as with other features, that the book is up-to-date in everything pertaining to the prac- tical therapeutical needs of the practitioner. The work has also been revised in such a way as to make it uniform with the United States Pharma- copoeia. — Medical Record. Maisch's Materia Medica.— New (6th) Edition. Just Ready. A Manual of Organic Materia Medica; Being a Guide to Materia Medica of the Vegetable and Animal Kingdoms. For the Use of Students, Druggists, Pharmacists and Physicians. By John M. Maisch, Phar. D., Prof, of Materia Medica and Botany in the Philadelphia College of Pharmacy. New (sixth) edition, thoroughly revised by H. C. C. Maisch, Ph.Gr., Ph. D. In one very handsome 12mo. volume of 509 pages, with 285 engravings. Cloth, $3.00. A notice of the previous edition is appended. We have nothing but praise for Professor Maisch's work. It presents no weak point, even for the most severe critic. The book fully sustains the wide and well-earned reputation of its popular author. After a careful perusal of the book, we do not hesitate to recommend Maisch's Manual] book. — Medical News. of Organic Materia Medica as one of the best, if not the best work on the subject thus far published. Its usefulness cannot well be dispensed with, and students, druggists, pharmacists and physicians should all possess a copy of such a valuable A System of Practical Therapeutics BY AHERICAN AND FOREIGN AUTHORS. Edited by HOBART AflORY HARE, H. D. Professor of Therapeutics and Materia Medica in the Jefferson Medical College of Philadelphia. In a series of contributions by seventy-eight eminent authorities. In three large octavo volumes of 3544 pages, with 434 illustrations. Price, per volume : Cloth, $5.00 ; leather, $6.00 ; half Russia, $7.00. For sale by subscription only. Address the Publishers. The various divisions have been elaborated by j is the treatment of disease, and a work which con- men selected in view of their special fitness. In j tributes to its successful management is to be every case there is to be found a clear and concise : looked upon as of vast use to humanity. It can- description of the disease under consideration, | not be denied that therapeutic resources, whether corresponding with the most recent and well- | the treatment be confined to the mere administra- established views of the subject. In treating of | tion of drugs, or allowed its more extended appli- the employment of remedies and therapeutical cation to the management of disease, have so measures, the writers have been singularly happy in giving in a definite way the exact methods em- ployed and the results obtained, both by them- selves and others, so that one might venture with confidence to use remedies with which he was previously entirely unfamiliar. The practitioner could hardly desire a book on practical thera- peutics which he could consult with more interest and profit. — The North American Practitioner. The scope of this work is beyond that of any previous one on the subject. The goal, after alJ, greatly multiplied within the last few years as to render previous treatises of little value. Herein will be found the great value of ii are's encyclo- pedic work, which groups together within a single series of volumes the most modern methods known in the management of disease. "We can- not commend Hare's System of Practical Thera- peutics too highly; it stands out first and foremost as a work to be consulted by authors, teachers, and physicians throughout the world. — Buffalo Medical and Surgical Journal. Edes' Therapeutics and Materia Medica. A Text-Book of Therapeutics and Materia Medica. Intended for the Use of Students and Practitioners. By Bobert T. Edes, M. D., Jackson Professor of Clinical Medicine in Harvard University. Octavo, 544 pp. Cloth, $3.50 ; leather, $4.50. COHEN'S HANDBOOK OF APPLIED THERA- PEUTICS. B«ing a Study of Principles Applic- able and an Exposition of Methods Employed in the Management of the Sick. Bv Solomon Solis-Cohen, M D., Professor of Clinical Medi- cine and Applied Therapeutics in the Philadel- phia Polyclinic. In one large 12mo. volume, with illustrations. Preparing. STILLE'S THERAPEUTICS AND MATERIA MEDICA. A Systematie Treatise on the Action and Uses of Medicinal .Agents, including their Description and History. Fourth edition, re- vised and enlarged. In two octavo volumes, coq- taining 1936 pages. Cloth, §10.00 ; leather, §12.00. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. Practice of Fledicine. 13 SEVENTH EDITION. FLINT'S PRACTICE OF MEDICINE A Treatise on the Principles and Practice of Medicine. Designed for the use of Students and Practitioners of Medicine. By Austin Flint, M. L>., LL. D., Professor of the Principles and Practice of Medicine and of Clinical Medicine in Belle- vue Hospital Medical College, N. Y. Seventh edition, thoroughly revised by Fred- erick P. Henry, M. D., Professor of Principles and Practice of Medicine in the Woman's Medical College of Pennsylvania, Philadelphia. In one very handsome octavo volume of 1143 pages, with illustrations. Cloth, $5.00 ; leather, $6.00. Among the large number of new books upon the practice of medicine which have been presented to the profession within the last few years, there is none which will stand better in the present or in the future than the seventh edition of this book. It has been a characteristic of Dr. Flint's book that its descriptions of clinical cases and of the practical side of diseases have always been wonderfully true to life. Further than this, we think the profession is to be congratulated that the publishers, in obtaining an editor, chose one so peculiarly well qualified to revise and bring up to date those articles in connection with which the greatest progress has been made in medical study, for Dr. Henry represents at once that side of professional life which appreciates all that is good and at the same time is not so optimistic as to swallow in addition much that is bad. We be- lieve that the profession, the teachers, and the students of the country will appreciate this volume as being one of the best all-around text-books which they can obtain. — Therapeutic Gazette. Its peculiar excellences and its breadth of con- ception have made it a recognized authority from the time its first edition appeared. The author was a born teacher, an indefatigable observer, a f>ainstaking worker and a thorough medical phil- osopher. His clinical pictures of diseases are models of graphic description, minuteness of detail and breadth of treatment This may appear to be high praise, but the work has so well earned its leading p'ace in medical literature that but one view can be expressed concerning its general character as a text-book. The editor has done his part in bringing it up to date, not only in refer- ence to treatment and the adaptation of the newer remedies, but has made numerous additions in the shape of the newly discovered forms of disease, and has elaborated much in the commoner forms which the recent advances have made necessary. The element of treatment is by no means ne- glected ; in fact, by the editor a fresh stimulus is given to this necessary department by a compre- hensive study of all the new and leading thera- peutic agents. — Medical Record. Hartshorne's Essentials of Practice.— Fifth Edition. Essentials of the Principles and Practice of Medicine. A Handbook for Students and Practitioners. By Henry Hartshorne, M. D., LL. D., lately Professor of Hygiene in the University of Pennsylvania. Fifth edition, thoroughly revised and rewritten. In one 12mo. vol. of 669 pages, with 144 illus. Cloth, $2.75 ; half leather, $3. Farquharson's Therapeutics and Materia Medica.— 4th Ed. A Guide to Therapeutics and Materia Medica. By Kobert Far- qtjharson, M. D., F. K. C. P., LL. D., Lecturer on Materia Medica at St. Mary's Hospi- tal Medical School, London. Fourth American, from the fourth English edition. Enlarged and adapted to the U. S. Pharmacopoeia. By Frank Woodbury, M. D., Pro- fessor of Materia Medica and Therapeutics and Clinical Medicine in the Medico-Chi- rurgical College of Philadelphia. In one handsome 12mo. vol. of 581 pp. Cloth, $2.50. It may correctly be regarded as the most modern work of its kind. It is concise, yet complete. Containing an account of all remedies that have a p±ace in the British and United States Pharma- copoeias, as well as considering all non-official but important new drugs, it becomes in fact a miniature dispensatory. — Pacific Medical Journal. Brace's Materia Medica and Therapeutics.— Fifth Edition. Materia Medica and Therapeutics. An Introduction to Rational Treat- ment. By J. Mitchell Bruce, M. D., F. R. C. P., Physician and Lecturer on Materia Medica and Therapeutics at Charing-Cross Hospital, London. Fifth edition. In one 12mo. volume of 591 pages. Cloth, $1.50. See Students 1 Series of Manuals, page 30. The pharmacology and therapeutics of each drug are given with great fulness, and the indications for its rational employment in the practical treatment of disease are pointed out. The Materia Medica proper contains ah that is necessary for a medical student to know at the present day. The third part of the book contains an outline of general therapeutics, each of the symptoms of the body being taken in turn, and the methods of treat- ment illustrated. A lengthy notice of a book so well known is unnecessary.— -.Med. Chronicle. FLINT'S PRACTICAL TREATISE ON THE DIAGNOSIS, PATHOLOGY AND TREATMENT OF DISEASES OF THE HEART. Second re- vised and enlarged edition. In one octavo vol- ume of 550 pagps, with a plate. Cloth, $4. FLINT ON PHTHISIS In one octavo volume of 442 pages. Cloth, $3.50. FLINT'S ESSAYS ON CONSERVATIVE MEDI- CINE AND KINDRED TOPICS. In one very handsome royal 12mo. volume of 210 pages. Cloth, $1.38. LYONS' TREATISE ON FEVER. In one Svo. volume af 354 pages. Cloth, $2.25. HUDSON'S LECTURES ON THE STUDY OF FEVER. In one octavo volume of 308 pages. Cloth, $2.50. LA ROCHE ON YELLOW FEVER, in its Histori- cal, Pathological, Etiological and Therapeutical Relations. Two octavo vols., 1468 pp. Cloth, $7.00. BRUNTON'S PHARMACOLOGY, THERAPEU- TICS AND MATERIA MEDICA. Octavo, 1305 pages, 230 illustrations. HERMANN'S EXPERIMENTAL PHARMACOL- OGY. A Handbook of Methods for Determining the Physiological Action of Drugs. Translated, with the Author's permission, and with exten- sive additions, by R. M. Smith, M. D. 12mo., 199 pages, with 32 illustrations. Cloth, $1.50. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 14 Prac. of fledicine, Treatment, Digestive Syst. Lyman's Practice of Medicine. The Principles and Practice of Medicine. For the Use of Medical Students and Practitioners. By Henry M. Lyman, M.D., Professor of the Principles and Practice of Medicine, Rush Medical College, Chicago. In one verv handsome octavo Cloth, $4.75 ; leather, $o.75. ascertain in a short time all the necessary facts concerning the pathology or treatment of any dis- ease will find here a safe and convenient guide. — The Charlotte Medical Journal. The reader of the above volume will be at once struck with its excellence. Its contents are com- plete and concise, it is fully abreast with the times, and is suih a book as is needed by students and practitioners. The average doctor tias neither the time nor the patience to read through the pages of an encyclopedia to gain the points he desires. This Practice will give him all the necessary in- formation in a form easily grasped. The parts of chapters relating to differential diagnosis leave nothing to be desired; they show the author's familiarity with his subjects, and bis methods as a teacher. Evidently the points are not culled from other volumes; they bear the stamp of originality. In a word, the volume is up to date, is readable and instructive, and is far superior to the majority of books of the kind. — University Medical Magazine. volume of 925 pages, with 170 illustrations, Professor Lyman's valued and extensive expe- rience here reduced in text- book form, is indeed very valuable both to college students and physi- cians. In this work we have aa excellent ti eatise on the practice of medicine, written by one who is not only familiar with his subject, but who has also learned through practical experience in teach- ing what are the needs of the student and how to present the facts to his mind in the most readily assimilable form. Each subject is taken up in order, treated clearly but briefly, and dismissed when all has been said that need be said in order to give the reader a clear cut picture of the dis- ease under discussion. The reader is not con- fused by having presented to him a variety of different methocs of treatment, among which he is left to choose the one most easy of execution, but the author describes the one whir>h is, in his judgment, the best. This is as it should be. The student and even the practitioner, should be taught the most approved method of treatment. The practical and busy physician, who wants to The Year-Book of Treatment for 1895, A Comprehensive and Critical Review for Practitioners of Medi- cine and Surgery. In one 12mo. vol. of 495 pages. Cloth, $1.50. **# For special commutations with periodicals see pages 1 and 2. It would be difficult indeed to imagine a book more nearly suited to the every day need3 of the medical practitioner or writer than this. The con- tributors to this volume are among the most promi- nent and well-known writers and teachers of the day, and their articles and opinions will be appre- ciated by all who are fortunate and wise enough to secure them. It is the very book the busy practitioner needs. He can find anything pertain- ing to any subject in a moment's time, and he may rest assured that it is the most modern and reliable view now accepted. It, year by year, keeps him apprised of important advances in all branches of medicine, and presents them in a well-con- densed and classified form. — The Charlotte Med- ical Journal, May, 1895. The Year-Books of Treatment for 1891, 1892, and 1893. 12mos., 485 pages Cloth, $1.50 each. The Year-Books of Treatment for 1888 and 1887. Habershon on the Abdomen. On the Diseases of the Abdomen ; Comprising those of the Stomach, and other parts of the Alimentary Canal, (Esophagus, Cascum, intestines and Peritoneum. By S. O. Habershon, M. D., Senior Physician to and late Lecturer on Principles and Prac- tice of Medicine at Guy's Hospital, London. Second American from third enlarged and revised English edition. In one handsome octavo vol. of 554 pages, with illus. Cloth, $3.50. This valuable treatise on diseases of the stomach rectum. A. fair proportion of each chapter is and abdomen will be found a cyclopaedia of infor- mation, systematically arranged, on all diseases of the alimentary tract, from the mouth to the devoted to symptoms, pathology, and therapeutics. — New York Medical Journal. TANNER'S MANUAL OF CLINICAL MEDICINE I AND PHYSICAL DIAGNOSIS. Third American from the second London edition. Revised am v ' enlarged by Tilbury Fox. M.D. In one 12mo. volume of 362 pp. with illus. Cloth, $1.50 DAVIS' CLINICAL LECTURES ON VARIOUS IMPORTANT DISEASES. By N. S. Dins, I M. D. Edited by Frank H. Davis, M. D Second edition. 12mo. 287 pages. Cloth,' $1 .1- WALSHE ON THE DISEASES OF THE HEART AND GREAT VESSELS. Third American edi- tion. In 1 vol. 8vo., 418 pp. Cloth, $3.00. HOLLAND'S MEDICAL NOTES AND REFLEO ' TIONS. 1 vol. 8vo., pp. 493. Cloth, $3.50. TODD'S CLINICAL LECTURES ON CERTAIN ACUTE DISEASES. In one octavo volume of 320 pages. Cloth. $2.50. FLINT'S PRACTICAL TREATISE ON THE PHYSICAL EXPLORATION OF THE CHEST AND THE DIAGNOSIS OF DISEASES AF- FECTING THE RESPIRATORY ORGANS. Second and revised edition. In one handsome octavo volume of 591 pages. Cloth, $4.50. STURGES' INTRODUCTION TO THE STUDY | OF CLINICAL MEDICINE. Being a Guide to the Investigation of Disease. In one handsome 12mo. volume of 127 pages. Cloth, $1.25. REYNOLDS' SYSTEM OF MEDICINE. With notes and additions by Henry Hartshorne, A.M., M. D. Three octavo volumes, containing 3056 double-columned pages, with 317 illustrations. Price per volume, cloth, $5.00; sheep, $6.00 ; half Russia, $6.50. Subscription only. WATSON'S LECTURES ON THE PRINCIPLES AND PRACTICE OF PHYSIC. Edited with additions, and 190 illustrations, by Henry Harts- horxe, A.M., M.D. In two large octavo volumes of 1840 pages Cloth, $9.00; leather, $11.00. PEPPER'-; SYSTEM OF PRACTICAL MEDI- CINE BY AMERICAN AUTHORS Edited by William Pepper, M. D., LL. D., Provost and Professor of the Tneoryand Practice of Medi- cine and of Cliuical Medicine in the Univer- sity of Pennsylvania. The complete work, in five volumes, contains 5573 pages, with 193 illus- trations. Price, per volume, cloth, $5; leather, $3; half Russia, $7. Subscription only. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. Practice of fledicine, Diagnosis, Heart. 15 Musser's Medical Diagnosis. A Practical Treatise on Medical Diagnosis. For the Use of Students and Practitioners. By John H. Mdsser, M. D., Assistant Professor of Clinical Medicine, University of Pennsylvania, Philadelphia. !n one very handsome octavo volume of 873 pages, with 162 illustrations and 2 colored plates. Cloth, |5; leather, $6. The aim of the author has been to make the work eminently practical. Dr. Musser has succeeded in bringing together a large and valuable collection of clinical data drawn from his own extended experience and from exhaustive literary research, and has presented them in an unusually clear and concise manner. In brief, the book is thoroughly modern, readable and in- structive, and, we believe, superior to any work of the kind before the profession.— University Medical Magizine. Modern methods of medical teaching and study have rendered treatises like the present an abso- lute necessity. The present work is to be com- mended alike for its logical arrangement, accurate observation and clearness of expression. The chapter on bacteriology is especially commenda- ble, because it contains everything practically necessary for clinical work. — Medical Record. The book should receive a hearty reception from students and medical men; it contains much in- formation essential to good, scientific medical work. It is with pleasure that we can state that the work has been adopted as a text- book at the Johns Hopkins Medical School and Harvard Uni- versity, and that it has met with marked approval in other teaching centres. — International Medical Magazine. The whole book impresses one as being the concentration of a very thorough knowledge of all the fact* resorted to in the making of a careful diagnosis by means of modern methods. Dr. Musser's book will at once take a prominent and permanent position among the text-books of the medical schools of the country, and we recom- mend it most highly to those practitioners who wish not only to get the views of the general pro- fession in regard to important points of diagnosis, but who also desire a work in which the author expresses his own opinions, based upon careful observation and wide experience. — The Thera- peutic Gazette. Flint on Auscultation and Percussion.— Fifth Edition. A. Manual of Auscultation and Percussion ; Of the Physical Diagnosis of Diseases of the Lungs and Heart, and of Thoracic Aneurism. By Austin Flint, M. D., LL. D., Professor of the Principles and Practice of Medicine in Bellevue Hospital Medi- cal College, New York. Fifth edition. Edited by James C. Wilson, M. D., Lecturer on Physical Diagnosis in the Jefferson Medical College, Philadelphia. In one hand- some royal 12mo. volume of 274 pages, with 12 illustrations. Whitla's Dictionary of Treatment. A Dictionary of Treatment ; or Therapeutic Index, including Medical and Surgical Therapeutics. By William Whitla, M. D., Professor of Materia Medica and Therapeutics in the Queen's College, Belfast. Revised and adapted to the United States Pharmacopoeia. In one square, octavo vol. of 917 pp. Cloth, $4.00. We have already dictionaries of medicine and dictionaries of surgery; Dr. Whitla now provides us with a dictionaryof treatment. And reference to the volume shows that it really is what it professes to be. The several diseased condi- tions are arranged in alphabetical order, and the methods— medical, surgical, dietetic, and climatic— by which they may be met, considered. On every page we find clear and detailed direc- tions for treatment supported by the author's personal authority and experience whilst the recommendations of other competent observers are also critically examined. The book abounds with useful, practical hints and suggestions, and the younger practitioner will find in it exactly the help he so often needs in the treatment both of those who are ill, and those who are ailing. At the same time the most experienced members of the profession may usefully consult its pages for the purpose of learning what is really trustworthy in the later therapeutic developments. The Diction- ary is, in short, the recorded experience of a prac- tical scientific therapeutist, who has carefully studied diseases and disorders at the bed-side and in the consulting-room, and has earnestly ad- dressed himself to the cure and relief of his patients. — The Glasgow Medical Journal. Taylor's Index of Medicine.— Just Ready. An Index of Medicine. By Seymour Taylob, M. D., M. E. C. P., Assistant Physician to the West London Hospi lal. In one 12mo. vol. of 802 pages. Cloth, $3.75. The author ha3 prepared a work of great value systems of the body are considered, and the alike to physicians and students. The volume is j cause, symptoms, pathology, treatment and a concise "Practice of Medicine," the diseases j prognosis of each affection are succinctly stated, being grouped systematically in order to secure I Numerous illustrations together with tabulations for the reader the many advantages resulting | of differential diagnosis, tests, etc., elucidate the from rational arrangement. After valuable chap- text and condense a great amount of necessary ters on "Disease," "General Pathology," "Gen knowledge in the clearest manner. The work is eral Diseases," "Specific Infectious Diseases" | one which merits and will doubtless obtain a and "Specific Fevers," the various organs and i wide popularity.— The St. Louis Clinique, May, 1895. Fothergill's Handbook of Treatment.— Third Edition. The Practitioner's Handbook of Treatment ; Or, The Principles of Therapeutics. By J. Milner Fothergill, M. D., Edin., M. E. C. P., Lond., Physician to the City of London Hospital for Diseases of the Chest. Third edition. In one 8vo. volume of 681 pages. Cloth, $3.75 ; leather, $4.75. This is a wonderful book. If there be such a together in a single chapter, and the relations thing as "medicine made easy," this is the work to between the two clearly stated, cannot fail to prove accomplish this result.— Virainia Medical Monthly, a great convenience to many thoughtful but busy To have a description of the normal physiologi- physicians. The practical value of the volume is cal processes of an organ and of the methods of greatly increased by the introduction of many treatment of its morbid conditions brought prescriptions.— New York Medical Journal. BROADBENT ON THE PULSE. In one 12mo. volume of 312 pages. Cloth, $1.75. See Series oj Clinical Manuals, page 30. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 16 Practice, Electricity, Cholera, Food, Hygiene. Hayem & Hare's Physical & Natural Therapeutics.— Just Ready. Physical and Natural Therapeutics. The Eemedial Use of Heat, Electricity, Modifications of Atmospheric Pressure, Climates, and Mineral Waters. By Georges Hayem, M.D., Professor of Clinical Melicine in the Faculty of Medicine of Paris. Edited with the assent of the author, by Hobart Amory Hare, M.D., Professor of Therapeutics in the Jefferson Medical College of Philadelphia. In one handsome octavo volume of 414 pages with 113 engravings. Cloth, $3.00. For many diseases the most potent remedies lie outside of the Materia Medica, a fact yearly attaining wider recognition. Within this large range of applicability physical agencies when compared with drugs are more direct and simple in their results. Medical literature has long been rich in treatises upon medicinal agents, but an authoritative work upon the other great branch of therapeutics has until now been a desideratum. The author and editor of this work enjoy equal standing, and the volume is certain to command attention and to render wide-spread service. The section on Climate, rewritten by Professor Hare, will for the first time, place the abundant resources of our own countiy at the intelligent command of American practitioners. The extended section on Medical Electricity, likewise rewritten, conforms to the American development of this subject, and explains the many excellent forms of apparatus readily available in this country. Herrick's Diagnosis.— Just Ready. A Handbook of Diagnosis. By James B. Herrick, M.D., Adjunct Pro- fessor of Medicine, Rush Medical College, Chicago. In one handsome 12mo. volume of 429 pages, with 80 engravings and 2 colored plates. Cloth, $2.50. This work affords students a compendious guide to the art of identifying disease. Prac- titioners likewise will find in its carefully prepared and well-illustrated pages a convenient means of refreshing and supplementing their knowledge of a department of medicine which underlies rational and successful treatment. Yeo's Medical Treatment. A Manual of Medical Treatment or Clinical Therapeutics. By 1. Burney Yeo, M. D., F. E. C. P., Prof, of Clinical Therapeutics in King's Coll., London. In two 12mo. volumes containing 1275 pages, with illustrations. Cloth, $5.50. The discussion of the different ailments has a j tion, which is a feature that cannot be too highly distinctly practical turn toward the main purpose j commended. It cannot fail to be an exceedingly of the book. Standard formulae are introduced useful, suggestive and instructive work to the from eminent practitioners, and all the drugs of physician who wishes to be well up ia the present recognized value are grouped in the order of their advanced and scientific therapeutics of the day. — importance. The dosage receives careful atten- Medical Record. Yeo on Food in Health and Disease. Food in Health and Disease. By I. Burney Yeo, M.D., F.R.C. P., Professor of Clinical Therapeutics in King's College, London In one 12mo. volume of 590 pages. Cloth, $2 00. See Series of Clinical Manuals, page 30, compass, and he has arranged and digested his materials with skill for the use of the practitioner. We have seldom seen a book which more thor- oughly realizes the object for which it was written than this little work of Dr. Yeo.— British Medical Dr. Yeo supplies in a compact form nearly all that the practitioner requires to know on the subject of diet. The work is divided into two parts — food in health and food in disease. Dr. Yeo has gathered together from all quarters an immense amount of useful information within a comparatively small Journal. BartMow on Cholera. Cholera : Its Causes, Symptoms, Pathology and Treatment. By Roberts Bartholow, M. D., LL. D., Emeritus Professor of Materia Medica, General Therapeutics and Hygiene in the Jefferson Medical College of Philadelphia. In one 12mo. volume of 127 pages, with 9 illustrations. Cloth, $1.25. Richardson's Preventive Medicine. Preventive Medicine. By B. W. Richardson, M. D., LL. D., F. R. S., Fel- low of the Royal Coll. of Phys., London. In one 8vo. vol. ot 729 pp. Cloth, $4; leather, $5. There is perhaps no similar work written for scholarly ; the discussion of the question of disease the general public that contains such a complete, is comprehensive, masterly and fully abreast with reliable and instructive collection of data upon the latest and best knowledge on the subject, and the diseases common to the race, their origins, the preventive measures advised are accurate, causes, and the measures for their prevention, j explicit and reliable.— TheAmerican Journal of the The descriptions of diseases are clear, chaste and ; Medical Sciences BARTHOLOW'S PRACTICAL TREATISE ON THE APPLICATIONS OF ELECTRICITY TO MEDICINE AND SURGERY. By Roberts Bartholow, A.M., M.D., LL.D., Emeritus Pro- fessor of Materia Medica and General Thera- peutics in the Jefferson Med. Coli. of Philadel- phia, etc. Third edition. In one octavo volume of 308 pages, with 110 illustrations. PAVY'S TREATISE ON THE FUNCTION OF DI- GESTION; its Disorders and their Treatment. From the second London edition. In one octavo volume of 238 pages. Cloth, $2.00. SCHREIBER'S MANUAL OF TREATMENT BY MASSAGE AND METHODICAL MUSCLE EX- ERCISE. Translated by Waiter Mendelson, M.D., of New York. In one 8vo. volume of 274 pp., with 117 engravings. CHAMBERS' MANUAL OF DIET AND REGIMEN IN HEALTH AND SICKNESS. In one hand- gome octavo volume of 302 pp. Cloth, 82.75. STILLE ON CHOLERA: Its Origin, History, Causation, Symptoms, Lesions, Prevention and Treatment. In one handsome 12mo. volume of 163 pages, with a chart. Cloth, $1.25. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. Throat, Nose, Lungs, Hind, Nerves, 17 Seiler on the Throat and Nose.— Fourth Edition. A Handbook of Diagnosis and Treatment of Diseases of the Throat, Nose and Naso-Pharynx. By Carl Seiler, M.D., Lecturer on Laryngoscopy in the University of Pennsylvania. Fourth edition. In one handsome 12nio. volume of 414 pages, with 107 illustrations and 2 colored plates. Cloth, $2.25. 1 come expeit in the use of the laryngeal mirror, a This little book is eminently practical, and will prove of interest not only to the specialist, but to :he general practitioner as well. It deals with the subject in a clear and distinct manner, and the text i* copiously il.ustrated with diagrams and colored plates. *S;> little attention is paid ordi- narily to the examination of the larynx that the need'of such a book has long been felt. By con suiting its pa^es anyone can learn the necessary manipulations, and, "by a little practice, soon be- method of examination too often neglected. The anatomy of the larynx is explained with especial care, and the operative procedures for various diseases of the throat, tonsils, etc., are carefully explained. Approved methods of tieatment are dealt with in a very satisfactory way, and all the most useful remedial agents are described. — International Medical Magazine. Browne on the Throat and Nose.— Fourth Edition The Throat and Nose and Their Diseases. By Lennox Browne, F. E. C. S., E., Senior Physician to the Central London Throat and Ear Hospital. Fourth and enlarged edition. In one imperial octavo volume of 751 pages, with 120 illustrations in color, and 235 engravings on wood. Cloth, $6.50. The subject is here exhaustively treated on lines of thorough acquaintance with the anatomy, the physiology and physics of the organs involved and the pathology of the disease to which they are subject. To the author we have awarded the credit of having added to a thorough understand- ing of the diseases with which he deals the choice of the best treatment afforded by the present state of knowledge. — The Amer, Practitioner and News. Although quite complete enough for the use of specialists, it is at the same time so clear as to be of daily value to the general practitioner, who will find at the end of the volume a number of well- tried formulas most in vogue at the London hos- pitals for diseases of the throat.— The Canada Medical Record. Tuke on the Influence of the Mind on the Body. Illustrations of the Influence of the Mind upon the Body in Health and Disease. Designed to elucidate the Action of the Imagination. By Daniel Hack Tuke, M. D., Joint Author of the Manual of Psychological Medicine, etc. New edition. Thoroughly revised and rewritten. In one 8vo. volume of 467 pages, with 2 colored plates. Cloth, $3 00. It is impossible to perase these interesting chap- ters without being convinced of the author's per- fect sincerity, impartiality, and thorough mental grasp. Dr. Tuke has exhibited the requisite amount of scientific address on all occasions, and the more intricate the phenomenathe more firmly has he adhered to a physiological and rational method of interpretation. Guided by an enlight- ened deduction, the author has reclaimed for science a most interesting domain in psychology, previously abandoned to charlatans and empirics. This book, well conceived and well written, must commend itself to every thoughtful understand- ing. — New York Medical Journal. Ross on Diseases of the Nervous System. A Handbook on Diseases of the Nervous System. By James Eoss, M. D., F. K. C.P., LL.D., Senior Assistant Physician to the Manchester Koyal Infirmary. In one octavo vol. of 725 pages, with 184 illus. Cloth, $4.50; leather, $5.50. Clouston on Mental Diseases. Clinical Lectures on Mental Diseases. By Thomas S. Clouston, M. D., Lecturer on Mental Diseases in the University of Edinburgh. With an Appen- dix, containing an Abstract of the Statutes of the United States and of the Several States and Territories relating to the Custody of the Insane. By Charles F. Folsom, M. D., Ass't Professor of Mental Diseases, Med. Dep. of Harvard Univ. In one octavo volume of 543 pages, with eight lithographic plates, four of which are colored. Cloth, $4. JiH^Dr. Folsom's Abstract also separate, in one 8vo. vol. of 108 pages, Cloth, $1.50. Playfair on Nerve Prostration and Hysteria. The Systematic Treatment of Nerve Prostration and Hysteria. By W. S. Playfair, M. D., F. B. C. P. In one 12mo. volume of 97 pages. Cloth, $1.00. savage on insanity and allied neu- KOSES. In one 12mo. volume of 551 pages, with 18 illustrations. Cloth, $2.00. See Serks of Clin- ical Manuals, page 30. BLANDFORD ON INSANITY AND ITS TREAT- MENT. Lectures on the Treatment, Medical and Legal, of Insane Patients. In one very handsome octavo volume. JONES' CLINICAL OBSERVATIONS ON FUNC- TIONAL NERVOUS DISORDERS. Second American Edition. In one handsome octavo volume of 340 pages. Cloth, $3.25. BROWNE ON KOCH'S REMEDY IN RELATION TO THROAT CONSUMPTION. In one octavo volume of 121 pages, with 45 illustrations, 4 of which are colored, and 11 charts, Cloth, $1.50. FULLER ON DISEASES OF THE LUNGS AND AIR-PASSAGES. Their Pathology, Physical Di- agnosis, Symptoms and Treatment. From the second and revised English edition. In one octavo volume of 475 pages. Cloth, $3.50. SLADE ON DIPHTHERIA; its Nature and Treat- ment, with an account of the History of its Pre- valence in various Countries. Second and revised edition. In one 12mo. vol., 158 pp. Cloth, $1.25. SMITH ON CONSUMPTION ; its Early and Reme- diable Stages. 1 vol. 8vo., 253 pp. Cloth, $2.25. LA ROCHE ON PNEUMONIA. 1 vol. Svo. of 490 pages. Cloth, $3.00. WILLIAMS ON PULMONARY CONSUMPTION; its Nature, Varieties and Treatment. With an analysis of one thousand cases to exemplify its duration. In one 8vo. vol. of 303 pp. Cloth, $2.50. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 18 Nervous and flental Diseases, Histology. Dercum on Nervous Diseases— Just Ready. A Text-Book on Nervous Diseases. By American Authors. Edited bv F. X. Derccm, M.D., Clinical Professor of Diseases of the Nervous System in the Jefferson Medical College, Philadelphia. In one handsome octavo volume of 1054r pages, with 341 engravings and 7 colored plates. Cloth, $6.00 ; leather, $7.00. LIST OF CONTRIBUTORS. N. E. Brill, M.D. S Weir Mitchell, M.D. Charles W. Burr, M.D. C. A. Herter, M.D. Charles A. Oliver, M.D. Joseph Collins, M.D. George W. Jacoby, M.D. William Osler, M.D. Charles L. I'ana, M.D. William W. Keen, M.D. Frederick Peterson, M.D. F. X. Dercum, M.D. Philip Coombs Knapp, M.D. Morton Prince, M.D. Geo. E. de Schweinitz, M.D. James Hendrie Lloyd, M.D. Wharton Sinklek, M.D. E. D. Fisher, M. D. Charles K. Mills, M.D. M. Allen Starr, M.D. Landon Carter Gray, M.D. James C. Wilson, M. D. The prevailing impression that Nervous Diseases present peculiar difficulties possibly arises not so much from the nature of the subject as from the manner in which it has generally been presented, a belief which has led, after careful study, to the somewhat novel arrange- ment of this work. In brief, the general affections are considered first, and attention is then progressively directed to those which are more and more special. The choice of subjects and the space devoted to each have been arranged with special reference to practical needs, and it is believed that the mode of handling details is conducive to clearness, utility and complete- ness. A glance at the List of Contributors will show that this volume represents the views of gentlemen widely recognized as authorities in neurological science, and especially known in connection with the subjects assigned to them. The work is likewise representative of our great medical schools, and hence it embodies not only high authority but is likewise illustra- tive of the best methods of instruction. Free use has been made of illustrations in black and colors. The series of pictures is largely original. Gray on Nervous and Mental Diseases.— New (2d) Ed. Just Ready. A Practical Treatise on Nervous and Mental Diseases. By Landon Carter Gray, M.D., Professor of Diseases of the Mind and Nervous System in the New York Polyclinic. New (2d) edition. In one very handsome octavo volume of 728 pages, with 172 engravings and 3 col -red plates. Cloth, $4.75 ; leather, $5.75. The period of less than two years which has sufficed to exhaust the first edition of this work has witnessed epoch-making discoveries in the data of the science, and the opportunity thus presented has been fully utilized in the revision now at the command of the profession. Dr. Gray's book is notable for its clear, adequate and masterly exposition of both nervous and mental diseases within the limits of a single convenient volume. These affections, owing to their widespread prevalence and their peculiarities in this country, possess unrivalled import- ance for American physicians. Their close interrelation gives especial value to an authorita- tive work which handles them in proper conjunction. The series of illustrations abounds in typical portraits, admirable engravings and clear diagrams, and in the present edition it has been enriched with colored plates. Mitchell on Nerve Injuries and Their Treatment.— In Press. Remote Consequences of Injuries of Nerves and Their Treat- ment. An examination of the present condition of wounds received in 1863-5, with additional illustrative cases. By John K. Mitchell, M. D., Assistant Physician to the Orthopaedic Hospital and Infirmary for Nervous Diseases, Philadelphia. In one hand- some 12mo. volume of 239 pages, with 12 illustrations. Cloth, $1.75. Just ready. The author has chosen a subject of great clinical importance to physicians as well as to surgeons. Injuries of the nerves are common in civil as well as in military life and lead to various painful and intractable conditions. Dr. Mitchell has had access to authentic records covering thirty years, and his researches arrive at important results based upon an ample number of cases "under observation for a prolonged period. Hamilton on Nervous Diseases.— Second Edition. Nervous Diseases ; Their Description and Treatment. By Allen McLane Hamilton, M. D., Attending Physician at the Hospital for Epileptics and Paralytics, Blackwell's Island, N. Y. Second edition, thoroughly revised and rewritten. In one octavo volume of 598 pages, with 72 illustrations. Cloth, $4.00. Klein's Histology.— Fourth Edition. Elements of Histology. By E. Klein, M. D., F. R. S., Joint Lecturer on General Anatomy and Physiology in the Medical School of St. Bartholomew's Hospital, London. Fourth edition. In one 12mo. volume of 376 pages, with 194 ilius. Limp cloth, $1.75. See Students 7 Series of Manuals, page 30. PEPPER'S SURGICAL PATHOLOGY. In one pocket-size 12mo. volume of 511 pages, with 81 illustrations. Limp cloth, red edges, $2.00 See Students' Series of Manuals, page 30. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. Pathology, Histology, Bacteriology, 19 Green's Pathology and Morbid Anatomy.— New (8th) Edition. Pathology and Morbid Anatomy. By T. Henry Green, M. D., Lecturer on Pathology and Morbid Anatomy at Charing-Cro?s Hospital Medical School, London. Seventh American from the eighth and revised English edition. In one handsome oclavo volume of 595 pages, with 224 engravings, and a colored plate Cloth, $2.75. Just ready. Green's Pathology and Morbid Anatomy has long been unquestionably the leading text- book on its subjects in English-speaking schools of medicine, a r ~ l American and eitdit English editions. The present iss fact attested by the demand c n.ngiLsn eiuuons. me present issue has been throughly revised to represent the latest knowledge, new chapters being added, and every page bearing evidence of change. The notable list of illustrations has been enriched by the addition of sixty new engravings and a colored plate. Gibbes' Practical Pathology and Morbid Histology. Practical Pathology and Morbid Histology. By Heneage Gibbes, M. D., Professor of Pathology in the University of Michigan, Medical Department. In one very handsome 8vo. vol. of 314 pp., with 60 illus., mostly photographic. Cloth, $2.75. the tissues for examination, cut, stain and mount In fulness of directions as to the modes of investigating morbid tissues the book leaves little to be desired. The work is throughout profusely illustrated with reproductions of micro- photographs. We may say that the practical histologist will gain much useful information from the book. — The London Lancet. The student of morbid histology and bacteri- ology has at his hand, in tnis neat volume of some three hundred pages, a most excellent guide and one which, unless he be a very advanced student, he cannot afford to be without. The work is divided into four parts, the first, that of practical pathology, containing clear and precise directions in histological technique, showing how to prepare sections, etc. The second part deals with bacteri- ology, with the different forms of cultivation, microscopic examinations of the bacteria, etc. The third part, which comprises more than half the book, treats of morbid histology. This partis illustrated with a great number of beautiful photo- micrographs in which the microscopic field is reproduced with a distinctness that is really remarkable. Tne fourth part contains some very practical instruction on photography with the microscope. Works like this of Dr. Gibbes will soon popularize histology among the profession at large, whereas it is now to a large number of physicians almost a sealed book. — Medical Record. Senn's Surgical Bacteriology.— Second Edition. Surgical Bacteriology. JBy Nicholas Senn, M. D., Ph. D., Professor of Surgery in Rush Medical College, Chicago. New (second) edition. In one handsome octavo of 268 pp., with 13 plates, of which 10 are colored, and 9 engravings. Cloth, $2.00. The book is really a systematic collection in the most concise form of such results as are published in current medical literature by the ablest workers in this field of surgical progress ; and to these are added the author's own views and the results of his clinical experience and original investigations. The book is valuable to the student, but its chief value lies in the fact that such a compilation makes it possible for the busy practitioner, whose time for reading is limited and whose sources of information are often few, to become conversant with the most modern and advanced ideas in sur- gical pathology, which have "laid the foundation for the wonderful achievements of modern sur- gery." — Annals of Surgery. Abbott's Bacteriology.— New (2d; Edition. The Principles of Bacteriology : a Practical Manual for Students and Physicians. By A. C. Abbott, M. D., First Assistant, Laboratory of Hygiene, University of Pennsylvania, Philadelphia. New (2d) edition, thoroughly revised and greatly enlarged. In one very handsome 12mo. volume of 472 pages, with 94 illustrations, of which 17 are colored. Cloth, $2.75. Its scope has been much extended, so that it now contains all that is necessary for a beginner to learn in order to gain a practical working knowledge of the subject. Ic is particularly adapted to the wants of students and practitioners who wish to pursue their study without the aid of an instructor. — Medicine, The instructions for methods of work are all lucid and concise. It is the most satisfactory and comprehensive book on practical bacteriology in our language.— Chicago Clinical Review, Nov., 1894. The second edition has been much enlarged by the addition of much new matter. Its illustra- tions, partly colored, are helpful in the elucidation of the text. Ample instruction is given as to needed apparatus, cultures, stainings, microscop- ic examinations, etc. The pathogenic bacilli are fully described both by the text and illustrations, and the methods of conducting examinations are fully set forth. It will win its way and become a favorite. — Virginia Medical Monthly. On the whole the book is one of the best of its kind and the most practical in the English lan- guage. — Maryland Medical Journal. Goats' Treatise on PatMogy. A Treatise on Pathology. By Joseph Coats, M. D., F. F. P. S., Patholo- gist to the Glasgow Western Infirmary. In one very handsome octavo volume of 829 pages, with 339 beautiful illustrations. Cloth, $5.50 ; leather, $6.50. Medical students as well as physicians, who desire a work for study or reference, that treats the subjects in the various departments in a very thorough manner, but without prolixity, will cer- tainly give this one the preference to any with which we are acquainted. It sets forth the most recent discoveries, exhibits, in an interesting manner, the changes from a normal condition effected in structures by disease, and points out the characteristics of various morbid agencies, so that they can be easily recognized. But, not limited to morbid anatomy, it explains fully how the functions of organs are disturbed by abnormal conditions. — Cincinnati Medical News. ScMfer's Histology.— Fourth Edition. The Essentials of Histology. By Edward A. Schafer, F. E.S., Jodrell Professor of Physiology in University College, London. New (fourth) edition. In one octavo volume of 311 pages, with 325 illustrations. Cloth, $3.00. PAYNE'S MANUAL OF GENERAL PATHOL- OGY. Designed as an Introduction to the Prac- tice of Medicine. By Joseph F. Payne, M. D., F. R. C. P., Lecturer on Pathological Anatomy, St. Thomas' Hospital, London. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 20 Surgery. Ashhurst's Surgery.— Sixth Edition. The Principles and Practice of Surgery. By John Ashhurst, Jr. M. D., Professor of Surgery and Clinical Surgery in the Univ. of Penna., Surgeon to the Penna. Hospital, Philadelphia, Sixth edition, enlarged and thoroughly revised. Octavo, 1161 pages, 656 engravingsand a colored plate. Cloth, $6.00 ; leather, $7.00. . In this edition he ha9 incorporated an ac- it of the more important recent observations in We have yet to see the same amount of scholarly and extensive information, on the subject of surgery in any other single volume — seldom in a number of volumes. As a masterly epitome of what has been said and done in surgery, as a succinct and logical statement of the principles of this subject, as a model text-book, we do not know its equal. It is the best single text-book of surgery that we have yet seen in this country. — New York Post Graduate. The author has been before the surgical world so long and is so versatile and resourceful that his several editions are rapidly taken up. Ashhurst has taken great pains to render this sixth edition fully equal to the demands of the present, and has constructed it on lines which merit a continuance of the confidence of the profes- sion. count oi the more important recent observations in surgical science, as well as such novelties in sur- gical practice as meritthe classification ofimprove- ments. Dr. Charles B. Nancrede, of Ann Arbor, has contributed a new chapter on surgical bacteri- ology; Dr. Barton C. Hirst has revised the sections- on gynecological subjects; and Drs. George E. de Schweinitz and B. Alexander Randall have re- vised the chapters on diseases of the eye and ear. Those surgeons who possess earlier editions of Ashhurst's treatise will make haste to obtain this new one, and those who are not familiar with the work will necessarily add it to their libraries. — Buffalo Medical and Surgical Journal. Young's Orthopedic Surgery. A Manual of Orthopedic Surgery, for Students and Practi- tioners. By James K. Young, M. D., Instructor in Orthopaedic Surgery, University of Pennsylvania, Philadelphia. In one octavo volume of 446 pages, with 285 illustrations. Cloth, $4; leather, $5. The present work will be found to meet a want among students in acquiring a knowledge of the subject, and among practitioners who constantly see a greater or less number of deformities and who desire information regarding the most recent views on the pathology and treatment of this subject. Dr. Young's large experience has particularly fitted him for the preparation of this work, which is based upon his personal observa- tions, although the literature of the subject has been carefully sifted, and whatever of import- ance he has thus obtained has been made full use of, due credit being given. The pathology will be found to correspond with the most approved modern views, and the treatment is very thoroughly and comprehensively considered. Especial attention has been given to the mechani- cal part of the subject. A very valuable feature of the work is the large number of excellently- executed drawings which illustrate the text. In those cases in which doubt is apt to occur, or in which the symptoms may be obscure, the differ- ential diagnosis has been very fully given. This ground has been well covered, and the work may be relied upon as reflecting the present position of the subject of which it treats. — Uni' versity Medical Magazine. Roberts' Modern Surgery. The Principles and Practice of Modern Surgery. For the use of Stu- dents and Practitioners of Medicine and Surgery. By John B. Koberts, M. D., Prof, of Anatomy and Surgery in the Philadelphia Polyclinic. Prof, of Surgery in the Woman's Medical College of Pennsylvania. Lecturer in Anatomy in the Univ. of Penna. Octavo, 780 pages, 501 illustrations. Cloth, $4.50; leather. $5.5 0. Erichsen's Science and Art oi Surgery.— Eighth Edition. The Science and. Art of Surgery ; Being a Treatise on Surgical Injuries, Diseases and Operations. By John E. Erichsen, F. R. S., F. R. C.S., Professor of Sur- gery in University College, London, etc. From the eighth and enlarged English edition. In two large 8vo. vols, of 2316 pp., with 984 engravings on wood. Cloth, $9; leather, $11. Bryant's Practice of Surgery.— Fourth Edition. The Practice of Surgery. By Thomas Bryant, F. R. C. S., Surgeon and Lecturer on Surgery at Gay's Hospital, London. Fourth American from the fourth and revised English edition. In one large and very handsome imperial octavo volume of 1040 with 727 illustrations. Cloth, $6.50; leather, $7.50. I of 589 pages. Cloth, $2.00. See Students' Series I of Manuals, page 30. I MILLER'S PRACTICE OF SURGERY. Fourth and revised American edition. In one large 8vo. vol. of 682 pp.. with 364 illustrations. Cloth, $3.75. MILLER'S PRINCIPLES OF SURGERY. Fourth American from the third Edinburgh ed. In one 8vo. vol. of 638 pages, with 340 illus. Cloth, $3.75. PIRRIE'S PRINCIPLES AND PRACTICE OF SURGERY. Edited by John Neill, M. D. In one 8vo. vol. of 784 pp. with 316 illus. Cloth, $3.75. GANT'S STUDENT'S SURGERY. By Frederick James Gant, F. R. C. S. Square octavo, 848 pages, 159 engravings. Cloth, $3.75. ! HOLMES' SYSTEM OF SURGERY. THEORET- ICAL AND PRACTICAL. By Various Authors. Edited by Timothy Holmes, M. A. American edi- tion, revised and re-edited by John H. Packard, j M. D. Three large octavo volumes, 3137 pages, 979 illustrations on wood and 13 lithographic plates. Per set, cloth, $18.00; leather, $21.00. Subscription only. DRUITT'S MANUAL OF MODERN SURGERY. Twelfth edition, thoroughly revised by Stanley Boyd, M. B 8vo. 965 pages, with 373 illustrations. Cloth, $4.00; leather,' $5.00. HOLMES' TREATISE ON SURGERY; ITS PRIN- CIPLES AND PRACTICE. From the fifth English edition, edited by T. Pickering Pick, F. R. C.S. In one octavo volume of 997 pages, with 428 illustrations. Cloth, $6.< ; leather, $7.00. MARSH ON THE JOINTS. In one 12mo. volume of 468 pages, with 64 woodcuts and a colored plate. Cloth, $2.00. See S'.riesof Clin>cal Manuals, page 30. BUTLIN ON DISEASES OF THE TONGUE. By Henry T. Butlin, F. R. C.S., Assistant Surgeon to St. Bartholomew's Hospital, London. In one 12mo. volume of 456 pages, with 8 colored plates and 3 woodcuts. Cloth, $3.50. See Series of Clin- ical Manuals page 30. GOULD'S ELEMENTS OF SURGICAL DIAG- NOSIS. By A. Pearce Gould, M. S., M. B., F. R. C. S., Assistant Surgeon to Middlesex Hos pital, London. In one pocket-size 12mo. volume Lea Brothers & Co., Publishers. 706, 708 & 710 Sansom Street Philadelphia. Surgery — (Continued). 21 Wharton's Minor Surgery and Bandaging.— Second Edition. Minor Surgery and Bandaging. By Henry E. Wharton, M. D., Demonstrator of Surgery in the University of Pennsylvania. In one 12mo. volume of 529 pages, with 416 engravings, many being photographic. Cloth, $3.00. The book is one of the very best treatises on ! localities of the body. The author has thoroughly minor surgery and it ought to be adopted as a revised that portion of the work relating to the text book on "the subjects of which it treats. It aseptic and antiseptic methods of wound treat- contains more practical surgery within its limits ment, than which there is no more important and boundaries than any book of its kind we have subject in the whole domain of surgery. Much ever seen. Its illustrations are to be specially new matter has been added, which brings it commended, particularly those that relate to abieastof the very latest knowledge on the sub- bandaging, most of which have been taken from jects of which it treats. — Buffalo Medical and Sur- photographs of applied bandages in the several gical Journal. Treves' System of Surgery.— Vol. I. Just Ready. A System of Surgery. In Contributions by twenty-five English Authors. Edited by Frederick Treves, F.E C.S , Surgeon to and Lecturer on Surgery at the Lon- don Hospital, Examiner in Surgery at the University of Cambridge. In two large octavo volumes. Vol. I., 1178 pages, with" 463 engravings, and 2 color* d plates Cloth, $8.00. Just Heady. Vol. II., Preparing. Treves' Operative Surgery.— Two Volumes. A Manual of Operative Surgery. By Frederick Treves, F. E. C. S., Surgeon and Lecturer on Anatomy at the London Hospital. In two octavo volumes containing 1550 pages, with 422 engravings. Complete work, cloth, $9.00; leather, $11.00. We have no hesitation in declaring it the best work on the subject in the English language, and indeed, in many respects, the best in any lan- guage. It cannot fail to be of the greatest use both to practical surgeons and to those general practitioners who, owing to their isolation or to other ciroumstances, are forced to do much of their own operative work. We feel called upon to recommend the book so strongly for the excellent judgment displayed in the arduous task of selecting from among the thousands of vary- ingprocedures those most worthy of description ; for the way in which the still more difficult task of choosing among the best of those ha3 been accomplished; and for the simple, clear, straightforward manner in which the information thus gathered from all surgical literature ha3 been conveyed to the reader. — Annals of Surgery. Treves' Student's Handbook of Surgical Operations. In one square 12mo. volume of 508 pages, with 94 illustrations. Cloth, $2.50. A Manual of Surgery. In Treatises by Various Authors, edited by Fred- erick Treves, F. R. C. S. in three 12mo. volumes, containing 1866 pages, with 213 engravings. Price per set, cloth, $6.00. See Students' Series of Manuals, page 30. Treves on Intestinal Obstruction. In one 12mo. volume of 522 pages, with 60 ill us. Limp cloth, blue edges, $2.00. See Series of Clinical Manuals, page 30. Smith's Operative Surgery.— Revised Edition. The Principles and Practice of Operative Surgery. By Stephen Smith, M. D., Professor of Clinical Surgery in the University of the City of New York. Second and thoroughly revised edition. In one very handsome octavo volume of 892 pages, with 1005 illustrations. Cloth, $4.00; leather, $5.00. This excellent and very valuable book is one of the most satisfactory works on modern operative surgery yet published. The book is a compendium for the modern surgeon. The present edition is much enlarged, and the text has been thoroughly revised, so as to give the most improved methods in aseptic surgery, and the latest instruments known for operative work. It can be truly said that as a handbook for the student, a companion for the surgeon, and even as a book of reference for the physician not especially engaged in the practice of surgery, this volume will long hold a most conspicuous place, and seldom will its readers, no matter how unusual the subject, consult its pages in vain. Its compact form, excellent print, num- erous illustrations, and especially its decidedly practical character, all combine to commend it.— Boston Medical and Surgical Journal. Ball on the Rectum and Anus.— New Edition. The Rectum and Anus, Their Diseases and Treatment. By Charles B. Bael, F. E. C. S., University Examiner in Surgery, Dublin. Second edi- tian. In one 12mo. volume of 453 pages, with 60 engravings and 4 colored plates. Cloth, $2.25. Just ready. See Series of Clinical Manuals, p. 30. Cheyne on Wounds, Dicers and Abscesses.— Just Ready. The Treatment of Wounds, Ulcers and Abscesses. By W.Watson Cheyne, M. B., F. K. S., F. B. C. S , Professor of Surgery in King's College, London. In one 12mo. volume of 207 pages. Cloth, $1.25. PICK ON FRACTURES AND DISLOCATIONS. 1 Limp cloth, $2.00. See Series of Clinical Manuals, In one 12mo. vol. of 530 pp., with 93 illustrations. | page 30. Lea Brothers & Co., Publishers, 70S, 708 & 710 Sansom Street, Philadelphia. 22 Surgery— (Continued), Fractures, Dislocations. Vols I. and II. Just Ready. Vol. ill. Shortly. Vol. IV. Preparing. A SYSTEM OF SURGERY. BY AMERICAN AUTHORS. Edited by Fkedeejc S. Dennis, M.D., Professor of the Principles and Practice of Surgery, Believue Hospital Medical College, New York; President of the American Surgical Association, etc. Assisted by John S. Bileings, M.D., LL.D, D.C.L., Deputy Surgeon-General, U. S. A. In four imperial octavo volumes of about 900 pages each, proiusely illustrated in black and colors. Price per volume, cloth, $6 ; leather, $7 ; half Morocco, gilt back and top, $8.50. For sale by subscription only. Address the Publishers. Robert Abbe, M.D , Oorham Bacon, M.D. Herman M. Biggs, M.D., John S. Billings, M.D., William T. Bull, M.D., William H. Carmalt, M.D., Henry C. Coe, M.D., P. S. Conner. M.D., William T. Councilman, M.D., D. Brtson Delavan, M.D., Frederic S Dennis, M D., Edward K. Dunham, M.D , William H. For wood. M.D., G-eorge R. Fowler, M. D. , Frederick H. Gerrish, M.D., Arpad G. Gerster, M. L>., There really is now no complete work in English which can be considered as the rival of this. That the editor has selected his collaborators judiciously will be conceded when the names are read over. Each one of them is a teacher of surgery or a director of some large clinic, and each is, there- fore, prepared to speak from an extended expe- rience as well as from extensive study. The three LIST OF CONTRIBUTORS Virgil P. Gibnet, M.D., William A. Hardawat. M.D., Frank T. Hartley, M.D., Joseph Taber Johnson, M.D., William W. Keen, M.D., William T. Lusk, M.D., Charles McBurney, M.D , Rudolph Matas, M.D., Henry H. Mudd, M.D., Charles B. Nancrede, M.D., Henry D. Noyes, M. D, Roswell Patsk, M.D , Willard Parker, M.D., Lewis S. Pilcher, M.D., William H. Polk, M.D., Charles H. Porter, M.D., Maurice H. Richardson, M.D., John B. Roberts, M.D., George E. de Schweinitz, M.D., Nicholas Senn, M.D., Stephen Smith, M.D., Lewis A. Stimson, M.D., Robert W. Taylor, M.D., Louis McL. Tiffany, M.D., J. Collins Warren, M.D., Henry R. Wharton, M.D., Robert F. Weir, M.D., William H. Welch, M.D., J. William White, M.D., Horatio C. Wood, M.D., volumes which are to succeed this are to be as replete with information and as abreast of the times as this one already furnished. The editors, the publishers and the profession at large may be warmly congratulated, and we may feel that a long felt want for some such general treatise has at last been supplied. — American Journal of the Medical Sciences, June, 1895. Stimson's Operative Surgery.— New (3d) Edition, Just Ready. A Manual of Operative Surgery. By Lewis A. Stimson, B. A ., M D., Professor of Clinical Surgery in the University of the City of New York. New (3d) edition. In one royal 12mo. volume of 614 pages, with 306 illustrations. Cloth, $3.75. The demand for a third edition of Professor Stimson's excellent Marmal of Operative Surgery attests the service it has rendered to thousands of physicians and surgeons. The author has utilized this opportunity to place the work fully abreast of the most advanced surgery. The profuse series of illustrations has been largely re-engraved and additions have been made to it wherever clearness and fulness of instruction could be promoted thereby. As surgery is chiefly operative, an authoritative volume on its procedures is an indispensable part of the equipment of every surgeon and likewise of every physician in general practice. Hamilton on Fractures and Dislocations.— Eighth Edition. A Practical Treatise on Fractures and Dislocations. By Frank H. Hamilton, M. D., LL.D., Surgeon to Believue Hospital, New York. New (8th) edi- tion, revised and edited by Stephen Smith, M. D. , Prof, of Clinical Surgery in Univ. of City of N. Y. In one octavo volume of 832 pp., with 507 illus. Cloth, $5.50 ; leather, $6.50. Its numerous editions are convincing proof if any jeet of such magnitude is no easy one. Dr. Smith Its numerous editions are convincing proof it any is needed, of its value and popularity. It is pre eminently the authority on fractures and disloca- tions, and universally quoted as such. In the new edition it has lost none of its former worth. The additions it has received by its recent revision make it a work thoroughly in accordance with modern Practice, theoretically, mechanica'ly, aseptically. 'he task of writing a complete treatise on a sub- ject of such magnitude is no easy has aimed to make the present volume a correct exponent of our knowledge of this department of surgery. The more one reads the more one is impressed with its completeness. The work has been accomplished, and has been done clearly, concisely, excellently well.— .Boston Medical and Surgical Journal. Stimson on Fractures and Dislocations. A Treatise on Fractures and Dislocations. By Lewis A. Stimson, M.D. In two handsome octavo volumes. Vol. I., Fractures, 582 pages, 360 illustra- tions. Vol. II., Dislocations, 540 pages, with 163 illustrations. Complete work, cloth, $5.50 ; leather, $7.50. Either volume separately, cloth, $3.00 ■ leather, $4.00. The appearance of the second volume marks the completion of the author's original plan of prepar- ing a work which should present in the fullest manner all that is known on the cognate subjects of Fractures and Dislocations. The volume on Fractures assumed at once the position of authority on the subject, and its companion on Dislocations will no doubt be similarly received. This volume exhibits the surgery of Dislocations as it is taught and practised by the most eminent surgeons of the present time. Containing the results of such ex- tended researches it must for a long time be re- garded as an authority on all subjects pertaining to dislocations. Every practitioner of surgery will feel it incumbent on him to have it for constant reference. — Cincinnati Medical News. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. Ophthalmology, 23 Norris & Oliver's Ophthalmology. A Text-Book of Ophthalmology. By William F. Norris, M. D., Professor of Ophthalmology in the University of Pennsylvania, and Charles A. Oliver, M. D., Surgeon to "Wills' Eye Hospital, Philadelphia. In one very handsome octavo vol. of 632 pages, with 357 engravings and 5 colored plates. Cloth, $5 ; leather, $6. This is the first text-book of diseases of the eye ! to any would-be competitor. Wonderfully cheap written by American authors for American col- legos and" students. Rules and procedures are made so plain and so evident that any student can easily understand and employ them. It is succinct in recital, practical in its teachings, judi- cious in the selection of material and conservative, yet radical when necessary. In treatment it can be accepted as from the voice and the pen of a respected and recognized authority. The illus- trations far outnumber those of its contempora- ries, whilst the high grade and unbiased opinions of the teachings serve to give it a rank superior in price, beautifully printed and exquisitely illus- trated, the mechanical make-up of the book is all that can be desired. After most conscientious and painstaking perusal of the work, we unre- servedly endorse it as the best, the safest and the most comprehensive volume upon the subject that has ever been offered to the American medical public. We sincerely hope that it may find its way into the list of text-books of every English- speaking college of medicine. — Annals of Ophthal- mology ayid Otology. Berry on the Eye.— New (2d) Edition. Diseases of the Eye. A Practical Treatise for Students of Ophthalmology. By George A. Berry, M.B., F. E. C. S., Ed., Ophthalmic Surgeon, Edinburgh Royal Infirmary. New (second) edition. In one octavo volume of 750 pages, with 197 illustra- tions, mostly lithographic. Cloth, $8.00. This is by far the best work upon its theme in the English language that we have seen, for the diction is pure and clear, and besides, the beauti- ful illustrations of normal and diseased conditions make it a valuable addition to the library of all practitioners, general as well as special. We have never seen more real delineation of disease, the coloring is perfect, and each illustration is an "object-lesson." We cannot but reiterate what we said at the beginning, that we have had great pleas- ure in the perusal of this work, and great profit, and that we consider it the best on the subject in the English language today, not only for its diction but for its instructive illustrations. — The American Journal of the Medical Sciences. Juler's Ophthalmic Science and Practice.— New (2d) Edition. A Handbook of Ophthalmic Science and Practice. By Henry E. Jtjler, F. K. C. S., Senior Assistant Surgeon, Royal Westminster Ophthalmic Hospital; Late Clinical Assistant, Moorfields, London. New (2d) edition. Handsome 870. volume of 561 pages, with 201 woodcuts, 17 colored plates, selections from Test-types of Jaeger and Snellen, and Holmgren's Color-blindness Test. Cloth, $5.50 ; leather, $6.50. The continuous approval manifested towards i matter of practical value. The sections devoted tb this work testifies to the success with which the treatment are singularly full, and at the same time author has produced concise descriptions and concise, and couched in language that cannot fail typical illustrations of all the important affections to be understood. — The Medical Age. of the eye. The volume is particularly rich in \ Nettleship on the Eye.— Fifth Edition. Diseases of the Eye. By Edward Nettleship, F. R. C. S., Ophthalmic Surgeon at St. Thomas' Hospital, London. Surgeon to the Royal London (Moorfields) Ophthalmic Hospital. Fourth American from the fifth English edition, thor- oughly revised. With a Supplement on the Detection of Color Blindness, by Wil- liam Thomson, M. D., Professor of Ophthalmology in the Jefferson Medical College Philadelphia. In one 12mo. volume of 500 pages, with 164 illustrations, selections from Snellen's test-types and formulae, and a colored plate. Cloth, $2.00. This is a well-known and a valuable work. It was primarily intended for the use of students, and supplies" their needs admirably, but it is as useful for the practitioner, or indeed more so. It does not presuppose the large amount of recondite knowledge to be present which seems to be as- sumed in some of our larger works, is not tedious from over- conciseness, and yet covers the more important parts of clinical ophthalmology. — New York Medical Journal. Carter & Frost's Ophthalmic Surgery. Ophthalmic Surgery. By R. Brudenell Carter, F.R. C. S., Lecturer on Ophthalmic Surgery at St. George's Hospital, London, and W. Adams Frost, F. R. C. S., Joint Lecturer on Ophthalmic Surgery at St. George's Hospital, London. In one 12mo. volume of 559 pages, with 91 woodcuts color-blindness test, test-types and dots and appen- dix of formulas. Cloth, $2.25. See Series of Clinical Manuals, page 30. THOMPSON ON THE URINARY ORGANS. Lectures on Diseases of the Urinary Organs. By Sir Henry Thompson, Professor of Clinical Surgerv in University College Hospital, London. Second American from the third English edition. Octavo, 203 pages, 25 illustrations Cloth, $2 25. THOMPSON ON THE PATHOLOGY AND TREATMENT OF STRICTURE OP THE URETHRA AND URINARY FISTULA. From the third English edition. In one octavo volume of 359 pages, with 47 engravings and 3 plates. Cloth, $3.50. BASHAM UN RENAL DISEASES: A Clinical Guide to their Diagnosis and Treatment. 12mo. 304 pages, with 21 illustrations. Cloth, $2.00. WELLS ON THE EYE. In one octavo volume. LAURENCE AND MOON'S HANDY BOOK OF OPHTHALMIC SURGERY, for the use of Prac- titioners. Second edition. In one octavo vol- ume of 227 pages, with 65 illus. Cloth, $2.75. LAWSON ON INJURIES TO THE EYE, ORBIT AND EYELIDS: Their Immediate and Remote Effects. In one octavo volume of 404 pages, with 92 illustrations ninth, £3.50 MORRIS ON SURGICAL DISEASES OF THE KIDNEY. By Henry Morris, F. R, C. S., Surgeon to Middlesex Hospital, London. 12mo., 554 pp., with 40 woodcuts, and 6 colored plates. Limp cloth, $2.25. See Series of Clinical Manuals, p. 30. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 24 Otology, Urinary & Renal Dis., Dentistry, Politzer on Diseases of the Ear.— Third Edition. A Text-Book of Diseases of the Ear and Adjacent Organs. By Dr. Adam Politzer, fmperial-Boyal Professor of Aural Therapeutics in the Univer- sity of Vienna, Chief of the Imperial -Koyal University Clinic for Diseases of the Ear in the General Hospital, Vienna. Translated into English from the third ai d revised German edition by Oscar Dodd, M. D., Clinical Instructor in Diseases of the Eye and Ear, College of Physicians and Surgeons, Chicago. Edited by Sir William Dalby, F. R. C. S., M. B., Consulting Aural Surgeon to St. George's Hospital, London. In one large octavo volume of 748 pages, with 330 illustrations. Cloth, $5.50. underlie the clinical remarks and details of meth- ods of treatment. The indications for treatment are clear and reliable. We can confidently rec- ommend it, for it contains, as stated by the editor in his preface, all that is known upon the subject. — London Lancet. This edition of the eminent Vienna professor's well-known work will be welcomed by those who wish to obtain a complete account of all that is known in connection with aural diseases. Who- ever peruses it carefully cannot fail to be struck with the details, the extensive references, and especially the valuable pathological data, which Field's Manual of Diseases of the Ear. Fourth Edition. A Manual of Diseases of the Ear. By George P. Field, M. E 4 C. S., Aural Surgeon and Lecturer on Aural Surgery in St Mary's Hospital Medical School, London. In one octavo of 39 1 pp., with 73 engravings and 2 1 colored plates. Cloth, $3.75. To those who desire a concise work on diseases large class of cases of ear disease that comes of the ear, clear and practical, this manual com- properly within his province. The illustrations mends itself in the highest degree. It is just such are apt and well executed while the make-up of a work as is needed by every general practi- the work is beyond criticism. — The American turner to enable him to treat intelligently the Practitioner and Neivs. Burnett on the Ear.— Second Edition. The Ear, Its Anatomy, Physiology and Diseases. A Practical Treatise for the use of Medical Students and Practitioners. By Charles H. Burnett, A. M., M. D., Professor of Otology in the Philadelphia Polyclinic ; President of the American Otological Society. Second edition. In one handsome octavo volume of 580 pages, with 107 illustrations. Cloth, $4.00 ; leather, $5.00. Black on the Urine.— Just Ready. The Urine in Health and Disease, and Urinary Analysis, Physi- ologically and Pathologically Considered. By D. Campbell Black, M. D., *L.Pv. C. S., Professor of Physiology, Anderson College Medical School. In one 12mo. volume of 256 pages, with 73 engravings. Cloth, $2.75. Roberts on Urinary and Renal Diseases.— Fourth Edition. A Practical Treatise on Urinary and Renal Diseases, including Urinary Deposits. By Sir William Eoberts, M. D., Lecturer on Medicine in the Manchester School of Medicine, etc. Fourth American from the fourth London edi- tion. In one handsome octavo volume of 609 pages, with 81 illustrations. Cloth, $3.50. Purdy on Bright's Disease and Allied Affections. Bright's Disease and Allied Affections of the Kidneys. By Charles W. Purdy, M. D., Professor of Genito-Urinary and Eenal Diseases in the Chi- cago Polyclinic. In one octavo vol. of 288 pages, with illustrations. Cloth, $2.00. The American Text-Books of Dentistry.— Preparing. In Contributions by Various Authors. In two octavo volumes of about 600 pages each, fully illustrated. Volume I., Operative Dentistry. Edited by Edward C. Kirk, D. D. S., Lecturer on Operative Dentistry, Dept. of Dentistry, Univ. of Penna. Volume IE., Mechanical Denttstry. Edited by Charles J. Essig, M. D., D. D. S , Prof, of Mechanical Dentistry and Metallurgy, Dept. of Dentistry, Univ. of Penna. The American System of Dentistry. Volume IV. Preparing. In Treatises by Various Authors. Edited by Wilbur F. Litch, M. D., D. D. S., Professor of Prosthetic Dentistry, Materia Medica and Therapeutics in the Pennsylvania College of Dental Surgery. In four very handsome octavo volumes con- taining over 4000 pages, with about 2400 illustrations and many full-page plates. Per volume, cloth, $6 ; leather, $7 ; half Morocco, gilt top, $8. For sale by subscription only. As an encyclopedia of Dentistry it has no su- I doubtless it is), to mark an epoch in the history of perior. It should form a part of every dentist's j dentistry. Dentists will be satisfied with it and library, as the information it contains is of the | proud of it — they must. It is sure to be precisely freatest value to all engaged in the practice of what the student needs to put him and keep him entistry. — American Journal of Dental Sciencf. j in the right track, while the profession at large A grand system, big enough and good enough | will receive incalculable benefit from it.— Odonto- and handsome enough for a monument (which | graphic Journal. COLEMAN'S MANUAL OF DENTAL SURGERY AND PATHOLO&Y. By Alfred Coleman, L.D.S. Thoroughly revised and adapted to the use of American Students, by Thomas C. Stellwagen, D. D.S. Octavo, 412 pages, with 331 illustrations. Cloth, $3.25. Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. Impotence, Sterility, Venereal, Skin. 25 Taylor on Venereal Diseases.— Sixth Edition. Just Ready. The Pathology and Treatment of Venereal Diseases. By Kobert W. Taylof, A.M., M.D., Clinical Professor of Genito-Urinary Diseases in the College of Physicians and Surgeons, New York. Sixth editioD. In one very handsome octavo volume of lOi 2 pages, with 230 engravings and 7 colored plates. Cloth, $5.50; leather, $6.50. The perennial prevalence of the Yenereal Diseases, and their power to invade all tissues of the body and consequently to modify all other human maladies, unite to render a working knowledge of this subject essential to every physician, surgeon and specialist. The writer of this book has lone enjoyed a position of preeminent authority. Since the exhaustion of the fifth edition of Bumstead c0 Taylor on Venereal Diseases, Dr. Taylor has been assiduously engaged in sifting the results of the immense activity directed towards this subject in recent years, and in the present volume he places at the command of the profession a body of knowledge, complete, clear, modern and authoritative, a work new both in text and illustra- tions. It is assured of the foremost position as a test-book and work of reference. Fuller on Male Sexual Disorders.— Just Ready. Disorders of the Sexual Organs in the Male. By Eugene Fuller, M.D., Instructor in Yenere.il and Genito-Urinary Diseases, New York Post-Graduate Medical School. In one very handsome octavo volume of 238 pages, with 25 engravings and 8 fuli-page.l plates. Cloth, 12.00. Extensive experience in private practice and in one of the leading New York medical schools has convinced the author that male sexual disorders arise more frequently from pathological states of the organs themselves than from neurological or mental causes. He has endeavored in this work to place the literature of sexual pathology abreast of that on sexual neurology and to furnish the profession with a guide to diagnosis and treatment in which all the etiological factors are considered according to their relative importance. The rich rewards obtained by charlatans practising in this branch of medicine may be considered in a certain sense as an expression of public opinion upon the comparative success of the regular practitioner. Rational methods must rescue this most important class of disease from the empirics, and a work pointing the way to successful treatment founded upon sound pathology and diagnosis will benefit the profession almost as much as their patients. Gross on Impotence, Sterility, etc.— Fourth Edition. A Practical Treatise on Impotence, Sterility, and Allied Dis- orders of the Male Sexual Organs. By Samuel W. Gross, A. M., M. D.> LL. D., Prof, of Surgery in the Jefferson Med. Coll. of Phila. Fourth edition, thoroughly revised by F. R. Sturgis, M.D., Prof, of Dis. of the Genito-Urinary Organs and of Venereal Dis., N. Y. Post Grad. Med. School. In one 8vo. vol. of 165 pp., with 18 illus. CI., $1.50, Culver & Hayden's Manual of Venereal Diseases. A Manual of Venereal Diseases. By Everett M. Culver, M. D., Pathologist and Assistant Attending Surgeon, Manhattan Hospital, New York, and James K. Hayden, M. D., Chief of Clinic Venereal Department, College of Physicians and Sur- geons, New York. In one 12mo. volume of 289 pages, with 33 illus. Cloth, $1.75. This bock is a practical treatise, presenting in a venereal diseases for the general practitioner to condensed form the essential features of our pres- adopt as a guide. The general practitioner needs ent knowledge of the three venereal diseases, a few simple, concise and clearly presented laws, syphilis, chancroid and gonorrhea. We have ex- in the execution of which he cannot fail either to amined this work carefully and have come to the cure or prevent the ravages of the maladies in conclusion that it is the most concise, direct and question and their direful results.— Buffalo Medical able treatise that has appeared on the subject of and Surgical Journal. Cornil on Syphilis. Syphilis, its Morbid Anatomy, Diagnosis and Treatment. By V. Cornil, M.D. Specially revised by the Author, and translated with notes and additions by J. Henry C. Simes, M. D., and J. William White, M.D. Octavo 461 pages, with 84 illustrations. Cloth, $3.75. Hardaway's Manual ol Skin Diseases. Manual of Skin Diseases. With Special Keferenceto Diagnosis and Treat- ment. For the u^e of Students and General Practitioners. By W. A. Haedaway, M. D., Professor of Skin Diseases in the Missouri Medical College. 12mo., 440 pp. Cloth, $3.00. GROSS' PRACTICAL TREATISE ON THE DIS- EASES, INJURES AND MALFORMATIONS OF THE URINARY BLADDER, THE PROS- TATE GLAND AND THE URETHRA. By Samuel D. Gross, M.D., LL.D., D.C.L., etc. Third edition, thoroughly revised by Samuel W. Gross, M.D. In one octavo volume of 574 pages, with 170 illustrations. Cloth, $4.50. volume of 542 pages, with 9 chromo-lithographs. Cloth, $2.25. See Seiies of Clinical Manuals, page 30. HILL ON SYPHILIS AND LOCAL CONTAGIOUS DISORDERS. In one 8vo vol. of 479 p. Cloth, $3.25. LEE'S LECTURES ON SYPHILIS AND SOME FORMS OF LOCAL DISEASE AFFECTING THE ORGANS OF GENERATION. In one HUTCHINSON ON SYPHILIS. In one 12mo. 8vo. volume of 246 pages. Cloth, $2.25, Lea Brothers & Co., Publishers, 706, 708 & 710 Sansom Street, Philadelphia. 26 Venereal and Skin Diseases, Hyde on the Skin.— Third Edition. A Practical Treatise on Diseases of the Skin. For the use of Students and Practitioners. By J. Nevins Hyde, A. M., M. D., Professor of Dermatology and Ven- ereal Diseases in Kush Medical College, Chicago. Third edition. In one octavo volume of 802 pages, with 9 colored plates and 108 engravings. Cloth, $5.00 ; leather, $6.00. The third edition, just issued, fulfils all the ex- pectations warranted by the great accumulation of dermatological material since the earlier editions were brought out, and puts this work at the head of the modern American treatises on skin diseases. The author has introduced thirty- five new diseases in this edition. He is especially to be congratulated on his chapter on tuberculosis. Five plates and twenty two woodcuts, all of great excellence, have been added to the illustrations. The excellence of the chapters on treatment, to- gether with the care that has been bestowed on subjects that have acquired new interest, make the book one to be warmly recommended. — Bus- ton Medical and Surgi